Robert E. Eckart, DO; Michael E. Field, MD; Tomasz W. Hruczkowski, MD; Daniel E. Forman, MD; Sharmila Dorbala, MBBS; Marcelo F. Di Carli, MD; Christine E. Albert, MD, MPH; William H. Maisel, MD, MPH; Laurence M. Epstein, MD; William G. Stevenson, MD
Potential Financial Conflicts of Interest:Honoraria: L.M. Epstein (Medtronic, Boston Scientific, St. Jude). Grants received: L.M. Epstein (Medtronic, Boston Scientific, Biosense Webster).
Reproducible Research Statement:Study protocol: Available from Brigham and Women's Hospital Institutional Review Board, 75 Francis Street, Boston, MA 02115. Statistical code: Available from Dr. Eckart (e-mail, firstname.lastname@example.org). Data set: Certain portions of the analytic data set are available to approved individuals through written agreements with Dr. Eckart (e-mail, email@example.com).
Requests for Single Reprints: MAJ Robert E. Eckart, MC, USA, Arrhythmia Service (ATTN: MCHE-MDC), 3851 Roger Brooke Drive, Brooke Army Medical Center, San Antonio, TX 78234; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Eckart: Arrhythmia Service (ATTN: MCHE-MDC), 3851 Roger Brooke Drive, Brooke Army Medical Center, San Antonio, TX 78234.
Dr. Field: Cardiovascular Consultants of Maine, P.A., 96 Campus Drive, Suite 1, Scarborough, ME 04074.
Dr. Hruczkowski: Cardiology Arrhythmia Services, 2C1.16 Walter Mackenzie Centre, University of Alberta, Edmonton, Alberta T6G 2B7, Canada.
Drs. Forman, Dorbala, Di Carli, Albert, Epstein, and Stevenson: Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.
Dr. Maisel: Cardiovascular Division, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Baker 4, Boston, MA 02215.
Author Contributions: Conception and design: R.E. Eckart, M.E. Field, C.E. Albert, W.H. Maisel, L.M. Epsteìn, W.G. Stevenson.
Analysis and interpretation of the data: R.E. Eckart, M.E. Field, T.W. Hruczkowski, M.F. Di Carli, C.E. Albert, W.H. Maisel.
Drafting of the article: R.E. Eckart, M.E. Field, T.W. Hruczkowski, M.F. Di Carli, W.H. Maisel, L.M. Epsteìn.
Critical revision of the article for important intellectual content: R.E. Eckart, S. Dorbala, M.F. Di Carli, C.E. Albert, W.H. Maisel, L.M. Epsteìn, W.G. Stevenson.
Final approval of the article: R.E. Eckart, S. Dorbala, M.F. Di Carli, W.H. Maisel, L.M. Epsteìn, W.G. Stevenson.
Provision of study materials or patients: R.E. Eckart, S. Dorbala, M.F. Di Carli, L.M. Epsteìn.
Statistical expertise: R.E. Eckart, W.H. Maisel.
Obtaining of funding: R.E. Eckart.
Administrative, technical, or logistic support: R.E. Eckart.
Collection and assembly of data: R.E. Eckart, T.W. Hruczkowskì, M.F. Di Carli.
The prognostic importance of exercise-induced ventricular arrhythmia (EIVA) may be confounded by the presence of lower-risk idiopathic right ventricular outflow tract arrhythmias with left bundle-branch block (LBBB) morphology.
To determine whether right bundle-branch block (RBBB)–morphology EIVA was associated with increased mortality.
Academic medical center.
585 unique patients with EIVA and 2340 patients without EIVA, matched by age, sex, and risk factor, who were referred for exercise testing in an academic medical center.
Deaths and ischemia and infarction found on perfusion scan.
During a mean follow-up of 24 months (SD, 13), 31 deaths occurred in the EIVA group compared with 43 deaths in the group without EIVA (5.3% vs. 1.8%; P < 0.001). Worse survival in patients with RBBB-morphology or multiple-morphology EIVA (6.9%) than in patients without EIVA caused this difference. Patients with LBBB-morphology EIVAs had a mortality rate (2.5%) similar to that of patients without EIVA (P = 0.93, log-rank test). Among patients without known atherosclerotic coronary artery disease, any RBBB-morphology EIVA was associated with death (hazard ratio, 2.73 [95% CI, 1.78 to 4.13]; P < 0.001), but LBBB-morphology EIVA was not (hazard ratio, 0.82 [CI, 0.18 to 2.04]; P = 0.72).
Not all LBBB-morphology EIVA can be dismissed, and not all RBBB-morphology EIVA is high risk. Further evaluation of patients for structural heart disease was clinically driven, not protocol-driven.
Right bundle-branch block– or multiple-morphology EIVA is associated with increased mortality. Inclusion of patients with isolated LBBB-morphology EIVA, which often is idiopathic, may contribute to differences in the prognostic importance of EIVA in previous studies.
Eckart RE, Field ME, Hruczkowski TW, Forman DE, Dorbala S, Di Carli MF, et al. Association of Electrocardiographic Morphology of Exercise-Induced Ventricular Arrhythmia with Mortality. Ann Intern Med. 2008;149:451–460. doi: 10.7326/0003-4819-149-7-200810070-00005
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Published: Ann Intern Med. 2008;149(7):451-460.
Cardiac Diagnosis and Imaging, Cardiology, Rhythm Disorders and Devices.
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