Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




Prof. Somashekhar Nimbalkar

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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
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Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : December | Volume : 17 | Issue : 12 | Page : OC26 - OC29 Full Version

Association between Frontal QRS-T Angle and Major Adverse Cardiovascular Events among Patients with Acute Myocardial Infarction: A Cross-sectional Study


Published: December 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/65266.18856
Jatin Praveen Panchal, Sharan Badiger

1. Postgraduate, Department of Medicine, Shri B.M. Patil Medical College, Hospital and Research Centre, BLDE (Deemed to be University), Vijayapura, Karnataka, India. 2. Professor and Head, Department of Medicine, Shri B.M. Patil Medical College, Hospital and Research Centre, BLDE (Deemed to be University), Vijayapura, Karnataka, India.

Correspondence Address :
Dr. Sharan Badiger,
Professor and Head, Department of Medicine, Shri B.M. Patil Medical College, Hospital and Research Centre, BLDE (Deemed to be University), Vijaypura-586101, Karnataka, India.
E-mail: sharanrb@rediffmail.com

Abstract

Introduction: Acute myocardial infarction has reached epidemic proportions in the Indian population. The premature onset of acute myocardial infarction has shifted the focus of research. An abnormal frontal QRS-T angle can be used as a marker of acute myocardial infarction and can also predict Major Adverse Cardiac Events (MACE) such as heart failure, complex ventricular arrhythmias (sustained ventricular tachycardia or ventricular fibrillation), early post-infarction angina, mechanical complications, and cardiac death resulting from acute myocardial infarction. Predicting the likelihood of serious adverse cardiovascular events and mortality in patients who have experienced an acute myocardial infarction aids in developing immediate and short-term treatment plans.

Aim: To assess the association between the Frontal QRS-T angle and MACE among patients with Acute Myocardial Infarction (MI).

Materials and Methods: A cross-sectional study was conducted on adult patients admitted with a diagnosis of acute MI at the Department of Medicine, BLDE (Deemed to be University) Shri B.M. Patil Medical College Hospital and Research Centre, Vijayapura, Karnataka, India from January 2021 to June 2022. A total of 95 patients were enrolled in the study and classified into two groups: Group A (n=68) with a frontal QRS-T angle of <100 degrees, and Group B (n=27) with a frontal QRS-T angle of >100 degrees. The patients were monitored for the emergence of serious MACE such as heart failure, pulmonary oedema, cardiogenic shock, arrhythmias, and death while they were in the hospital. Statistical analysis was performed using the Chi-square test, Independent t-test, and Mann-Whitney U test as applicable. A p-value of <0.05 was considered statistically significant.

Results: The most common age group in Group A was 60-70 years, while in Group B it was 50-60 years. A total of 95 patients with acute MI were enrolled and divided into two groups. Out of 95 patients, 68 patients with a frontal QRS-T angle <100 degrees were in Group A, and 27 patients with a frontal QRS-T angle >100 degrees were in Group B. There was a significant difference between the two groups with respect to MACE, including heart failure (Group A=8.8%, Group B=77.8%, p=0.00), pulmonary oedema (Group A=10.3%, Group B=77.8%, p=0.00), and cardiogenic shock (Group A=7.4%, Group B=40.7%, p=0.00).

Conclusion: A frontal QRS-T angle of >100 degrees was a reliable factor for assessing in-hospital major adverse cardiac outcomes such as heart failure, pulmonary oedema, and cardiogenic shock. Hence, a frontal QRS-T angle of >100 degrees on a 12-lead ECG is a cost-effective, reliable, and non-invasive parameter of MACE in patients with acute MI.

Keywords

Acute coronary syndrome, Cardiogenic shock, Electrocardiogram, Heart failure, Major adverse cardiac events

Ischaemic heart disease is one of the leading causes of death worldwide. It was responsible for 19 million fatalities globally in 2020 (1). In developing nations, acute Myocardial Infarction (MI) is a significant risk factor for morbidity and mortality. The diagnosis and prognosis of acute MI are directly connected to Electrocardiogram (ECG) alterations. As the leading cause of death in India, acute MI has already surpassed communicable diseases. Approximately three million cases of ST-Segment Elevation Myocardial Infarction (STEMI) alone burden the healthcare system each year (2).

