See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/279115483

QT interval changes during the management of decompensated heart

failure in the emergency care setting

Article  in  Acta Medica Mediterranea · January 2015

CITATIONS READS

0 45

7 authors, including:

Mehmet Unaldi Fikret Bildik

10 PUBLICATIONS   20 CITATIONS    Gazi University
37 PUBLICATIONS   121 CITATIONS   
SEE PROFILE
SEE PROFILE

Ahmet Demircan Isa Kilicaslan

Gazi University Gazi University
66 PUBLICATIONS   263 CITATIONS    30 PUBLICATIONS   113 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

herbal poisoning View project

Determining emergency physicians' and nurses' views concerning older patients: A mixed-method study View project

All content following this page was uploaded by Isa Kilicaslan on 29 December 2015.

The user has requested enhancement of the downloaded file.

Acta Medica Mediterranea, 2015, 31: 137

QT INTERVAL CHANGES DURING THE MANAGEMENT OF DECOMPENSATED HEART FAILURE

IN THE EMERGENCY CARE SETTING

ERKAN TEMIZKAN1, MEHMET UNALDI1, FIKRET BILDIK2, AHMET DEMIRCAN2, AYFER KELES2, ISA KILICARSLAN2,
HATICE ERYIGIT3
¹Medipol University Medical Faculty, Department of Emergency Medicine, Istanbul - 2Gazi University Medical Faculty, Department
of Emergency Medicine, Ankara - 3Lutfi Kirdar Kartal Training and Research Hospital, Department of Thoracic Surgery, Istanbul,
Turkey

ABSTRACT

Introduction: Reliable and objective diagnostic tools are needed for heart failure to assist prompt intervention, diagnosis,
treatment, and admission and/or discharge decisions in the emergency room. The aim of this study was to assess the treatment-asso-
ciated changes in corrected QT interval in patients with decompensated heart failure in the emergency care setting.
Materials and methods: Thirty-nine adult patients with known heart failure presenting to the emergency room with New York
Heart Association Class III-IV decompensated systolic heart failure symptoms were included in this study. Initial and post-treatment
electrocardiography recordings were examined for corrected QT interval changes.
Results: Treatment of decompensated heart failure resulted in a statistically significant reduction in QT interval when compa-
red to pre-treatment measurements: 432.3±43.3 (range, 320-508) vs. 486.3±44.1 (range, 414-600) milliseconds, p=0.001.
Discussion: Monitoring corrected QT interval may represent a useful additional assessment tool that may aid in the asses-
sment of decompensated heart failure patients in the emergency room and in the decision for admission and discharge. However,
further studies are warranted.

Key words: decompensated heart failure, corrected QT interval, emergency care, treatment.

