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QRS-T angle: is it a specific parameter associated with sudden cardiac death in type 2 diabetes? Results from the SURDIAGENE and the Mini-Finland prospective cohorts

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Abstract

Aims/hypothesis

Type 2 diabetes is associated with a high risk of sudden cardiac death (SCD), but the risk of dying from another cause (non-SCD) is proportionally even higher. The aim of the study was to identify easily available ECG-derived features associated with SCD, while considering the competing risk of dying from non-SCD causes.

Methods

In the SURDIAGENE (Survie, Diabete de type 2 et Genetique) French prospective cohort of individuals with type 2 diabetes, 15 baseline ECG parameters were interpreted among 1362 participants (mean age 65 years; HbA1c 62±17 mmol/mol [7.8±1.5%]; 58% male). Competing risk models assessed the prognostic value of clinical and ECG parameters for SCD after adjusting for age, sex, history of myocardial infarction, N-terminal pro b-type natriuretic peptide (NT-proBNP), HbA1c and eGFR. The prospective Mini-Finland cohort study was used to externally validate our findings.

Results

During median follow-up of 7.4 years, 494 deaths occurred including 94 SCDs. After adjustment, frontal QRS-T angle ≥90° (sub-distribution HR [sHR] 1.68 [95% CI 1.04, 2.69], p=0.032) and NT-proBNP level (sHR 1.26 [95% CI 1.06, 1.50] per 1 log, p=0.009) were significantly associated with a higher risk of SCD. Nevertheless, frontal QRS-T angle was the only marker not to be associated with causes of death other than SCD (sHR 1.08 [95% CI 0.84, 1.39], p=0.553 ). These findings were replicated in the Mini-Finland study subset of participants with diabetes (sHR 2.22 [95% CI 1.05, 4.71], p=0.04 for SCD and no association for other causes of death).

Conclusions/interpretation

QRS-T angle was specifically associated with SCD risk and not with other causes of death, opening an avenue for refining SCD risk stratification in individuals with type 2 diabetes.

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Abbreviations

bpm:

Beats per minute

CSC:

Cause-specific Cox

ICC:

Intraclass correlation coefficient

NT-proBNP:

N-terminal pro b-type natriuretic peptide

SCD:

Sudden cardiac death

sHR:

Sub-distribution HR

SURDIAGENE:

Survie, Diabete de type 2 et Genetique

References

  1. Gräsner J-T, Lefering R, Koster RW et al (2016) EuReCa ONE-27 Nations, ONE Europe, ONE Registry: a prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation 105:188–195. https://doi.org/10.1016/j.resuscitation.2016.06.004

    Article  PubMed  Google Scholar 

  2. Virani SS, Alonso A, Benjamin EJ et al (2020) Heart disease and stroke statistics-2020 update: a report from the American heart association. Circulation 141:e139–e596. https://doi.org/10.1161/CIR.0000000000000757

    Article  PubMed  Google Scholar 

  3. Merchant FM, Levy WC, Kramer DB (2020) Time to shock the system: moving beyond the current paradigm for primary prevention implantable cardioverter-defibrillator use. J Am Heart Assoc 9:e015139. https://doi.org/10.1161/JAHA.119.015139

    Article  PubMed  PubMed Central  Google Scholar 

  4. Yun J-S, Ko S-H (2021) Current trends in epidemiology of cardiovascular disease and cardiovascular risk management in type 2 diabetes. Metabolism 123:154838. https://doi.org/10.1016/j.metabol.2021.154838

    Article  CAS  PubMed  Google Scholar 

  5. International Diabetes Federation. IDF Diabetes Atlas, 10th edn. Brussels, Belgium: 2021. Available from https://diabetesatlas.org/atlas/tenth-edition/. Accessed 4 Apr 2023

