Circulation, Vol 87, 1083-1092, Copyright © 1993 by American Heart Association
DM Mancini, KL Wong and MB Simson
BACKGROUND. An abnormal signal-averaged ECG (SAECG) has predictive value
for arrhythmic events in patients with coronary artery disease. The purpose
of this study was to investigate whether an abnormal SAECG could provide
prognostic information in patients with nonischemic dilated cardiomyopathy.
METHODS AND RESULTS. We prospectively obtained SAECGs in 114 patients with
dilated nonischemic cardiomyopathy. Twelve- lead ECGs, left ventricular
ejection fractions, hemodynamic measurements, and peak exercise oxygen
consumption (VO2) also were measured. An SAECG was defined as abnormal by
any one of the three following criteria: filtered QRS duration > 120
msec, root-mean-square voltage in the last 40 msec < 20 microV, or
duration < 40 microV > 38 msec at 40 Hz. Sixty-six patients had a
normal SAECG, 20 patients had an abnormal SAECG, and 28 patients had bundle
branch block (BBB). Mean follow-up was 10 +/- 5 months. Age, ejection
fraction, peak VO2, pulmonary capillary wedge pressure, and cardiac index
were not statistically different among the three groups. Use of
antiarrhythmic drugs was similar among the three groups, although patients
with BBB had more implantable defibrillators (p < 0.05). The incidence
of previous atrial arrhythmias was similar for the three groups. Patients
with abnormal SAECG or BBB had more past episodes of sustained ventricular
tachycardia and/or sudden death episodes (n = 9) than patients with normal
SAECG (n = 1) (p < 0.01). Prospectively, none of the 66 patients with
normal SAECG died suddenly or had sustained ventricular arrhythmias. Two
deaths occurred from progressive heart failure, and three patients required
urgent transplant. In the 20 patients with an abnormal SAECG, four patients
had sustained ventricular tachycardia, five patients died suddenly, two
patients died from progressive heart failure, and one patient required
urgent transplant. In the patients with BBB, four patients had sustained
ventricular tachycardia, and four patients required urgent transplant.
One-year event-free survival, i.e., absence of ventricular tachycardia
and/or death, was 95% in patients with normal SAECG, 88% in patients with
BBB, and only 39% in patients with an abnormal SAECG (p < 0.001).
Multivariate analysis demonstrated that SAECG and New York Heart
Association classification were independent predictors of survival.
CONCLUSIONS. Patients with an abnormal SAECG had a statistically
significant increase in sustained ventricular arrhythmias and/or death than
did patients with a normal SAECG or BBB. This study demonstrates that an
abnormal SAECG is a marker of past and future arrhythmic events in patients
with nonischemic dilated cardiomyopathy. In contrast, patients with a
dilated cardiomyopathy with a normal SAECG have an excellent prognosis with
adverse outcome only from progressive heart failure.
ARTICLES
Prognostic value of an abnormal signal-averaged electrocardiogram in patients with nonischemic congestive cardiomyopathy
Cardiology Division, Hospital of the University of Pennsylvania, Philadelphia 19104.
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