Complications such as heart failure, cardiogenic shock, pulmonary oedema, arrhythmias, and re-infarction are considered Major Adverse Cardiovascular Events (MACE) (3). Predicting the likelihood of serious MACE and mortality in patients who have experienced acute MI aids in developing both immediate and short-term treatment plans.

An ECG machine is a valuable tool in the diagnosis of acute MI and has shown to be highly effective in categorising patients based on the degree of risk for a range of cardiac morbidity and overall mortality (4). Population-based studies have shown that certain electrocardiographic variables can be used for clinical risk stratification for MACE (5).

Literature has shown that regional myocardial lesions are associated with changes in QRS complex configuration, which can cause a change in the frontal QRST angle on a 12-lead ECG (6). Recent research suggests that the frontal QRST angle is a relevant electrocardiographic measure of the dispersion between depolarisation and repolarisation. Additionally, it has been demonstrated that a higher spatial QRS-T angle is linked to higher mortality in the general population (6). Measuring the spatial QRS-T angle requires specialised software as it is not routinely measured on 12-lead electrocardiographic machines. On the other hand, the frontal QRS-T angle can be easily calculated from a routine 12-lead ECG without the need for specialised software. Studies have revealed a substantial link between the frontal and spatial QRS-T angles (7).

Therefore, an abnormal frontal QRS-T angle can be used as a marker of acute MI and can also predict MACE such as heart failure, complex ventricular arrhythmias (sustained ventricular tachycardia or ventricular fibrillation), early post-infarction angina, mechanical complications, and cardiac death resulting from acute MI (8).

However, research on the predictive value of the frontal QRS-T angle in the occurrence of MACE following acute MI is limited. The aim of the study was to assess the association between the frontal QRS-T angle and MACE among patients with acute MI. The objective of the study was to evaluate modifiable and non modifiable risk factors for acute MI.

Material and Methods

This cross-sectional study was conducted in the Intensive Cardiac Care Unit (ICCU) of BLDE (Deemed to be University), Shri B.M. Patil Medical College Hospital and Research Centre, Vijayapura, Karnataka, India, between January 2021 and June 2022. Approval for present study was obtained from the Institutional Ethics Committee with the number (IEC/NO-09/2021 dated on 22/01/2021) and the study was also registered in the Clinical Trials Registry-India with the number (CTRI/2021/04/032888).

The frontal QRS-T was calculated as the absolute value of difference between the QRS axis and T axis yielding value of difference between 0 degree and 180 degrees. The QRS axis was calculated using the isoelectric method and T axis was determined in which leads the highest T-waves were seen.

Inclusion criteria: The inclusion criteria were patients admitted with acute myocardial infarction (STEMI and NSTEMI).

Exclusion criteria: Patients with unstable angina, patients having bundle branch block on ECG (LBBB or RBBB), patients on a temporary or permanent pacemaker and patients with old ischaemic heart disease disease were excluded from the study.

Sample size calculation: With an anticipated proportion of mortality among patients with acute MI and a higher frontal QRS-T angle at 28%, the study would require a sample size of 95 patients with a 95% level of confidence and 10% absolute precision (8). The formula used was:

Formula used: n= z2p*q/d2

{Where Z=Z statistic at α level of significance, d^2=Absolute error, P=Proportion rate (Prevalence=28%), q=(100-p)}.

Study Procedure

A total of 102 patients with acute MI admitted to the ICCU were screened, and 95 patients who satisfied the inclusion criteria were enrolled using convenience sampling (Table/Fig 1). Written informed consent was obtained before enrolling the patients in the study. The study also assessed the risk factors associated with acute MI, including both non modifiable factors (age, sex) and modifiable factors (diabetes, hypertension, smoking, alcohol, tobacco chewing) (9).

The patients were divided into two groups based on their frontal QRS-T angle. Patients with a frontal QRS-T angle <100 degrees were assigned to Group A, and patients with a frontal QRS-T angle >100 degrees were assigned to Group B (8). The patients included in the study underwent a standardised assessment, including history and examination, ECG at admission, cardiac enzymes {Troponin I/Troponin T, Creatine Phosphokinase- MB (CPK-MB)}, and other necessary laboratory investigations such as complete blood count, renal function test, serum electrolytes, and 2D echo study (10).