  6. Aune D, Schlesinger S, Norat T, Riboli E (2018) Diabetes mellitus and the risk of sudden cardiac death: a systematic review and meta-analysis of prospective studies. Nutr Metab Cardiovasc Dis 28:543–556. https://doi.org/10.1016/j.numecd.2018.02.011

    Article  CAS  PubMed  Google Scholar 

  7. Lynge TH, Svane J, Pedersen-Bjergaard U et al (2020) Sudden cardiac death among persons with diabetes aged 1–49 years: a 10-year nationwide study of 14 294 deaths in Denmark. Eur Heart J 41:2699–2706. https://doi.org/10.1093/eurheartj/ehz891

    Article  PubMed  Google Scholar 

  8. Jouven X, Lemaître RN, Rea TD, Sotoodehnia N, Empana J-P, Siscovick DS (2005) Diabetes, glucose level, and risk of sudden cardiac death. Eur Heart J 26:2142–2147. https://doi.org/10.1093/eurheartj/ehi376

    Article  PubMed  Google Scholar 

  9. Goldenberg I, Vyas AK, Hall WJ et al (2008) Risk stratification for primary implantation of a cardioverter-defibrillator in patients with ischemic left ventricular dysfunction. J Am Coll Cardiol 51:288–296. https://doi.org/10.1016/j.jacc.2007.08.058

    Article  PubMed  Google Scholar 

  10. Balkau B, Jouven X, Ducimetière P, Eschwège E (1999) Diabetes as a risk factor for sudden death. Lancet 354:1968–1969. https://doi.org/10.1016/S0140-6736(99)04383-4

    Article  CAS  PubMed  Google Scholar 

  11. Sharma A, Green JB, Dunning A et al (2017) Causes of death in a contemporary cohort of patients with type 2 diabetes and atherosclerotic cardiovascular disease: insights from the TECOS trial. Diabetes Care 40:1763–1770. https://doi.org/10.2337/dc17-1091

    Article  CAS  PubMed  Google Scholar 

  12. Hadjadj S, Fumeron F, Roussel R et al (2008) Prognostic value of the insertion/deletion polymorphism of the ACE gene in type 2 diabetic subjects: results from the Non-insulin-dependent Diabetes, Hypertension, Microalbuminuria or Proteinuria, Cardiovascular Events, and Ramipril (DIABHYCAR), Diabete de type 2, Nephropathie et Genetique (DIAB2NEPHROGENE), and Survie, Diabete de type 2 et Genetique (SURDIAGENE) studies. Diabetes Care 31:1847–1852. https://doi.org/10.2337/dc07-2079

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Saulnier P-J, Gand E, Ragot S et al (2014) Association of serum concentration of TNFR1 with all-cause mortality in patients with type 2 diabetes and chronic kidney disease: follow-up of the SURDIAGENE Cohort. Diabetes Care 37:1425–1431. https://doi.org/10.2337/dc13-2580

    Article  CAS  PubMed  Google Scholar 

  14. Oehler A, Feldman T, Henrikson CA, Tereshchenko LG (2014) QRS-T angle: a review. Ann Noninvasive Electrocardiol 19:534–542. https://doi.org/10.1111/anec.12206

    Article  PubMed  PubMed Central  Google Scholar 

  15. Surawicz B, Childers R, Deal BJ et al (2009) AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology. Circulation 119:e235-240. https://doi.org/10.1161/CIRCULATIONAHA.108.191095

    Article  PubMed  Google Scholar 

  16. Rautaharju PM, Kooperberg C, Larson JC, LaCroix A (2006) Electrocardiographic predictors of incident congestive heart failure and all-cause mortality in postmenopausal women: the Women’s Health Initiative. Circulation 113:481–489. https://doi.org/10.1161/CIRCULATIONAHA.105.537415

    Article  PubMed  Google Scholar 

  17. Hancock EW, Deal BJ, Mirvis DM et al (2009) AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology. Circulation 119:e251-261. https://doi.org/10.1161/CIRCULATIONAHA.105.537415

