OBJECTIVE: To test the hypothesis that in recipients of primary prophylactic implantable cardioverter-defibrillators (ICDs), the non-planarity of ECG vector loops predicts (a) deaths despite ICD protection and (b) appropriate ICD shocks. METHODS: Digital pre-implant ECGs were collected in 1948 ICD recipients: 21.4% females, median age 65 years, 61.5% ischaemic heart disease (IHD). QRS and T wave three-dimensional loops were constructed using singular value decomposition that allowed to measure the vector loop planarity. The non-planarity, that is, the twist of the three-dimensional loops out of a single plane, was related to all-cause mortality (n=294; 15.3% females; 68.7% IHD) and appropriate ICD shocks (n=162; 10.5% females; 87.7% IHD) during 5-year follow-up after device implantation. Using multivariable Cox regression, the predictive power of QRS and T wave non-planarity was compared with that of age, heart rate, left ventricular ejection fraction, QRS duration, spatial QRS-T angle, QTc interval and T-peak to T-end interval. RESULTS: QRS non-planarity was significantly (p<0.001) associated with follow-up deaths despite ICD protection with HR of 1.339 (95% CI 1.165 to 1.540) but was only univariably associated with appropriate ICD shocks. Non-planarity of the T wave loop was the only ECG-derived index significantly (p<0.001) associated with appropriate ICD shocks with multivariable Cox regression HR of 1.364 (1.180 to 1.576) but was not associated with follow-up mortality. CONCLUSIONS: The analysed data suggest that QRS and T wave non-planarity might offer distinction between patients who are at greater risk of death despite ICD protection and those who are likely to use the defibrillator protection.

Cardiology and Pneumology Heart Center University Hospital Göttingen Göttingen Germany

Department of Cardiology and Pneumology University Medical Center Göttingen Gottingen Germany

Department of Cardiology Inselspital Bern University Hospital Bern Switzerland

Department of Cardiology University Hospital of Basel Basel Switzerland

Department of Cardiovascular Sciences University of Leuven Leuven Belgium

Department of Internal Medicine and Cardiology Masaryk University Brno Czech Republic

Department of Internal Medicine and Cardiology University Hospital Brno Brno Czech Republic

Department of Medical Physiology University Medical Center Utrecht Utrecht The Netherlands

Department of Medical Statistics University Medical Center Göttingen Göttingen Germany

Division of Clinical Cardiology University Hospitals Leuven Leuven Belgium

Division of Experimental Cardiology Department of Cardiovascular Diseases University of Leuven Leuven Belgium

German Center of Cardiovascular Research partner site Göttingen Göttingen Germany

Medizinische Klinik Klinikum rechts der Isar der Technischen Universität München Munich Germany

MRC Oulu University Central Hospital of Oulu and University of Oulu Oulu Finland

National Heart and Lung Institute Imperial College London London UK

University Central Hospital of Oulu and University of Oulu Oulu Finland

University Hospital for Internal Medicine 3 Medical University Innsbruck Innsbruck Austria

doi: 10.1136/heartjnl-2023-323232 PubMed

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