Electrical risk score beyond the left ventricular ejection fraction: Prediction of sudden cardiac death in the Oregon Sudden Unexpected Death Study and the Atherosclerosis Risk in Communities Study

Aapo L. Aro, Kyndaron Reinier, Carmen Rusinaru, Audrey Uy-Evanado, Navid Darouian, Derek Phan, Wendy J. Mack, Jonathan Jui, Elsayed Z. Soliman, Larisa Tereshchenko, Sumeet S. Chugh

Research output: Contribution to journalArticle

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Abstract

Aims There is an urgent need to extend sudden cardiac death (SCD) risk stratification beyond the left ventricular ejection fraction (LVEF). We evaluated whether a cumulative electrocardiogram (ECG) risk score would improve identification of individuals at high risk of SCD. Methods and results In the community-based Oregon Sudden Unexpected Death Study (catchment population 1/41 million), 522 SCD cases with archived 12-lead ECG available (65.3 ± 14.5 years, 66% male) were compared with 736 geographical controls to assess the incremental value of multiple ECG parameters in SCD prediction. Heart rate, LV hypertrophy, QRS transition zone, QRS-T angle, QTc, and Tpeak-to-Tend interval remained significant in the final model, which was externally validated in the Atherosclerosis Risk in Communities (ARIC) Study. Sixteen percent of cases and 3% of controls had ≥4 abnormal ECG markers. After adjusting for clinical factors and LVEF, increasing ECG risk score was associated with progressively greater odds of SCD. Overall, subjects with ≥4 ECG abnormalities had an odds ratio (OR) of 21.2 for SCD [95% confidence interval (CI) 9.4-47.7; P < 0.001]. In the LVEF >35% subgroup, the OR was 26.1 (95% CI 9.9-68.5; P < 0.001). The ECG risk score increased the C-statistic from 0.625 to 0.753 (P < 0.001), with net reclassification improvement of 0.319 (P < 0.001). In the ARIC cohort validation, risk of SCD associated with ≥4 ECG abnormalities remained significant after multivariable adjustment (hazard ratio 4.84; 95% CI 2.34-9.99; P < 0.001; C-statistic improvement 0.759-0.774; P = 0.019). Conclusion This novel cumulative ECG risk score was independently associated with SCD and was particularly effective for LVEF >35% where risk stratification is currently unavailable. These findings warrant further evaluation in prospective clinical investigations.

Original languageEnglish (US)
Pages (from-to)3017-3025
Number of pages9
JournalEuropean Heart Journal
Volume38
Issue number40
DOIs
StatePublished - Oct 21 2017

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Sudden Cardiac Death
Sudden Death
Stroke Volume
Atherosclerosis
Electrocardiography
Odds Ratio
Confidence Intervals
Hypertrophy
Heart Rate
Population

Keywords

  • Death
  • Electrocardiography
  • Left ventricular ejection fraction
  • Prevention
  • Risk stratification
  • Sudden cardiac

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Electrical risk score beyond the left ventricular ejection fraction : Prediction of sudden cardiac death in the Oregon Sudden Unexpected Death Study and the Atherosclerosis Risk in Communities Study. / Aro, Aapo L.; Reinier, Kyndaron; Rusinaru, Carmen; Uy-Evanado, Audrey; Darouian, Navid; Phan, Derek; Mack, Wendy J.; Jui, Jonathan; Soliman, Elsayed Z.; Tereshchenko, Larisa; Chugh, Sumeet S.

In: European Heart Journal, Vol. 38, No. 40, 21.10.2017, p. 3017-3025.

Research output: Contribution to journalArticle

Aro, Aapo L. ; Reinier, Kyndaron ; Rusinaru, Carmen ; Uy-Evanado, Audrey ; Darouian, Navid ; Phan, Derek ; Mack, Wendy J. ; Jui, Jonathan ; Soliman, Elsayed Z. ; Tereshchenko, Larisa ; Chugh, Sumeet S. / Electrical risk score beyond the left ventricular ejection fraction : Prediction of sudden cardiac death in the Oregon Sudden Unexpected Death Study and the Atherosclerosis Risk in Communities Study. In: European Heart Journal. 2017 ; Vol. 38, No. 40. pp. 3017-3025.
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abstract = "Aims There is an urgent need to extend sudden cardiac death (SCD) risk stratification beyond the left ventricular ejection fraction (LVEF). We evaluated whether a cumulative electrocardiogram (ECG) risk score would improve identification of individuals at high risk of SCD. Methods and results In the community-based Oregon Sudden Unexpected Death Study (catchment population 1/41 million), 522 SCD cases with archived 12-lead ECG available (65.3 ± 14.5 years, 66{\%} male) were compared with 736 geographical controls to assess the incremental value of multiple ECG parameters in SCD prediction. Heart rate, LV hypertrophy, QRS transition zone, QRS-T angle, QTc, and Tpeak-to-Tend interval remained significant in the final model, which was externally validated in the Atherosclerosis Risk in Communities (ARIC) Study. Sixteen percent of cases and 3{\%} of controls had ≥4 abnormal ECG markers. After adjusting for clinical factors and LVEF, increasing ECG risk score was associated with progressively greater odds of SCD. Overall, subjects with ≥4 ECG abnormalities had an odds ratio (OR) of 21.2 for SCD [95{\%} confidence interval (CI) 9.4-47.7; P < 0.001]. In the LVEF >35{\%} subgroup, the OR was 26.1 (95{\%} CI 9.9-68.5; P < 0.001). The ECG risk score increased the C-statistic from 0.625 to 0.753 (P < 0.001), with net reclassification improvement of 0.319 (P < 0.001). In the ARIC cohort validation, risk of SCD associated with ≥4 ECG abnormalities remained significant after multivariable adjustment (hazard ratio 4.84; 95{\%} CI 2.34-9.99; P < 0.001; C-statistic improvement 0.759-0.774; P = 0.019). Conclusion This novel cumulative ECG risk score was independently associated with SCD and was particularly effective for LVEF >35{\%} where risk stratification is currently unavailable. These findings warrant further evaluation in prospective clinical investigations.",
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T2 - Prediction of sudden cardiac death in the Oregon Sudden Unexpected Death Study and the Atherosclerosis Risk in Communities Study