    Article  PubMed  Google Scholar 

  18. Wagner GS, Macfarlane P, Wellens H et al (2009) AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part VI: acute ischemia/infarction: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology. Circulation 119:e262-270. https://doi.org/10.1161/CIRCULATIONAHA.108.191098

    Article  PubMed  Google Scholar 

  19. Panikkath R, Reinier K, Uy-Evanado A et al (2011) Prolonged Tpeak-to-tend interval on the resting ECG is associated with increased risk of sudden cardiac death. Circ Arrhythm Electrophysiol 4:441–447. https://doi.org/10.1161/CIRCEP.110.960658

    Article  PubMed  PubMed Central  Google Scholar 

  20. Das MK, Khan B, Jacob S, Kumar A, Mahenthiran J (2006) Significance of a fragmented QRS complex versus a Q wave in patients with coronary artery disease. Circulation 113:2495–2501. https://doi.org/10.1161/CIRCULATIONAHA.105.595892

    Article  PubMed  Google Scholar 

  21. Aro AL, Huikuri HV, Tikkanen JT et al (2012) QRS-T angle as a predictor of sudden cardiac death in a middle-aged general population. Europace 14:872–876. https://doi.org/10.1093/europace/eur393

    Article  PubMed  Google Scholar 

  22. Fishman GI, Chugh SS, DiMarco JP et al (2010) Sudden cardiac death prediction and prevention. Circulation 122:2335–2348. https://doi.org/10.1161/CIRCULATIONAHA.110.976092

    Article  PubMed  PubMed Central  Google Scholar 

  23. Knekt P, Rissanen H, Järvinen R, Heliövaara M (2017) Cohort profile: the Finnish mobile clinic health surveys FMC, FMCF and MFS. Int J Epidemiol 46:1760–1761i. https://doi.org/10.1093/ije/dyx092

    Article  PubMed  Google Scholar 

  24. Schröder LC, Holkeri A, Eranti A et al (2022) Poor R-wave progression as a predictor of sudden cardiac death in the general population and subjects with coronary artery disease. Heart Rhythm 19:952–959. https://doi.org/10.1016/j.hrthm.2022.02.010

    Article  PubMed  Google Scholar 

  25. Fine JP, Gray RJ (1999) A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc Taylor Francis 94:496–509. https://doi.org/10.1080/01621459.1999.10474144

    Article  MathSciNet  Google Scholar 

  26. Pencina MJ, D’Agostino RB (2004) Overall C as a measure of discrimination in survival analysis: model specific population value and confidence interval estimation. Stat Med 23:2109–2123. https://doi.org/10.1002/sim.1802

    Article  PubMed  Google Scholar 

  27. Finnish Institute for Health and Welfare (2020) Mini-Finland Health Survey. Available from https://thl.fi/en/web/thlfi-en/research-and-development/research-and-projects/finnish-mobile-clinic/mini-finland-health-survey. Accessed June 2023

  28. Stecker EC, Vickers C, Waltz J et al (2006) Population-based analysis of sudden cardiac death with and without left ventricular systolic dysfunction: two-year findings from the Oregon Sudden Unexpected Death Study. J Am Coll Cardiol 47:1161–1166. https://doi.org/10.1016/j.jacc.2005.11.045

    Article  PubMed  Google Scholar 

  29. Sabbag A, Suleiman M, Laish-Farkash A et al (2015) Contemporary rates of appropriate shock therapy in patients who receive implantable device therapy in a real-world setting: from the Israeli ICD Registry. Heart Rhythm 12:2426–2433. https://doi.org/10.1016/j.hrthm.2015.08.020

    Article  PubMed  Google Scholar 

  30. Dagres N, Hindricks G (2013) Risk stratification after myocardial infarction: is left ventricular ejection fraction enough to prevent sudden cardiac death? Eur Heart J 34:1964–1971. https://doi.org/10.1093/eurheartj/eht109

