QRS Fragmentation

QRS fragmentation (fQRS) refers to additional notches/spikes within the QRS complex of at least 2 contiguous leads corresponding to a coronary artery territory
- - fQRS sign is comparable to the epsilon wave seen in arrhythmogenic right ventricular dysplasia/cardiomyopathy, but in this case more specifically indicative of a myocardial scar
  - fQRS is thought to represent abnormal myocardial activation and conduction delay thought to be due to myocardial scarring in patients with coronary artery disease
  - Indicator of previous myocardial injury and a significant predictor of future adverse cardiac events (i.e. decreased time to first arrhythmic event) and mortality in various heart diseases (documented in both ischemic and nonischemic cardiomyopathies)
    - - Predictor of mortality and major adverse cardiac events in STEMI/NSTEMI
      - Predictor of adverse clinical events in patients with acute pulmonary embolism, and may have value in risk stratification
      - Predictor of arrhythmic events in patients with Brugada syndrome, congenital long QT syndrome, hypertrophic obstructive cardiomyopathy, and arrhythmogenic right ventricular dysplasia/cardiomyopathy
fQRS includes various RSR' patterns, and may include additional R waves or R prime (R'), notching of the R or S wave, or presence of multiple (>2) R waves, in the absence of a wide QRS. The following examples below from Das et al., show different fQRS morphologies in a patient with coronary artery disease. fQRS is seen best in the inferior leads:

KEY PEARLS:

QRS fragmentation (fQRS) refers to an abnormal QRS morphology where there are additional notches/spikes suggestive of abnormal conduction delay from myocardial scaring. fQRS is a sign that may predict future arrhythmic events and increased risk of mortality in a variety of heart diseases. Check out the following pertinent references for a deeper dive!

Das MK, Saha C, El Masry H, et al. Fragmented QRS on a 12-lead ECG: A predictor of mortality and cardiac events in patients with coronary artery disease. Heart Rhythm. 2007;4(11):1385-1392. PMID: 17954396
Das MK, Saha C, El Masry H, et al. Fragmented QRS on a 12-lead ECG: A predictor of mortality and cardiac events in patients with coronary artery disease. Heart Rhythm. 2007;4(11):1385-1392. PMID: 20129288
Güngör B, Özcan KS, Karataş MB, et al. Prognostic Value of QRS Fragmentation in Patients with Acute Myocardial Infarction: A Meta-Analysis. Ann Noninvasive Electrocardiol. 2016;21(6):604-612. PMID: 27018003
Xia W, Feng XY. Fragmented QRS (fQRS) complex predicts adverse cardiac events of ST-segment elevation myocardial infarction patients undergoing percutaneous coronary intervention and thrombolysis. Med Sci Monit. 2018;24:4634-4640. PMID: 29974889
Seong CS, Gwag H Bin, Hwang JK, et al. Clinical significance of fragmented QRS complexes or J waves in patients with idiopathic ventricular arrhythmias. PLoS One. 2018;13(4):1-11. PMID: 29694354
Cetin MS, Ozcan Cetin EH, Arisoy F, et al. Fragmented QRS Complex Predicts In-Hospital Adverse Events and Long-Term Mortality in Patients with Acute Pulmonary Embolism. Ann Noninvasive Electrocardiol. 2016;21(5):470-478. PMID: 26701225
Qaddoura A, Digby GC, Kabali C, et al. Use of fragmented QRS in prognosticating clinical deterioration and mortality in pulmonary embolism: A meta-analysis. Ann Noninvasive Electrocardiol. 2018;23(5):1-7. PMID: 29676061
Rattanawong P, Riangwiwat T, Prasitlumkum N, et al. Baseline fragmented QRS increases the risk of major arrhythmic events in Brugada syndrome: Systematic review and meta-analysis. Ann Noninvasive Electrocardiol. 2018;23(2):1-8. PMID: 29030919
Temiz A, Gazi E, Altun B, et al. Fragmented QRS is associated with frequency of premature ventricular contractions in patients without overt cardiac disease. Anadolu Kardiyol Derg. 2015;15(6):456-462. PMID: 25430411
Zhang L, Liu L, Kowey P, Fontaine G. The Electrocardiographic Manifestations of Arrhythmogenic Right Ventricular Dysplasia. Curr Cardiol Rev. 2014;10(3):237-245. PMID: 24827798
Ogura S, Nakamura K, Morita H, et al. New Appearance of Fragmented QRS as a Predictor of Ventricular Arrhythmic Events in Patients With Hypertrophic Cardiomyopathy. Circ J. 2020;84(3):487-494. PMID: 32037379
Haukilahti MAE, Eranti A, Kenttä T, et al. QRS fragmentation patterns representing myocardial scar need to be separated from benign normal variants: Hypotheses and proposal for morphology based classification. Front Physiol. 2016;7(DEC):1-10. PMID: 28082919

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