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AU - Reinier, Kyndaron

AU - Rusinaru, Carmen

AU - Uy-Evanado, Audrey

AU - Darouian, Navid

AU - Phan, Derek

AU - Mack, Wendy J.

AU - Jui, Jonathan

AU - Soliman, Elsayed Z.

AU - Tereshchenko, Larisa

AU - Chugh, Sumeet S.

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N2 - Aims There is an urgent need to extend sudden cardiac death (SCD) risk stratification beyond the left ventricular ejection fraction (LVEF). We evaluated whether a cumulative electrocardiogram (ECG) risk score would improve identification of individuals at high risk of SCD. Methods and results In the community-based Oregon Sudden Unexpected Death Study (catchment population 1/41 million), 522 SCD cases with archived 12-lead ECG available (65.3 ± 14.5 years, 66% male) were compared with 736 geographical controls to assess the incremental value of multiple ECG parameters in SCD prediction. Heart rate, LV hypertrophy, QRS transition zone, QRS-T angle, QTc, and Tpeak-to-Tend interval remained significant in the final model, which was externally validated in the Atherosclerosis Risk in Communities (ARIC) Study. Sixteen percent of cases and 3% of controls had ≥4 abnormal ECG markers. After adjusting for clinical factors and LVEF, increasing ECG risk score was associated with progressively greater odds of SCD. Overall, subjects with ≥4 ECG abnormalities had an odds ratio (OR) of 21.2 for SCD [95% confidence interval (CI) 9.4-47.7; P < 0.001]. In the LVEF >35% subgroup, the OR was 26.1 (95% CI 9.9-68.5; P < 0.001). The ECG risk score increased the C-statistic from 0.625 to 0.753 (P < 0.001), with net reclassification improvement of 0.319 (P < 0.001). In the ARIC cohort validation, risk of SCD associated with ≥4 ECG abnormalities remained significant after multivariable adjustment (hazard ratio 4.84; 95% CI 2.34-9.99; P < 0.001; C-statistic improvement 0.759-0.774; P = 0.019). Conclusion This novel cumulative ECG risk score was independently associated with SCD and was particularly effective for LVEF >35% where risk stratification is currently unavailable. These findings warrant further evaluation in prospective clinical investigations.

AB - Aims There is an urgent need to extend sudden cardiac death (SCD) risk stratification beyond the left ventricular ejection fraction (LVEF). We evaluated whether a cumulative electrocardiogram (ECG) risk score would improve identification of individuals at high risk of SCD. Methods and results In the community-based Oregon Sudden Unexpected Death Study (catchment population 1/41 million), 522 SCD cases with archived 12-lead ECG available (65.3 ± 14.5 years, 66% male) were compared with 736 geographical controls to assess the incremental value of multiple ECG parameters in SCD prediction. Heart rate, LV hypertrophy, QRS transition zone, QRS-T angle, QTc, and Tpeak-to-Tend interval remained significant in the final model, which was externally validated in the Atherosclerosis Risk in Communities (ARIC) Study. Sixteen percent of cases and 3% of controls had ≥4 abnormal ECG markers. After adjusting for clinical factors and LVEF, increasing ECG risk score was associated with progressively greater odds of SCD. Overall, subjects with ≥4 ECG abnormalities had an odds ratio (OR) of 21.2 for SCD [95% confidence interval (CI) 9.4-47.7; P < 0.001]. In the LVEF >35% subgroup, the OR was 26.1 (95% CI 9.9-68.5; P < 0.001). The ECG risk score increased the C-statistic from 0.625 to 0.753 (P < 0.001), with net reclassification improvement of 0.319 (P < 0.001). In the ARIC cohort validation, risk of SCD associated with ≥4 ECG abnormalities remained significant after multivariable adjustment (hazard ratio 4.84; 95% CI 2.34-9.99; P < 0.001; C-statistic improvement 0.759-0.774; P = 0.019). Conclusion This novel cumulative ECG risk score was independently associated with SCD and was particularly effective for LVEF >35% where risk stratification is currently unavailable. These findings warrant further evaluation in prospective clinical investigations.

KW - Death

KW - Electrocardiography

KW - Left ventricular ejection fraction

KW - Prevention

KW - Risk stratification

KW - Sudden cardiac

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