A 12-Lead surface electrocardiography was performed using BPL Cardiart 6108T or VESTA 301i, with a paper speed of 25 mm/sec and voltage of 10 mm/sec. The ECG machine was used for the diagnosis of acute MI and was assessed for the frontal QRS-T angle. Heart rate, PR interval, QRS duration, QT interval, corrected QT interval, QRS axis, T wave, and T axis were analysed from each patient’s initial ECG recording.

Patients were followed-up during their in-hospital course for the occurrence of MACE, namely: death, heart failure, complex ventricular arrhythmias (sustained ventricular tachycardia or ventricular fibrillation), early post-infarction angina, or mechanical complications. Heart failure was diagnosed clinically according to the American Heart Association guidelines of 2022 (11). Complex ventricular arrhythmias were monitored using ECG strips or 12-lead ECG recordings. Early post-infarction angina was defined as recurrent typical chest discomfort during hospital admission following relief of the index MI. Mechanical complications, as recorded by echocardiography, included acute mitral regurgitation, rupture of the interventricular septum, left ventricle pseudoaneurysm formation, and rupture of the left ventricle free wall. The relationship between the in-hospital outcome of MACE and the frontal QRS-T angle was studied.

Statistical Analysis

The primary outcome measure was to study the association between the frontal QRS-T angle and MACE between the two groups. The association between the frontal QRS-T angle and non modifiable and modifiable risk factors was also studied. The data obtained were entered into a Microsoft Excel sheet, and statistical analysis was performed using Statistical Packages for Social Sciences (SPSS) version 20.0. Categorical variables were compared using the Chi-square test. The Chi-square test was used to compare categorical variables between the two groups. A p-value of less than 0.05 was considered statistically significant. All statistical tests performed were two-tailed.

Results

Out of the 95 patients, 32 patients (33.7%) were female and 63 patients (66.3%) were male. The most common age group in Group A was 60-70 years, while in Group B it was 50-60 years. Depending on the nature of work, the patients were further classified into four categories: business, service, housewife, and farmer.

The modifiable and non modifiable risk factors were studied (Table/Fig 2). Out of the 95 patients in the study, 49 patients (72.1%) in Group A and 21 patients (77.8%) in Group B were over the age of 50, which was one of the risk factors. Male sex was observed in 46 patients (67.6%) compared to 17 patients (63%) in Group B.

Smoking was observed in 33 patients, of which 24 patients (35.3%) were in Group A and 9 patients (33.3%) were in Group B. Hypertension was observed in 21 patients, with 13 patients (19.1%) in Group A and 8 patients (29.6%) in Group B. Diabetes was observed in six patients, with 4 patients (5.9%) in Group A and 2 patients (7.4%) in Group B. Tobacco chewing was observed in 39 patients, with 27 patients (39.7%) in Group A and 12 patients (44.4%) in Group B. Alcohol consumption was observed in 12 patients in Group A and zero patients in Group B. There was a significant difference in alcohol consumption with a p-value of 0.020.

The Left Ventricular Ejection Fraction (LVEF) was studied using 2D Echo Doppler (Table/Fig 3). In Group A, among 68 cases, LVEF <40% was observed in 21 patients (30.9%), while LVEF >40% was observed in 47 patients (69.1%). In Group B, out of 27 cases, LVEF <40% was observed in 22 patients (81.5%), while LVEF >40% was observed in 5 patients (18.5%).

The relationship between MACE and the frontal QRS-T angle was studied (Table/Fig 4). Heart failure was found in 6 (8.8%) patients in Group A and 21 (77.8%) patients in Group B (p=0.00). Pulmonary oedema was found in 7 (10.3%) patients in Group A compared to 21 (77.8%) patients in Group B (p=0.00). Cardiogenic shock was found in 5 (7.4%) patients in Group A compared to 11 (40.7%) patients in Group B (p=0.00).

Thus, a frontal QRS-T angle >100 degrees was found to be associated with the occurrence of major adverse events in patients with acute MI.

Discussion

The study aimed to investigate the frontal QRS-T angle as an important parameter in assessing the in-hospital outcome of MACE in patients with acute MI. The modifiable and non modifiable risk factors of acute MI were also assessed. A total of 95 patients with acute MI were enrolled in present study. Among these, 68 patients with a frontal QRS-T angle <100 degrees were in Group A, while 27 patients with a frontal QRS-T angle >100 degrees were in Group B. There was a significant difference (p<0.05) in the occurrence of MACE, including heart failure (p=0.00) (Group A=8.8%, Group B=77.8%), pulmonary oedema (p=0.00) (Group A=10.3%, Group B=77.8%), and cardiogenic shock (p=0.00) (Group A=7.4%, Group B=40.7%).

