Cardiac disease (CVD) has become the world's top cause of death in the last ten years. Recently, many high-income countries have seen a scary and fast rise in cardiovascular disease. Now, the same is happening in low- and middle-income countries [1]. According to the World Health Organization (WHO), nine million people will have died from ischemic heart disease (IHD) by 2030, up from seven million in 2012 [2]. Cardiovascular disease spread like wildfire as more people lived longer and weren't killed by common diseases or poor diet. Asthmatic coronary syndrome (ACS) includes unstable angina, non–ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction as clinical signs and symptoms of cardiac ischemia. Acute coronary syndromes (ACS) without ST-segment elevation include unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI).Acute myocardial infarction (AMI) is identified by changes in cardiac biomarker levels (most preferably cardiac troponin) that are higher than the upper reference limit of the 99th percentile and are accompanied by one of the following: signs of ischemia, new ST-segment and/or T-wave changes, or imaging evidence of a new regional wall motion abnormality[3]. Although UA and NSTEMI are clinically identical, UA can be told apart from NSTEMI because cardiac biomarkers do not rise in two or more tests taken at least six hours apart[4].Atrial myocardial necrosis (AMI) happens quickly when blood flow stops completely and stays off of a part of the heart for a long time.[5]. When a big coronary artery (usually damaged by atherosclerosis) clots and blocks blood flow, causing transmural ischemia, an ST-segment elevation myocardial infarction (STEMI) happens. Additionally, blood cardiac biomarkers are released, and the ECG shows ST increase (and probably a Q wave)[6]. According to the definition, fragmented QRS means that there is an extra R wave (R′) or that the R or S wave is notched in two consecutive leads that relate to a major coronary artery and the QRS length is less than 120 milliseconds. No. 9 Finding fQRS on an ECG usually matches up well with finding myocardial scars on cardiac magnetic resonance imaging (cMRI). For people who have had a STEMI, fQRS shows the size of the infarct and the sudden reshaping of the ventricles. Finding fQRS is linked to a bigger infarct and peri-infarct zone, problems with cardiac perfusion, bigger heart masses on the left side of the heart, and a smaller left ventricular ejection fraction (LVEF) [7]. A higher percentage of people with fQRS have bad peripheral circulation or a myocardial scar when they have a chronic total blockage. Due to regional conduction slowing or block, scar tissue and ischemic areas in the heart cause non-homogenous activation, which can lead to ECG readings that are thought to be fQRS[8]. Because of scarring, fibrosis, inflammation, or ischemia, FQRS shows a limited slowing of conduction in the ventricular myocardium.In some cases, the abnormal processes that cause fQRS can be undone. For example, fQRS may go away from an ECG during a heart retraining program after a STEMI and in people with high blood pressure[9]. Tests that are invasive and benign for figuring out the risk of rapid cardiac death have been looked at. These tests have mostly been used to look at structural heart diseases like coronary artery disease (CAD), cardiomyopathy, and heart failure[10]. An irregular depolarization is indicated by the appearance of the fQRS on a normal 12-lead ECG. Heart failure and death rates are higher in people with fQRS [11]. As well as CAD, fQRS can also happen in other heart diseases affecting the myocardium, like cardiomyopathy and fetal heart disease. Additionally, fQRS has been identified as a sign of arrhythmogenic right ventricular dysplasia/cardiomyopathy and Brugada syndrome. We need to learn more about how useful fQRS is for figuring out who is most likely to die suddenly from a heart problem, especially in cases of non-ischemic cardiomyopathy and heart failure[12]. The aim of the study was to assess the clinical significance and prognostic value of fQRS for patients who are presenting with acute ST elevation myocardial infarction.

Study Design and Setting

This prospective study included seventy patients (48 males and 22 females) with a mean age of 54.9 ± 9 years. The study was conducted in the Coronary Care Unit (CCU) at Azadi Teaching Hospital (ATH) in Kirkuk from 15^th of May  to 15^th December , 2018.

Inclusion and Exclusion Criteria

Patients included in the study were those with acute ST elevation myocardial infarction (STEMI) who were admitted to the CCU and had electrocardiograms (ECGs) showing fragmented QRS (fQRS). Exclusion criteria were as follows: duration of symptoms exceeding 7 days, non-ST elevation myocardial infarction (NSTEMI), left ventricular hypertrophy, left bundle branch block, right bundle branch block, ventricular rhythm disturbances, pacemaker implantation, severe valvular heart disease, and congenital heart disease.