    Article  PubMed  Google Scholar 

  31. Venkateswaran RV, Moorthy MV, Chatterjee NA et al (2021) Diabetes and risk of sudden death in coronary artery disease patients without severe systolic dysfunction. JACC Clin Electrophysiol 7:1604–1614. https://doi.org/10.1016/j.jacep.2021.05.014

    Article  PubMed  PubMed Central  Google Scholar 

  32. Sharma A, Al-Khatib SM, Ezekowitz JA et al (2018) Implantable cardioverter-defibrillators in heart failure patients with reduced ejection fraction and diabetes. Eur J Heart Fail 20:1031–1038. https://doi.org/10.1002/ejhf.1192

    Article  PubMed  Google Scholar 

  33. Scott PA, Barry J, Roberts PR, Morgan JM (2009) Brain natriuretic peptide for the prediction of sudden cardiac death and ventricular arrhythmias: a meta-analysis. Eur J Heart Fail 11:958–966. https://doi.org/10.1093/eurjhf/hfp123

    Article  CAS  PubMed  Google Scholar 

  34. Hillis GS, Welsh P, Chalmers J et al (2014) The relative and combined ability of high-sensitivity cardiac troponin T and N-terminal pro-B-type natriuretic peptide to predict cardiovascular events and death in patients with type 2 diabetes. Diabetes Care 37:295–303. https://doi.org/10.2337/dc13-1165

    Article  CAS  PubMed  Google Scholar 

  35. American Diabetes Association Professional Practice Committee: 10 (2021) Cardiovascular disease and risk management: standards of medical care in diabetes—2022. Diabetes Care 45(Suppl 1):S144–S174. https://doi.org/10.2337/dc22-S010

    Article  Google Scholar 

  36. Aro AL, Reinier K, Rusinaru C et al (2017) 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. Eur Heart J 38:3017–3025. https://doi.org/10.1093/eurheartj/ehx331

    Article  PubMed  PubMed Central  Google Scholar 

  37. Chatterjee NA, Tikkanen JT, Panicker GK et al (2020) Simple electrocardiographic measures improve sudden arrhythmic death prediction in coronary disease. Eur Heart J 41:1988–1999. https://doi.org/10.1093/eurheartj/ehaa177

    Article  PubMed  PubMed Central  Google Scholar 

  38. de Bie MK, van Rees JB, Thijssen J et al (2012) Cardiac device infections are associated with a significant mortality risk. Heart Rhythm 9:494–498. https://doi.org/10.1016/j.hrthm.2011.10.034

    Article  PubMed  Google Scholar 

  39. Pavri BB, Hillis MB, Subacius H et al (2008) Prognostic value and temporal behavior of the planar QRS-T angle in patients with nonischemic cardiomyopathy. Circulation 117:3181–3186. https://doi.org/10.1161/CIRCULATIONAHA.107.733451

    Article  PubMed  Google Scholar 

  40. Shah AM, Uno H, Køber L et al (2010) The inter-relationship of diabetes and left ventricular systolic function on outcome after high-risk myocardial infarction. Eur J Heart Fail 12:1229–1237. https://doi.org/10.1093/eurjhf/hfq179

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Clinical Investigation Centre CIC 1402, University of Poitiers, CHU Poitiers, Inserm, Poitiers, France

    Rodrigue Garcia, Elise Gand, Joe de Keizer, Claire Bouleti, Stéphanie Ragot & Pierre-Jean Saulnier

  2. Department of Cardiology, University Hospital of Poitiers, Poitiers, France

    Rodrigue Garcia, Marine Tavernier, Nicolas Bidegain, Benjamin Alos, Pierre Roumegou, Alexandre Gamet, Claire Bouleti & Bruno Degand

  3. Division of Internal Medicine, Department of Internal Medicine and Rehabilitation, Helsinki University Hospital and University of Helsinki, Helsinki, Finland