Received May 18, 2014; Accepted September 02, 2014

Introduction However, none of these is disease-specific for

Heart failure (HF) represents an important
public health problem, particularly in the developed
world, owing to its high prevalence and increasing
incidence rates, poor prognosis, and the associated
economic burden. In contrast with the decreased
mortality of acute coronary syndrome in the last
two decades due to advances in the field of medi-
cine, HF mortality has remained stable with a 150%
increase in hospital admissions(1-2).
In addition to history and physical examina-
tion, radiological imaging studies, electrocardiogra-
phy (ECG), and several biochemical tests are also
commonly utilized for the emergency diagnostic
work-up, treatment, and for the decision to admit or
discharge patients with HF.
HF, warranting more reliable and objective diag-
nostic tools for prompt intervention, diagnosis,
treatment, and admission and/or discharge decisions
in the emergency room.
Numerous studies examining the utility of
ECG, a heart-specific assessment tool routinely
used in HF patients, has been and is currently being
carried out. In electrophysiological studies and ani-
mal experiments, heart failure is generally assumed
to represent an acquired corrected QT (QTc) inter-
val prolongation. Clinically, acquired QTc prolon-
gation is thought to occur during the decompensa-
tion stage of heart failure, with an eventual shorten-
ing of QTc interval after compensation (3) .
Monitoring QTc interval in decompensated HF
patients presenting to the emergency room with
138
dyspnea may represent an objective, feasible, and
reliable method that may assist in quick differential
diagnosis, treatment, and admission and discharge
decisions.
This study was undertaken to assess the treat-
ment-associated changes in QTc interval in patients
presenting to the emergency room with a previous
diagnosis of decompensated heart failure.
Materials and methods
This prospective observational study was car-
ried out between January 2013 and March 2013 in
the Department of Emergency Medicine for Adult
Patients and Coronary Care unit of our institution.
The institutional ethics committee approved the
study protocol; all the study procedures were con-
ducted in accordance with the Declaration of
Helsinki. All patients gave written informed con-
sent prior to study entry.Table
Patients
Adult patients presenting to the emergency
room with dyspnea, providing consent for study
participation, and meeting the following eligibility
criteria were included in the study: age > 18 years,
prior diagnosis of heart failure, and presence of
New York Heart Association (NYHA) Class III-IV
decompensated heart failure symptoms. Exclusion
criteria included: a preliminary diagnosis of heart
failure that was subsequently ruled out; other caus-
es of widened QRS complex such as left bundle
branch block, pacemaker rhythm, ventricular tachy-
cardia; current or recent use of cardiac or non-car-
diac drugs known to be associated with prolonged
QT interval; presence of ST elevation; electrolyte
imbalance; pregnancy or breastfeeding; require-
ment for cardiopulmonary resuscitation (CPR); a
diagnosis of diastolic heart failure (ejection fraction
(EF) greater than 50%); and unwillingness to con-
tinue study participation at any stage of the study.
Management
Demographic and clinical characteristics were
recorded at the time of emergency room consulta-
tion, and the initial ECG recordings were included
in the study file for subsequent analyses. All
patients were consulted by Cardiologists and admit-
ted to the Coronary Intensive Care unit. An
echocardiography was performed in each partici-
pant using a General Electric Medical Systems Ge
Vingmed Ultrasound As Mod: VIVID 7 Dimension
Erkan Temizkan, Mehmet Unaldi et Al
device in order to ascertain the presence of systolic
heart failure with regard to EF values. Patients with
diastolic heart failure, as evidenced by an EF of
greater than 50%, were excluded from the study.
During the decompensated stage, standard
treatment consisting of diuretics (parenteral
furosemide) was given. In addition, vasodilators
(parenteral isosorbide monohydrate) were adminis-
tered when tolerated by the patients. Patients con-
tinued their existing therapies (e.g. angiotensin con-
verting enzyme antagonists, angiotensin II receptor
blockers etc.). If no improvement was observed in
heart failure symptoms, digoxin was added to the
treatment. After compensation was achieved, beta-
blocker treatment was also given. Although beta-
blockers and digoxin, which are commonly used by
many HF patients, are associated with reduced QT
interval, these were added to the protocol since they
represent established treatment for the condition.
An ECG was performed at the end of the treatment
and the ECG recordings were kept in the study file.
A telephone call was made after 6 months to collect
information on clinical status and mortality.
QT Measurement
Pre- and post-treatment 12-lead ECG record-
ings were manually obtained at a speed of 25
mm/sec and amplitude of 10 mm/mV using a Nihon
Kohden ECG-9020 K device. ECG recordings were
scanned and transferred into digital environment,
magnified (200%), and the analyses were per-
formed in the electronic environment (visual deter-
mination “eyeball/caliper” technique) by manual
ECG readings. QTc was defined as the interval
between the start of the Q wave and end of T wave.
In the presence of a U wave, the deepest point
between T and U waves was accepted as the end of
T wave. In derivations where the end of the T wave
could not be determined no measurements were
performed and the measurements in the nearest
group derivations were used. In the 12-lead ECG,
measurements were performed in at least seven
derivations, including those considered most sensi-
tive for QTc such as standard DI and aVL deriva-
tions and V4 chest derivation, with at least three of
these measurements being performed in the precor-
dial derivations. Average QTc length was calculated
using Bazzet’s formula adjusted for heart rate.
Statistical analyses
Al data were analyzed using Statistical
Package for Social Sciences (SPSS) for Windows
Qt Interval Changes During The Management Of Decompensated Heart Failure In The Emergency Care Setting 139

16.0 (SPSS Inc. Chicago, USA) software package. Almost two-thirds of the patients were using ≥5
Pre- and post-treatment QTc intervals were com- different drugs daily; however, compliance was low.
pared using paired samples t test. A p value <0.05 Treatment resulted in a statistically significant
was considered as an indication of statistical signif- reduction in QT interval when compared to pre-treat-
icance. ment measurements: 432.3±43.3 (range, 320-508)
vs. 486.3±44.1 (range, 414-600) milliseconds,
Characteristic n=39
p=0.001.
Female gender, n (%) 20 (51.3%)