Sampling

A convenient sample of 70 acute STEMI patients with fQRS who were admitted to the CCU of Azadi Teaching Hospital was enrolled in the study after fulfilling the inclusion and exclusion criteria.

Data Collection

Data were collected through direct patient interviews using a prepared questionnaire. The questionnaire was originally in English and translated into the local languages for the patients' understanding. The collected data included demographic characteristics (age and gender), clinical presentations (symptoms and duration), and risk factors such as diabetes mellitus (DM), hypertension (HT), family history of ischemic heart disease (IHD), smoking status, and waist circumference-related obesity (measured by a tape measure). Additionally, the data covered the presence or absence of a previous history of IHD, vital signs (pulse rate and blood pressure measured using a mercury sphygmomanometer), ECG findings, echocardiography findings, troponin test results, and in-hospital complications (hemodynamic and electrical instability, Killip's class, hypotension, and arrhythmias).The diagnosis of acute STEMI was based on clinical presentations, ECG, and troponin test results. ECGs were conducted by well-trained medical staff using a FAZZINI 12-channel electrocardiogram at a speed of 25 mm/s and an amplitude of 10 mm/mV. All patients had ≥1 mm ST-segment elevation in ≥2 contiguous limb leads and/or ST-segment elevation of ≥2 mm in ≥2 contiguous precordial leads, with the presence of  additional R waves or notching in R or S waves in the QRS complex (<120 ms) in at least two contiguous leads related to a major coronary artery territory. Cardiac enzyme tests were conducted at Azadi Teaching Hospital using the Biozec Medical 1-step rapid test. Echocardiography was performed by a cardiologist using a Philips TX50 color Doppler echocardiogram (with a 2.5 MHz “phased-array” transducer), and left ventricular ejection fraction (LV EF) was determined using Simpson's method while patients were in the left lateral position at rest.

Follow-Up and Treatment

After the diagnosis of acute STEMI with fQRS, patients received full medical therapy and were followed up in the CCU for an average of 3 days. Percutaneous coronary intervention (PCI) was not available in the hospital.

Ethical Considerations

The study was approved by the Internal Medicine Scientific Committee of the Iraqi Board. An agreement for the research was obtained from Azadi Hospital authorities, and oral informed consent was obtained from each patient.

Statistical Analysis

All patients' data were entered into computerized statistical software, and the Statistical Package for Social Sciences (SPSS) version 20 was used for analysis. In all statistical analyses, the level of significance (p-value) was set at ≤ 0.05, and results were presented in tables and/or graphs. The statistical analysis of the study was conducted by a community medicine specialist.

This study included seventy patients presented to ATH with MI and ECG features showed fQRS with mean age of 54.9±9 years; those less than 50 years age represented 22.9% , age group 50-59 years were 41.4% , age group 60-69 years were 25.7% and age group ≥70 years were 10% . In our study, 68.6% were male & 31.4% were female. All these findings are shown in table 1.

Table 1: Demographic characteristics of our patients with fQRS MI.

All of the patients were presented with chest pain (100%), 38.6% of them were also presented with shortness of breath and 12.8% were presented with palpitation . The mean prehospital symptoms duration of our patients was 1.3± 0.38 days; 65.7% of them had symptoms duration equal or less than 1day, while 34.3% of them had symptoms duration of more than 1 day. All these findings are shown in table 2.

Table 2: Clinical presentations of our patients.

The common risk factors for our patients were family history of IHD (54.3%), smoking (50%),DM(48.6%),HT(47.1%),Waist circumference related obesity (5.7%). All these findings are shown in table 3

Table 3: Risk factors of our MI patients with fQRS.

 On arrival to CCU, mean blood pressure of our patients was 128.2/79.5±29.3/15.9 mmHg; 11.4% of them had low blood pressure, 74.3% of them had normal blood pressure and 14.3% of them had high blood pressure. Mean pulse rate was 86.8±22.2 b/m; 4.3% of them had bradycardia , 75.7% of them had normal pulse rate and 20% of them had tachycardia . All these findings are shown in table 4.

Table 4:Pulse and blood pressure of our patients On arrival to CCU

 The ischemic territory (by ECG) of our patients was anteriolateral (37.14%), inferior (32.85%), inferiolateral (22.85) and lateral (7.14%). The troponin test was positive in 78.6% of MI patients with fQRS .All these findings are shown in table 5.