    Linda C. Schröder

  4. Division of Cardiology, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland

    Arttu Holkeri & Aapo L. Aro

  5. Heart Center, Central Hospital of North Karelia, Joensuu, Finland

    Antti Eranti

  6. Research Unit of Internal Medicine, Medical Research Center, Oulu University Hospital and University of Oulu, Oulu, Finland

    Juhani Junttila

  7. Finnish Institute for Health and Welfare, Helsinki, Finland

    Paul Knekt

  8. L’Institut du Thorax, Université de Nantes, CHU Nantes, CNRS, Nantes, France

    Samy Hadjadj

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  1. Rodrigue Garcia
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Consortia

on behalf of the SURDIAGENE and the Mini-Finland study groups

Corresponding author

Correspondence to Rodrigue Garcia.

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Acknowledgements

All participants included and followed in the cohort study are warmly thanked for their kind participation in this research. Their general practitioners are acknowledged for their help in collecting clinical information. E. Migault (Inserm CIC 1402, Poitiers, France) and the staff of the Diabetes Department at Poitiers hospital are acknowledged for their help with data collection and monitoring. We also thank S. Brishoual (Biological Resources Center, BRC BB-0033-00068, Poitiers, France) for biological determinations and sample handling. The authors thank J. Arsham (University Hospital of Poitiers, France) for proofreading and editing this manuscript. We acknowledge A. Pavy, M.-C. Pasquier (Information Technology Department, CHU de Poitiers, Poitiers, France) and A. Neveu and J. Guignet (Medical Information Department, CHU de Poitiers, Poitiers, France) for IT support. Part of this work was presented at the American Diabetes Association 2022 conference: oral presentation, ‘Control #2022-A-4161-Diabetes, ECG-Derived QRS-T Angle Is an Independent Predictor of Sudden Cardiac Death in Patients with Type 2 Diabetes: From the SURDIAGENE Prospective Study’.

Data availability

The datasets generated during and/or analysed during the current study are not publicly available but are available from the corresponding author upon reasonable request.

Funding

The SURDIAGENE cohort was supported by grants from the French Ministry of Health (PHRC-Poitiers 2004; PHRC-IR 2008), the Association Française des Diabétiques (Research Grant 2003) and the Groupement pour l’Etude des Maladies Métaboliques et Systémiques (GEMMS Poitiers, France). LCS was supported by research grants from the Medical Society of Finland, Victoriastiftelsen and the Aarne Koskelo Foundation. ALA was supported by grants from the Finnish Foundation for Cardiovascular Research and the Sigrid Juselius Foundation.

Authors’ relationships and activities

P-JS served as a consultant and/or on advisory panels for AstraZeneca, Novo Nordisk and Grünenthal. SH reports personal fees and non-financial support from AstraZeneca, Bristol-Myers Squibb, Janssen, Merck Sharp & Dohme and Sanofi; and personal fees from Abbott, Boehringer Ingelheim, Eli Lilly and Company, Novartis, Novo Nordisk, Servier and Takeda. The authors declare that there are no other relationships or activities that might bias, or be perceived to bias, their work.

Contribution statement

RG, LCS, MT, AH, AE, NB, BA, JJ, PK, PR, AG, SR, SH, ALA and P-JS researched data or contributed to the analysis. RG, LCS, EG, JK and P-JS designed the study. RG, LCS and P-JS wrote the manuscript. MT, NB, BA and AG drafted and reviewed the manuscript. EG, JK, AH, AE, JJ, PK, PR, CB, BD, SR, SH and ALA reviewed and edited the manuscript and contributed to the discussion. All the authors approved the final version.

RG is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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Garcia, R., Schröder, L.C., Tavernier, M. et al. QRS-T angle: is it a specific parameter associated with sudden cardiac death in type 2 diabetes? Results from the SURDIAGENE and the Mini-Finland prospective cohorts. Diabetologia 67, 641–649 (2024). https://doi.org/10.1007/s00125-023-06074-4

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