Age, years 72.4±12.4 (31-90) Discussion

Systolic pressure, mmH2O 135.4±29.6 (80-240)
Our results indicate a statistically significant
Diastolic pressure, mmH2O 84.3±18.1 (50-130) decrease in the QTc interval from emergency room
Heart rate, beats/min. 96.3±22.4 (45-154)
visit to discharge after treatment among NYHA
Class III-IV decompensated heart failure patients
Oxygen saturation, % SpO2 87.2±9.2 (55-100) presenting to the emergency room with dyspnea.
Symptomatology of heart failure patients is not
Night cough, n (%) 9 (23.1%)
limited to their primary condition, i.e. HF, but may
Dispne on exertion, n (%) 34 (87.2%) also include symptoms due to co-morbid conditions.
Thus, reliable classification systems and objective
Ankle edema, n (%) 26 (66.7%)
assessments that are agreed upon are warranted for
Pulmonary rales, n (%) 34 (87.2%) the diagnosis and admission decisions in HF patients.
According to the updated American College of
Cardiomegaly, n (%) 16 (41.2%)
Cardiology Foundation/American Heart Association
Pleural effusion, n (%) 9 (23.1%) (ACCF/AHA) 2009 HF guidelines, a recommenda-
Pulmonary edema, n (%) 12 (30.2%) tion is made regarding the use of NYHA classifica-
tion to obtain information on the prognosis and func-
Duration of ICU stay, hours 20.9±2.2 (0.8-99.4)
tional capacity of HF patients. While a special
Mortality (at 6 months), n (%) 3 (5.9%) emphasis was placed upon the use of exercise test as
an additional modality, since NYHA classification is
Table 1: Demographical and clinical characteristics of an observer dependent tool that is unable to provide
the patients. a complete and objective assessment of the function-
Unless otherwise stated, data are presented as mean ± stan-
dard deviation (range)
al capacity(4). A critical view of the signs and symp-
toms of HF in terms of sensitivity, specificity, and
predictive value reveals that dyspnea singles out as
Results the symptom with the highest sensitivity(5-6). Also,
although the determination of the ejection fraction by
During the study period, 726 patients were echocardiography represents the most important
admitted to the intensive care unit with dyspnea. diagnostic tool for predicting the cardiac events in
Among them, 90 had a previous diagnosis of heart the emergency room, cardiology unit, discharge and
failure, thus were eligible for the study. Fifty-one post-discharge period, limitations in the availability
patients were excluded after the initial assessment of emergency echocardiography in many settings
due to the following reasons: diastolic heart failure means that only a fraction of the patients may be
(n=23), NYHA Class II (n=12), using medications examined by this tool in the emergency room. In this
with the potential of affecting QT interval (n=11), respect, measurement of the QT interval may repre-
left bundle branch block (n=2), pacemaker (n=1), sent an additional diagnostic method that may be
high potassium level (n=1), and unwilling to partici- useful for the assessment of treatment response.
pate (n=1). Thus, data of 39 patients were analyzed. Prolonged QT interval has been described in
Demographic and clinic data of the patients are many different conditions such as diabetes, chronic
shown in Table 1. All patients had additional co-mor- renal failure, dialysis, and cardiac valvular diseases
bidity with hypertension (69.2%), diabetes (53.8%) and is classified as an acquired prolonged QT syn-
and hyperlipidemia (53.8%) being the most frequent drome. In addition, many pharmaceutical agents may
co-morbid conditions. prolong QT (Table 2).
140
Class IA, quinidine, disopyra-
mide, procainamide
Class IB, mexiletine
Antiarrhythmic drugs Class IC, moricizine
Class III, sotalol, amiodarone,
ibutilide, almokalant, dofetilide
Class IV, bepridil
Erythromycin, clarithromycin, clin-
damycin, trimethoprim/sulfamethoxazo-
le, grepafloxacin, sparfloxacin, oxifloxa-
Antibiotics cin, gatifloxacin, levofloxacin, amanta-
dine, pentamidine, fluconazole, ketoco-
nazole, chloroquine, quinidine, halofan-
trine
Antivirals Foscarnet
Antineoplastic agents Tamoxifen, arsenic trioxide
Antimigren medications Sumatriptan, zolmitriptan, naratriptan
Antihypertensive medications Isradipine, nicardipine
Antihistamines
Terfenadine, astemizole, diphen-
hydramine
Amitriptyline, nortriptyline,
desipramine, maprotiline, clomipramine,
Antidepressants