Table 5: Ischemic territory (ECG) & troponin test of our MI patients

The Killips' class of our patients was distributed as followings; 70% class I, 21.42% class II, 2.857% class III and 5.71% class IV. The arrhythmia was detected among 34.3% of MI patients with fQRS and hypotension was present among 20% of them. Mean ejection fraction of MI patients with fQRS was 47.5±7.6 %; 77.1% of them had low ejection fraction. 11.4% of our patients were died. All these findings are shown in table 6 . 

Table 6: Outcome of our patients during hospitalization

There was a highly significant association between older age MI patients with fQRS and low ejection fraction (p<0.001). A highly significant association was observed between male MI patients with fQRS and low ejection fraction (p<0.001). All these findings are shown in table 7 

Table 7:Distribution of demographic characteristics according to EF.

There was a significant association between MI patients with low EF and long prehospital symptoms duration. This finding is shown in table 8.

Table 8: Distribution of prehospital symptoms duration according to ejection fraction.

There was a highly significant association between DM and low EF of our patients (p<0.001). There was also significant association between HT and low EF (p=0.01), and significant association between previous IHD and low EF (p=0.01). But no significant differences were observed between our patients with low EF and those with normal EF regarding family history of IHD, smoking and waist circumference related obesity. All these findings are shown in table 9.

Table 9: Distribution of previous IHD and risk factors of IHD according to ejection fraction.

A significant association was observed between low EF and our patients whose ECGs showed anteriolateral fQRS MI (p=0.004). A low EF was significantly associated with development of hypotension during hospitalization (p=0.02). No significant differences in ejection fraction of our patients regarding arrhythmia and elevated troponin test. There was a significant association between advanced Killips classes and low EF of our patients (p=0.03).. All these findings are shown in table 10.

Table 10: Distribution of ECG findings , tropnin and outcome according to ejection fraction.

