Diagnostic Value of Slow Conduction Index in Differential Diagnosis of Wide QRS Complex Arrhythmias with Left Bundle Branch Block Morphology

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Abstract

BACKGROUND: Differential diagnosis of arrhythmias with wide QRS complexes remains an unresolved problem in clinical practice. After decades of careful research, many different criteria and algorithms have been proposed, but many of them are not quite accurate and effective in real clinical conditions. One of the approaches is to use ECG to estimate the speed of propagation of excitation through the ventricular myocardium. The estimation is based on the ratio of the amplitudes of the initial and final parts of the QRS complex, in particular, using the slow conduction index.

AIM: To study the possibility of using the slow conduction index in the differential diagnosis of arrhythmias with wide QRS complexes and to carry out a detailed comparative analysis of the diagnostic value of this criterion in all 12 ECG leads with evaluation and comparison of the obtained values of diagnostic accuracy.

MATERIALS AND METHODS: The study included 280 single wide QRS complexes with a form of left bundle branch block (LBBB) detected during one-day and multi-day ECG monitoring in randomly selected 28 patients. For a detailed analysis, a comparison of the original 12-lead ECG and individual scalable ECG graphs for selected leads was carried out, followed by measurement of the absolute values of the total amplitudes during the initial and final 40 ms wide QRS complexes. For a qualitative and quantitative assessment of diagnostic significance, ROC analysis was used to determine the informative value of a diagnostic test based on sensitivity (Sn), specificity (Sp) and diagnostic accuracy (Acc).

RESULTS: According to the obtained values of Sn, Sp and Acc, all 12 leads were arranged in the following order as the diagnostic value of the slow conduction index decreased: aVL, V2, aVF, V5, III, V1, V4, II, aVR, V6, V3 and I. In the first six ECG leads, Acc was consistently above 90%, gradually decreasing in the next six leads from 89% to 67%, respectively (p < 0.001 for all leads).

CONCLUSIONS: The results of this study showed that the slow conduction index can be used in any ECG leads as a criterion for the differential diagnosis of arrhythmias with wide QRS complexes with a form of LBBB. The study also demonstrated the importance of a comprehensive approach to the analysis of the form of the QRS complex and the need for a consistent detailed analysis of the existing criteria for the differential diagnosis of arrhythmias with wide QRS complexes in different clinical groups of patients.

About the authors

Mikhail P. Chmelevsky

Almazov National Medical Research Centre

Author for correspondence.
Email: boxmch@gmail.com
ORCID iD: 0000-0002-8985-4437
SPIN-code: 6445-1447

Senior Scientific Researcher

Russian Federation, Saint Petersburg

Margarita A. Budanova

Almazov National Medical Research Centre

Email: budanovamargarita@gmail.com
ORCID iD: 0000-0002-7189-8773
SPIN-code: 1890-7821

Scientific Researcher

Russian Federation, Saint Petersburg

Danila A. Stepanov

Almazov National Medical Research Centre

Email: daniel36611b@gmail.com
ORCID iD: 0000-0001-7032-8800
SPIN-code: 9013-5135

Junior Scientific Researcher

Russian Federation, Saint Petersburg

Ekaterina S. Zhabina

Almazov National Medical Research Centre

Email: zhabina-ekaterina@mail.ru
ORCID iD: 0000-0002-9001-8743
SPIN-code: 5964-5382

PhD, Scientific Researcher

Russian Federation, Saint Petersburg

Tatiana E. Tulintseva

Almazov National Medical Research Centre

Email: tulinta@mail.ru
ORCID iD: 0000-0001-6843-302X
SPIN-code: 6076-0246

PhD, Senior Scientific Researcher

Russian Federation, Saint Petersburg

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Supplementary files

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2. Fig. 1. Histogram of slow conduction index Sensitivity (Sn), Specificity (Sp) and diagnostic Accuracy (Acc) for 12 lead ECG

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3. Fig. 2. ROC curves comparison charts as an illustration of slow conduction index diagnostic value difference for 12 lead ECG. Cut-off values are marked as red marker on each of ROC curves

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4. Fig. 3. Diagram of AUC difference between ROC curves (right upper triangle) and corresponding p-value (left bottom triangle) illustrating a difference of slow conduction index diagnostic value in 12 lead ECG. Leads are sorted towards a decrease of their diagnostic value from up to down (left column) and from left to the right (upper row) according to the calculated absolute value. A color palette of diagram shows changing of AUC difference absolute values from min (green) to max (red) and p-values from max (green) to min (red). AUC difference with corresponding p < 0.001 are marked with red font on white background

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5. Fig. 4. ECG example of supraventricular extrasystoles with LBBB aberration. Borders of all QRS complex are marked with small red vertical lines. Borders of selected for analysis wide QRS complex are marked with solid red vertical lines in all 12 ECG leads. Leads with correct results (Vi / Vt > 1) of slow conduction index calculations in differential diagnosis are marked with green color while leads with wrong results (Vi / Vt < 1) for this case are marked with red color

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6. Fig. 5. ECG plot in aVL lead and determination of an absolute values of initial (Vi) and terminal (Vt) 40 ms of wide QRS complex for the case of supraventricular extrasystoles with LBBB aberration where calculation of slow conduction index (Vi / Vt) shows wrong results (Vi / Vt < 1) in differential diagnosis. Voltage (µV) — ECG amplitude (microVolts), time in ms

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7. Fig. 6. ECG example of ventricular extrasystoles with LBBB type morphology. Borders of all QRS complex are marked with small red vertical lines. Borders of selected for analysis wide QRS complex are marked with solid red vertical lines in all 12 ECG leads. Leads with correct results (Vi / Vt < 1) of slow conduction index calculations in differential diagnosis are marked with green color while leads with wrong results (Vi / Vt> 1) for this case are marked with red color

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8. Fig. 7. ECG plot in aVR lead and determination of an absolute values of initial (Vi) and terminal (Vt) 40 ms of wide QRS complex for the case of ventricular extrasystoles with LBBB type morphology where calculation of slow conduction index (Vi / Vt) shows wrong results (Vi / Vt > 1) in differential diagnosis. Voltage (µV) — ECG amplitude (microVolts), time in ms

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