doxepin, fluoxetine, pimozide,
imipramine, sertraline
Chlorpromazine, haloperidol,
Neuroleptics/antipsychotics
droperidol, pimozide, thioridazine, sertin-
dole, risperidone, ziprasidone, quetiapine,
trifluoperazine, thiothixene
Cholinergics Cisapride
Sildenafil, carbamazepine,
Other medications
probucol, octreotide, amrinone, milrinone
Table 2: Cardiac and non-cardiac drugs with potential of
prolonging QT interval.
Prolonged QT, whether congenital, acquired or
iatrogenic, is associated with an increased risk of
fatal arrhythmias. Many studies have established a
link between prolonged QT and mortality in these
conditions. Studies in animals have suggested that
HF may actually represent a form of acquired QT
syndrome(7-10).
In a study by Koyoma et al. examining dogs
with or without HF, it has been proposed that QTc
may represent a good indicator for the severity of
HF(11). Harding et al. observed changes in QRS, QT
and QTc intervals over time in a total of 23 patients
with left ventricular dysfunction who were using a
left ventricular assist device (LVAD)(12). In the first
seven days after the operation, use of LVAD was
Erkan Temizkan, Mehmet Unaldi et Al
associated with a decrease in QRS and in QTc (from
504.61 to 445.69 msec). These authors had the
objective of achieving compensated HF state with
the aid of left ventricular assist device. In our study,
this was achieved through medical treatment and
QTc intervals were compared, revealing a decrease
of QTc from presentation (486.2 msec) to pre-dis-
charge (432.3 msec).
In their study Brooksby P. et al., examined the
association of corrected QT interval, heart rate, and
certain biochemical parameters with mortality and
sudden death, in patients with HF, and found that
QTc and JT emerged as strong and independent pre-
dictors in moderately severe congestive heart failure
in mild heart failure(13). Similarly, prolongation in
QTc was found to be associated with increased in-
hospital mortality(14) and increased sudden cardiac
death in the long term (3 months)(15). On the other
hand, other studies did not confirm an association
between prolonged QTc and long-term mortality(14, 16-
17)
. Padmanabhan S. et al. studied QT interval, QT
dispersion, and their prognostic value in 2265 post-
myocardial infarction (post-MI) patients with sys-
tolic heart failure and an EF below 40%. They found
a strong relation between prolongation of QTc and
high mortality among those patients with moderate
to severe left ventricular dysfunction(3).
Kolo et al. examined Nigerian patients with
heart failure and demonstrated a prolongation of QTc
interval and a significant association between ven-
tricular arrhythmias and prolonged QTc. These
authors concluded that a significant proportion of
patients with chronic heart failure had prolonged
QTc, resulting an increased risk of ventricular
arrhythmias and sudden death(18).
In the study by Foroughi M. et al.(9) patients
with HF and coronary heart disease were compared
and it was concluded that prolonged QTc was an
independent risk factor, after 3 years of follow-up. In
addition, patients with systolic HF were found to
have enhanced sensitivity to drug-induced QT inter-
val prolongation(19), and a prolonged QT interval was
found to predict the development of new onset heart
failure in post-liver transplant patients(20). QT vari-
ability over time represents another intriguing area of
research in HF patients. For instance, in a study by
Dobson et al. QT variability over 24 hours was asso-
ciated with an increased risk for total and cardiovas-
cular mortality in heart failure patients(21).
QT interval is a measure of cardiac depolariza-
tion and re-polarization(22). QT and QTc intervals are
also among significant clinical determinants of mor-
Qt Interval Changes During The Management Of Decompensated Heart Failure In The Emergency Care Setting
bidity and mortality(23-24). Despite contrary views,
there are important studies that showed that pro-
longed QTc interval is associated with an increased
ventricular sensitivity and may result in increased
mortality and morbidity in conjunction with other
clinical factors(25).
The basic underlying electrophysiological
mechanism for the prolonged QT interval consists of
the absence or blockade of certain electrical currents
responsible for the repolarization process. In our