We conducted a research to examine the initial predictive value of the presence of fragmented QRS complexes (fQRS) on electrocardiograms (ECGs) in patients with acute ST-segment elevation myocardial infarction (STEMI). Accurately predicting the risk and prognosis of acute myocardial infarction (MI) is crucial for effectively planning the treatment and follow-up care of patients. The fQRS, or fragmented QRS, is a measurable electrocardiographic indicator that is utilized in the prognosis of patients with acute myocardial infarction, as well as in predicting mortality [13]. The average age of patients with acute ST-elevation myocardial infarction (STEMI) with fragmented QRS complexes (fQRS) in this research was 54.9 years, with a higher prevalence in the 50-59 age range. The mean age in this study is lower than the findings of the Akgul et al study, which reported a mean age of 60 years for acute STEMI patients with fQRS [14]. This discrepancy might perhaps be attributed to the prevalence of common risk factors for fQRS STEMI in the younger population of our nation. There was a higher prevalence of fQRS STEMI in male patients compared to females. This finding aligns with the results of the study conducted by Athar et al, which indicated that males had a twofold higher probability of experiencing fragmented STEMI compared to girls [15]. Our study revealed that 34.4% of patients diagnosed with acute ST-elevation myocardial infarction (STEMI) and presenting with fragmented QRS complexes (fQRS) had the development of arrhythmia while being hospitalized. This conclusion is consistent with the results of the Wang research, which demonstrated that fQRS accurately predicted the occurrence of arrhythmia in about 33% of patients with acute myocardial infarction [16].  During hospitalization, hypotension occurred in 20% of our patients, which contrasts with the findings of Abdulmateen et al.'s study. Their study showed that 77% of patients experienced hypotension. This difference may be attributed to the absence of control patients and the small sample size in our study [17]. The present investigation revealed that 77.1% of our patients exhibited a reduced left ventricular ejection fraction (EF). This conclusion aligns with the results of the research conducted by Kothi et al, which indicated that the average ejection fraction (EF) of patients with acute myocardial infarction (MI) and fragmented QRS (fQRS) was considerably lower compared to the average EF of patients with acute MI but without fQRS [18]. Our study also found that the mortality rate among acute STEMI patients with fQRS was 11.4%. The mortality rate in this study is similar to the findings of the Liang et al study. They observed that out of 87 patients with acute MI and fQRS, 9 (10.3%) patients died during the follow-up period. In contrast, among 153 patients with acute MI but without fQRS, only 3 (1.9%) patients died during the follow-up period [19]. Rosengarten et al conducted a meta-analysis research which found a substantial correlation between fragmented QRS (fQRS) in patients with acute myocardial infarction (MI) and both all-cause mortality and sudden cardiac arrest. The mortality risks associated with fragmented QRS (fQRS) in patients with acute myocardial infarction (MI) are elevated in individuals with a low left ventricular ejection fraction (EF) of 23%. The current investigation found a strong and statistically significant relationship between older age acute STEMI patients with fragmented QRS complexes (fQRS) and poor ejection fraction (EF) (p<0.001). This data aligns with the results of the study conducted by Torigoe et al., which indicated that older age, acute myocardial infarction patients with fragmented QRS complexes and poor ejection fraction are commonly associated with increased risk of mortality and hospitalization [20].Our study also shown a strong and statistically significant correlation between male patients who experienced myocardial infarction (MI) and had fragmented QRS (fQRS) patterns, as well as a poor ejection fraction (EF) (p<0.001). Similarly, the study conducted by Bekler et al. found that being male is a risk factor for acute myocardial infarction (MI) with fragmented QRS (fQRS) and poor ejection fraction (EF) [21]. The results of our study showed a strong association between patients with acute ST-elevation myocardial infarction (STEMI) and fragmented QRS (fQRS) patterns, who also had a poor ejection fraction (EF), and a prolonged duration of symptoms before arriving at the hospital. This discovery aligns with the findings of the study conducted by Dagres and Hindricks, which indicated that a delay in patients seeking medical attention at the emergency hospital after experiencing symptoms of acute myocardial infarction (MI) increases the likelihood of having a poor ejection fraction (EF) [22]. The risk variables that showed a significant association with fragmented QRS (fQRS) and poor ejection fraction (EF) were diabetes mellitus (DM) (p<0.001), hypertension (HT) (p=0.01), and a prior history of ischemic heart disease (IHD) (p=0.01). The aforementioned findings align with the results of the study conducted by Yildirm et al., which shown an elevated risk of reduced ejection fraction (EF) in patients with ST-elevation myocardial infarction (STEMI) and fragmented QRS (fQRS) who also had comorbidities such as diabetes mellitus (DM), hypertension (HT), and ischemic heart disease (IHD) [13]. In this investigation, we found a strong correlation between advanced Killips classes and poor ejection fraction (EF) in myocardial infarction (MI) patients with fragmented QRS (fQRS) patterns (p=0.03).  The study conducted by Li et al. discovered a strong association between fQRS and the progression of Killips classes. This progression was identified as a predictor of a high risk of reduced EF and heart failure [23]. Our study found a significant association between fQRS acute STEMI patients with anterolateral area on ECG and poor EF (p=0.004). This finding is consistent with the results of the study conducted by Das et al, which identified fQRS as a predictor for unfavorable cardiac outcomes, including heart failure and death, in patients with anterolateral acute MI [24]. Our study demonstrated a notable correlation between reduced ejection fraction (EF) and acute ST-elevation myocardial infarction (STEMI) patients who had hypotension while hospitalized and had fragmented QRS complexes (fQRS) (p=0.02). The study conducted by Meredith et al. concluded that hypotension is considered a negative prognostic factor for heart failure, particularly when it is accompanied by low ejection fraction (EF) and fragmented QRS (fQRS) (29).

Fragmented QRS in acute ST elevation myocardial infarction (STEMI) is a predictor of adverse cardiac outcomes and increased mortality. There is a high prevalence of low ejection fraction among STEMI patients with fragmented QRS. Common cardiac complications in these patients include heart failure, arrhythmia, and hypotension. Risk factors for low ejection fraction in STEMI patients with fragmented QRS include older age, male gender, prolonged duration of pre-hospital symptoms, diabetes, hypertension, and a previous history of ischemic heart disease.

Fragmented QRS should be adopted as a common electrocardiographic marker for predicting adverse cardiac outcomes and mortality in STEMI patients. It is important to consider risk factors associated with acute STEMI and fQRS. National multi-center controlled studies should be conducted to further evaluate fQRS for the prognosis of cardiac complications.