The most common age group in present study was 50-70 years. Similar findings were reported by Sawant AC et al., where the mean age of the enrolled patients ranged from 50 to 70 years (8). Another study by Lown MT et al., included 1843 patients with a mean age of 70.1±13.1 years (12). Our results are consistent with these previous studies, indicating that increasing age is an important non modifiable risk factor for the development of MI (12). Additionally, advanced age can affect the diagnosis, leading to decreased sensitivity and specificity of troponins among patients (13).

In present study, there was a male predominance, with 63 patients (66.3%) being males and 32 patients (33.7%) being females. This finding is similar to the study conducted by Sawant AC et al., in 2019, which included 267 patients and reported that 187 (70%) were male (8). The disparity in gender distribution may be attributed to increased exposure to risk factors such as smoking, drinking, hypertension, and diabetes mellitus among males.

In another study by Zadeh B et al., conducted from February 2015 to March 2017, out of 169 patients, 125 (73.96%) were male and 44 (26.03%) were females (14). This further supports the male predominance in the development of MI. Modifiable risk factors such as smoking and alcohol consumption, which are more common in males compared to females, may contribute to this disparity.

The LVEF is a measure used to assess the systolic function of the heart and is an important predictor of cardiac mortality. It has been observed that patients with a frontal QRS-T angle >100 degrees have a higher incidence of reduced ejection fraction and depressed left ventricular systolic function (14).

In a study conducted by Brezinov OP et al., LVEF was evaluated as an independent factor for predicting the prognosis of Acute Coronary Syndrome (ACS). The study concluded that there is a strong correlation between LVEF and the prognosis of ACS (15). Similarly, a study by Li YH et al., found a negative correlation between the planar QRS-T angle and LVEF in patients with old MI, with a larger planar QRS-T angle indicating a lower LVEF. Their analysis showed that for every 13.8° increase in the planar QRS-T angle, LVEF decreased by 5% when LVEF was less than 50% (16).

The relationship between the frontal QRS-T angle and major adverse cardiac events was also investigated in present study. The results showed that a frontal QRS-T angle >100 degrees was associated with the occurrence of major adverse events in patients with acute MI. These findings are consistent with a study conducted by Sawant AC et al., which identified the frontal QRS-T angle as a strong predictor of mortality in patients with acute MI (8).

In a study by Gotsman I et al., involving 2929 heart failure patients, it was concluded that the frontal QRS-T angle has a strong predictive value for outcomes and is an ominous sign (17).

The MACE remain significant adverse outcomes of MI, as concluded in a study by Poudel I et al., in 2019 (3). The present study also found a positive relationship between an increase in the frontal QRS-T angle and MACE. This could be because the widening of the frontal QRS-T angle is proportional to the amount of potentially recoverable myocardium at risk. Hence, the frontal QRS-T angle can be used to predict treatment outcomes in patients presenting with MI, allowing for heightened vigilance and the development of better immediate and short-term treatment plans.

Limitation(s)

The study was conducted at a single centre, limited to one institute only. Future multicentre studies with larger sample sizes will be beneficial in providing more accurate predictions of MACE using the frontal QRS-T angle in patients with acute MI.

Conclusion

The current study of patients with acute MI revealed an elevated risk of major adverse cardiac outcomes, such as heart failure, pulmonary oedema, and cardiogenic shock, among those with a frontal QRS-T angle >100 degrees on electrocardiograph. Additionally, an increase in the frontal QRS-T angle was associated with a decrease in Left Ventricular Ejection Fraction (LVEF). Therefore, the frontal QRS-T angle can provide insight into anticipating in-hospital MACE in patients with acute MI.

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DOI and Others

DOI: 10.7860/JCDR/2023/65266.18856

Date of Submission: May 06, 2023
Date of Peer Review: Jul 19, 2023
Date of Acceptance: Oct 21, 2023
Date of Publishing: Dec 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 06, 2023
• Manual Googling: Aug 18, 2023
• iThenticate Software: Oct 18, 2023 (12%)

ETYMOLOGY: Author Origin

EMENDATIONS: 6

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