study, HF patients with low EF had a significant
decrease in QTc interval following treatment. We
believe that this finding might be associated with a
number of factors such as loss of muscle tissue
resulting in low EF and altered intracellular potassi-
um and calcium balance. Prolonged action potential
time at the cellular level is thought to result indirect-
ly in a prolongation of the repolarization time, which
is the second phase of the QT interval. As the
requirement for muscular strength is decreased, repo-
larization returns to near-normal levels, electrolyte
balance is restored, and the time to return to resting
potential also approaches normal levels. As a result,
of the changes occurring in the second phase of the
QT interval, the relative refractory period in the
decompensated stage is prolonged. An increased
incidence of fatal ventricular arrhythmias among HF
patients is supportive of this view(26).
The most important limitation of this study is
represented by the facts that ECG recordings were
performed by different study personnel and a manual
assessment of QTc was done. Following the scan-
ning process, difficulty was experienced in certain
readings of QT interval due to arrhythmias or arti-
facts. However, we do believe that manual readings
or use of different study personnel for ECG record-
ings are unlikely to significantly jeopardize the
objectivity of our results. Patients currently taking
drugs known to be associated with prolonged QTc
interval were excluded from the study. However,
beta-blockers and digoxin, which are commonly
used by many HF patients, are associated with
reduced QT interval. This represents another poten-
tial limitation. However, this is again unlikely to
result in a significant bias, since the QTc difference
between emergency room presentation and discharge
was assessed. QT dispersion, an important parame-
ter, was not examined in our study. However, practi-
cal, readily available, and reliable tools are required
to exploit QT interval for providing guidance in
monitoring and treatment of patients in the emer-
gency room.
141
Conclusions
The results of our study suggest that monitoring
QTc interval may represent a useful additional
assessment tool that may aid in the assessment of
decompensated HF patients in the emergency room
and in the decision for admission and discharge.
Further studies with larger sample populations are
warranted before firmer conclusions can be drawn on
the potential benefits of QTc interval in this clinical
setting.
List of abbreviations
NYHA, New York Heart Association
ECG, electrocardiography
HF, heart failure
QTc, corrected QT interval
CPR, cardiopulmonary resuscitation
EF, ejection fraction
ACCF/AHA, American College of Cardiology
Foundation/American Heart Association
LVAD, left ventricular assist device
MI, myocardial infarction
ICU, intensive care unit
References
1) Hunt SA. ACC/AHA 2005 guideline update for the
diagnosis and management of chronic heart failure in
the adult: a report of the American College of
Cardiology/American Heart Association Task Force on
Practice Guidelines (Writing Committee to Update the
2001 Guidelines for the Evaluation and Management of
Heart Failure). J Am Coll Cardiol 2005; 46: e1-82.
2) Douglas SA. Heart failure management in the emer-
gency department. In: Peacock FW, Tiffany RB, editors.
Cardiac emergencies. First. Istanbul: McGraw-Hill;
2009; 321-8.
3) Padmanabhan S, Silvet H, Amin J, Pai RG. Prognostic
value of QT interval and QT dispersion in patients with
left ventricular systolic dysfunction: results from a
cohort of 2265 patients with an ejection fraction of <
or =40%. Am Heart J 2003; 145: 132-8.
4) Jessup M, Abraham WT, Casey DE, Feldman AM,
Francis GS, et al. 2009 focused update: ACCF/AHA
Guidelines for the Diagnosis and Management of Heart
Failure in Adults: a report of the American College of
Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines: developed in col-
laboration with the International Society for Heart and
Lung Transplantation. Circulation 2009; 119: 1977-
2016.
5) Harlan WR, oberman A, Grimm R, Rosati RA. Chronic
congestive heart failure in coronary artery disease:
clinical criteria. Ann Intern Med 1977; 86: 133-8.
6) Coumel P, Blanche PM, Breithardt G. QT dynamicity
as a predictor for arrhythmia development. In: Oto A,
 142 Erkan Temizkan, Mehmet Unaldi et Al

