Differential Diagnostics of Wide QRS Complex Arrhythmias with Left Bundle Branch Block Morphology Using Slow Conduction Index

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Abstract

Differential diagnosis of wide QRS complex arrhythmias is one of the most challenging tasks in routine practice arrhythmology. The analysis of the wide QRS complex morphology has been introduced due to the complex problem of detecting atrial waves on ECG. A slow conduction index based on the ratio of the initial and terminal QRS amplitudes is one of the solutions to evaluate conduction velocity based on the surface ECG due to a significant variability of QRS morphology and real complexity of its detailed assessment. However, one of the significant limitations of this algorithm is a need to search for the RS wide complex type and randomly select an ECG lead with this morphology which can finally create a contradictory result.

AIM: To evaluate a possibility of using the slow conduction index for differential diagnosis of wide QRS complex arrhythmias with left bundle branch (LBBB) morphology in any of 12-leads ECG followed by evaluation of the obtained diagnostic accuracy values.

MATERIALS AND METHODS: The study included 280 single premature wide QRS complexes with LBBB morphology recorded during holter ECG monitoring in randomly selected 28 patients. Atrial extrasystoles were recorded in 14 patients and ventricular extrasystoles were captured during sinus rhythm in other 14 patients. A ROC analysis was used for the qualitative and quantitative assessment of a slow conduction index diagnostic values based on sensitivity (Sn), specificity (Sp) and accuracy (Acc).

RESULTS: The highest values of Sn and Sp were obtained for a slow conduction index in the leads aVL, V2, aVF, V5 and III, and the lowest — for the leads I, V3 and V6 based on the calculated area (AUC) under the ROC curves (p < 0.001 for all leads).

CONCLUSION: The study presented the fundamental possibility of using a slow conduction index in any of 12-lead ECG for the differential diagnosis of wide QRS complex arrhythmias with LBBB morphology.

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
Scopus Author ID: 56318896700
ResearcherId: M-4796-2015

senior scientific researcher, Scientific Research Laboratory of Electrocardiology

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
Scopus Author ID: 57192640888
ResearcherId: AAG-6964-2021

PhD, senior scientific researcher, Scientific Research Laboratory of Electrocardiology

Russian Federation, Saint-Petersburg

Tatiana V. Treshkur

Almazov National Medical Research Centre

Email: meinetvt@mail.ru
ORCID iD: 0000-0002-7976-5588
SPIN-code: 4029-8204
Scopus Author ID: 6602364495
ResearcherId: AAD-5675-2022

PhD, Head of Scientific Research Laboratory of Electrocardiology

Russian Federation, Saint-Petersburg

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Supplementary files

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2. Fig. 1. A method of determining the amplitudes during the initial (Vi = X mV) and terminal (Vt = Y mV) 40 ms of QRS complex and slow conduction index calculation (Vi / Vt = X / Y).

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3. Fig. 2. ECG example of supraventricular extrasystoles with LBBB aberration

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4. Fig. 3. ECG example of ventricular extrasystoles with LBBB type morphology

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5. Fig. 4. An example of slow conduction index calculation (Vi /Vt). Voltage (µV) — ECG amplitude (microVolts), time in ms

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6. Fig. 5. ROC curves with 95% CI (light blue color) as an illustration of diagnostic value of slow conduction index in 12 lead ECG. Cut-off values are marked as red round marker on each of ROC curves. Area under curve (AUC) with p-value are shown at the right bottom corner of each graph

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7. Fig. 6. Line plot of slow conduction index Accuracy (Acc) with 95% CI in all 12 leads. LB-UB – lower bound-upper bound of 95% CI.

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