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the Azadi Teaching Hospital

1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2095–2128
2. The Global Burden of Disease: 2013 update. http://ghdx.healthdata.org/gbd-data-tool; 2016.
3. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statisticsÑ2012 update:a report from the American Heart Association. Circulation. 2012; 125(1):e2-e220
4. Anderson JL, Adams CD, Antman EM, et al. 2012 ACCF/AHA focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non- ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(23):e663-e828.
5. PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012; 33(20):2569-2619
6. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for themanagement of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am CollCardiol. 2014;64(24): e139-e228. doi:10.1016/j.jacc.2014.09.017
7. Kligfield P, Gettes L, Bailey JJ, et al. Recommendations for the standardization and interpretation of the electrocardiogram. Part I. The electrocardiogram and its standardization. JAmCollCardiol 2007; 49:1109.
8. Lorgis L., Cochet A., Chevallier O., Angue M., Gudjoncik A., Lalande A., et al. . (2014). Relationship between fragmented QRS and no-reflow, infarct size, and peri-infarct zone assessed using cardiac magnetic resonance in patients with myocardial infarction. Can. J. Cardiol. 30, 2. 10.1016/j.cjca.2013.11.026
9. Das, M.K., Khan, , et al . Significance of a fragmented QRS complex versus  a  Q  wave  in  patients  with  coronary  artery disease. Circulation. 2006; 113: 2495–2501.
10. Das MK, Maskoun W, Shen C, Michael MA, Suradi H, Desai M, et al. Fragmented QRS on twelve-lead electrocardiogram predicts arrhythmic events in patients with ischemic and nonischemic cardiomyopathy. Heart Rhythm 2010;7:74-80.Sha J, Zhang S, Tang M, Chen K, Zhao X, Wang F. Fragmented QRS is associated with all- cause mortality and ventricular arrhythmias in patient with idiopathic dilated cardiomyopathy. Ann Noninvasive Electrocardiol 2011;16:270-5.
11. Temiz A, Gazi E, Güngör O, Altun B, Barutcu A, Bekler A, et al. Fragmented QRS and prediction of paroxysmal atrial fibrillation episodes. Pak J Med Sci 2014;30:862-7
12. Yilmaz H, Gungor B, Kemaloglu T, Sayar N, Erer B, Yilmaz M, et al. The presence of fragmented QRS on 12-lead ECG in patients with coronary slow flow. Kardiol Pol 2014;72:14-9.
13. Yıldırım E, Karaçimen D, Ozcan KS, et al. The relationship between fragmentation on electrocardiography and in-hospital prognosis of patients with acute myocardial infarction. Med Sci Monit 2014; 20:913-919.
14. Akgul O, Uyarel H, Pusuroglu H, et al. Predictive value of a fragmented QRS complex in patients undergoing primary angioplasty for ST elevation myocardial infarction. Ann Noninvasive Electrocardiol 2015; 20(3):263-272.
15. Athar AM, Kothi ZS, Patil BS, , et al. Fragmented QRS – A simple bedside non invasive predictor of early mortality and morbidity in STEMI. J Med Sci 2016; 9(4):253-257.
16. Wang CL. Usefulness of Fragmented QRS Complex for Diagnosis and Outcome Prediction in Patients with Coronary Artery Disease. Acta Cardiol Sin 2017; 33(6):596-597
17. Abdul Mateen Athar, Zuber Suleman Kothi, Basanagouda S. Patil, et al. fragmented QRS- A simple bedside non invasive predictor of early mortality and morbidity in STEMI. Al Ameen J Med Sci 2016; 9(4):253-257
18. Kothi ZS, Athar AM, Yenkanchi AP, et al. The usefulness of fragmented QRS in predicting the successful reperfusion by using non invasive criteria of reperfusion in STEMI after thrombolytic therapy. International Journal of Contemporary Medical Research 2016; 3(10):2965-2968
19. Liang D, Zhang J, Lin L, et al. The Difference on Features of Fragmented QRS Complex and Influences on Mortality in Patients with Acute Coronary Syndrome. Acta Cardiol Sin 2017; 33(6):588- 595.
20. Rosengarten JA, Scott PA, Morgan JM, et al. Fragmented QRS for the prediction of sudden cardiac death: a meta-analysis. Europace 2015; 17(6):969-977.
21. Torigoe K, Tamura A, Kawano Y, et al. The number of leads with fragmented QRS is independently associated with cardiac death or hospitalization for heart failure in patients with prior myocardial infarction. J Cardiol 2012; 59(1):36-41.
22. Bekler A, Barutçu A, Tenekecioglu E, et al. The relationship between fragmented QRS complexes and SYNTAX and Gensini scores in patients with acute coronary syndrome. Kardiol Pol 2015; 73(4):246– 254.
23. Dagres N, Hindricks G. Risk stratification after myocardial infarction: is left ventricular ejection fraction enough to prevent sudden cardiac death? Eur Heart J 2013; 34(26):1964-1971.
24. Li M, Wang X, Mi SH, Chi Z, et al. Short-term Prognosis of Fragmented QRS Complex in Patients with Non-ST Elevated Acute Myocardial Infarction. Chin Med J (Engl). 2016; 129(5):518-522