Breithardt G, eds. Myocardial repolarization: from failure: analysis of Gruppo Italiano per lo Studio della
gene to bedside NewYork, NY: 2001: 580-1. Sopravvivenza nell’Insufficienza Cardiaca (GISSI-HF)
7) Zipes DP. Arrhytmias, sudden death and syncope. In: trial. Heart Rhythm 2011; 8: 1237-42.
Libby P, Bonow RO, Mann DL, Zipes DP, eds. 22) Castellanos A, Interian A and Myerburg JR. The resting
Braunwald’s heart disease: a textbook of cardiovascu- electrocardiogram. In: Fuster V, Alexander RW,
lar medicine. Eight Edition. Philadelphia: 2007: 724- O’Rourke RA, Roberts R, King SB, Nash IS, editors.
44. Hurst’s the heart. Philadelphia: McGraw-Hill; 2004. p.
8) Moore JP, Alejos JC, Perens G, Wong S, Shannon KM. 295-325.
The corrected QT interval before and after heart trans- 23) Algra A, Tijssen JG, Roelandt JR, Pool J, Lubsen J.
plantation. Am J Cardiol 2009; 104: 596-601. QTc prolongation measured by standard 12-lead elec-
9) Foroughi M, Karkhaneh Yousefi Z, Majidi Tehrani M, trocardiography is an independent risk factor for sud-
Noori Foroutaghe A, et al. Prolonged QT interval and den death due to cardiac arrest. Circulation 1991; 83:
coronary artery bypass mortality due to heart failure. 1888-94.
Asian Cardiovasc Thorac Ann 2009; 17: 604-7. 24) Perkiomaki JS, Huikuri HV, Koistinen JM, Makikallio
10) VanHoose L, Sawers Y, Loganathan R, Vacek JL, T, Castellanos A, et al. Heart rate variability and dis-
Stehno-Bittel L, et al. Electrocardiographic changes persion of QT interval in patients with vulnerability to
with the onset of diabetes and the impact of aerobic ventricular tachycardia and ventricular fibrillation
exercise training in the Zucker Diabetic Fatty (ZDF) after previous myocardial infarction. J Am Coll Cardiol
rat. Cardiovasc Diabetol 2010; 9: 56. 1997; 30: 1331-8.
11) Koyama H, Yoshii H, Yabu H, Kumada H, Fukuda K, 25) Mayuga KA, Parker M, Sukthanker ND, Perlowski A,
et al. Evaluation of QT interval prolongation in dogs Schwartz JB, et al. Effects of age and gender on the QT
with heart failure. J Vet Med Sci 2004; 66: 1107-11. response to exercise. Am J Cardiol 2001; 87: 163-7.
12) Harding JD, Piacentino V, 3rd, Gaughan JP, Houser SR, 26) Kitzman DW, Little WC, Brubaker PH, Anderson RT,
Margulies KB. Electrophysiological alterations after Hundley WG, et al. Pathophysiological characteriza-
mechanical circulatory support in patients with tion of isolated diastolic heart failure in comparison to
advanced cardiac failure. Circulation 2001; 104: 1241- systolic heart failure. JAMA 2002; 288: 2144-50.
7.
13) Brooksby P, Batin PD, Nolan J, Lindsay SJ, Andrews
R, et al. The relationship between QT intervals and
mortality in ambulant patients with chronic heart fail-
ure. The united kingdom heart failure evaluation and
assessment of risk trial (UK-HEART). Eur Heart J
1999; 20: 1335-41.
14) Vaclavik J, Spinar J, Vindis D, Vítovec J, Widimsky P,
et al. ECG in patients with acute heart failure can pre-
dict in-hospital and long-term mortality. Intern Emerg
Med 2014; 9: 283-91.
15) Maeder MT, Ammann P. Changes in BNP and QTc for
prediction of sudden death in heart failure. Future
Cardiol 2013; 9: 317-20.
16) Breidthardt T, Christ M, Matti M, Schrafl D, Laule K,
et al. QRS and QTc interval prolongation in the predic-
tion of long-term mortality of patients with acute desta-
bilised heart failure. Heart 2007; 93: 1093-97.
17) Dzudie A, Milo O, Edwards C, Cotter G, Davison BA,
et al. Prognostic significance of ECG abnormalities for
mortality risk in acute heart failure: insight from the
Sub-Saharan Africa Survey of Heart Failure (THESUS-
HF). J Card Fail 2014; 20: 45-52.
18) Kolo PM, Opadijo OG, Omotoso AB, Balogun MO,
Araoye MA, et al. Prevalence of QTc prolongation in
adult Nigerians with chronic heart failure. West Afr J
Med 2008; 27: 69-73.
19) Tisdale JE, Overholser BR, Wroblewski HA, Sowinski
KM, Amankwa K, et al. Enhanced sensitivity to drug-
induced QT interval lengthening in patients with heart
failure due to left ventricular systolic dysfunction. J
Clin Pharmacol 2012; 52: 1296-305. _________
20) Qureshi W, Mittal C, Ahmad U, Alirhayim Z, Hassan S,
Correspoding author
et al. Clinical predictors of post-liver transplant new-
Dr. MEHMET UNALDI
onset heart failure. Liver Transpl 2013; 19: 701-10.
Gumuspinar Mah. Kumral Sok. Demirlipark Sitesi D-5
21) Dobson CP, La Rovere MT, Pinna GD, Goldstein R,
Yakacik Kartal
Olsen C, et al. QT variability index on 24-hour Holter
34876 Istanbul
independently predicts mortality in patients with heart
(Turkey)

View publication stats