Abstract
Aims
The aim of this study was to conduct a meta-analysis of prospective studies assessing the relationship between bundle branch block (BBB) or wide QRS and risk of all-cause mortality in patients with acute heart failure (AHF).
Methods and results
We searched the PubMed, Scopus and Web of Science database from inception to February 2022 to identify single centre or multicentre studies including a minimum of 400 patients and assessing the association between BBB or wide QRS and mortality in patients with AHF. Study-specific hazard ratio (HR) estimates were combined using a random-effects meta-analysis. Two meta-analyses were performed: (1) grouping by conduction disturbance and follow-up length and, (2) using the results from the longest follow-up for each study and grouping by the type of BBB. The meta-analysis included 21 publications with a total of 116,928 patients. Wide QRS (considering right (RBBB) and left (LBBB) altogether) was associated with a significant increment in the risk of all-cause mortality (pooled adjusted HR 1.112, 95% CI 1.065–1.160). The increased risk of death was also present when LBBB (HR 1.121, 95% CI 1.042–1.207) and RBBB (HR 1.187, 95% CI 1.045–1.348) were considered individually. There was no difference in risk between LBBB and RBBB (P for interaction = 0.533). Other outcomes including sudden death, rehospitalization and a combination of cardiovascular death or rehospitalization were also increased in patients with BBB or wide QRS.
Conclusions
This meta-analysis suggests a modest increase in the risk of all-cause mortality among patients with AHF and BBB or wide QRS, irrespective of the type of BBB.
Similar content being viewed by others
References
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine SA (2021) 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 42(48):4901. https://doi.org/10.1093/eurheartj/ehab670
Butler J, Yang M, Manzi MA, Hess GP, Patel MJ, Rhodes T, Givertz MM (2019) Clinical course of patients with worsening heart failure with reduced ejection fraction. J Am Coll Cardiol 73(8):935–944. https://doi.org/10.1016/j.jacc.2018.11.049
Kurmani S, Squire I (2017) Acute heart failure: definition, classification and epidemiology. Curr Heart Fail Rep 14(5):385–392. https://doi.org/10.1007/s11897-017-0351-y
Sinnenberg L, Givertz MM (2020) Acute heart failure. Trends Cardiovasc Med 30(2):104–112. https://doi.org/10.1016/j.tcm.2019.03.007
Miró Ò, López-Díez MP, Cardozo C, Moreno LA, Gil V, Jacob J, Herrero P, Llorens P, Escoda R, Richard F, Alquézar-Arbé A, Masip J, García-Álvarez A, Martín-Sánchez FJ, ICA-SEMES group (2022) Impact of hospital and emergency department structural and organizational characteristics on outcomes of acute heart failure. Rev Esp Cardiol (Engl Ed). 75(1):39–49. https://doi.org/10.1016/j.rec.2020.11.022
Miró Ò, Aguirre A, Herrero P, Jacob J, Martín-Sánchez FJ, Llorens P (2015) PAPRICA-2 study: role of precipitating factor of an acute heart failure episode on intermediate term prognosis. Med Clin (Barc) 145(9):385–389. https://doi.org/10.1016/j.medcli.2015.01.014
Madias JE (2007) The resting electrocardiogram in the management of patients with congestive heart failure: established applications and new insights. Pacing Clin Electrophysiol 30(1):123–128. https://doi.org/10.1111/j.1540-8159.2007.00586.x
Shenkman HJ, Pampati V, Khandelwal AK, McKinnon J, Nori D, Kaatz S, Sandberg KR, McCullough PA (2002) Congestive heart failure and QRS duration: establishing prognosis study. Chest 122(2):528–534. https://doi.org/10.1378/chest.122.2.528
Sandhu R, Bahler RC (2004) Prevalence of QRS prolongation in a community hospital cohort of patients with heart failure and its relation to left ventricular systolic dysfunction. Am J Cardiol 93(2):244–246. https://doi.org/10.1016/j.amjcard.2003.09.053
Kashani A, Barold SS (2005) Significance of QRS complex duration in patients with heart failure. J Am Coll Cardiol 46(12):2183–2192. https://doi.org/10.1016/j.jacc.2005.01.071
Fabiszak T, Łach P, Ratajczak J, Koziński M, Krupa W, Kubica J (2020) Influence of QRS duration and axis on response to cardiac resynchronization therapy in chronic heart failure with reduced left ventricular ejection fraction: a single center study including patients with left bundle branch block. Cardiol J 27(5):575–582. https://doi.org/10.5603/CJ.a2018.0138
Park SJ, On YK, Byeon K, Kim JS, Choi JO, Choi DJ, Ryu KH, Jeon ES (2013) Short- and long-term outcomes depending on electrical dyssynchrony markers in patients presenting with acute heart failure: clinical implication of the first-degree atrioventricular block and QRS prolongation from the Korean Heart Failure registry. Am Heart J 165(1):57-64.e2. https://doi.org/10.1016/j.ahj.2012.10.009
Breidthardt T, Christ M, Matti M, Schrafl D, Laule K, Noveanu M, Boldanova T, Klima T, Hochholzer W, Perruchoud AP, Mueller C (2007) QRS and QTc interval prolongation in the prediction of long-term mortality of patients with acute destabilised heart failure. Heart 93(9):1093–1097. https://doi.org/10.1136/hrt.2006.102319
Lund LH, Jurga J, Edner M, Benson L, Dahlström U, Linde C, Alehagen U (2013) Prevalence, correlates, and prognostic significance of QRS prolongation in heart failure with reduced and preserved ejection fraction. Eur Heart J 34(7):529–539. https://doi.org/10.1093/eurheartj/ehs305
Gouda P, Brown P, Rowe BH, McAlister FA, Ezekowitz JA (2016) Insights into the importance of the electrocardiogram in patients with acute heart failure. Eur J Heart Fail 18(8):1032–1040. https://doi.org/10.1002/ejhf.561
Harjola VP, Follath F, Nieminen MS, Brutsaert D, Dickstein K, Drexler H, Hochadel M, Komajda M, Lopez-Sendon JL, Ponikowski P, Tavazzi L (2010) Characteristics, outcomes, and predictors of mortality at 3 months and 1 year in patients hospitalized for acute heart failure. Eur J Heart Fail 12(3):239–248. https://doi.org/10.1093/eurjhf/hfq002
Václavík J, Špinar J, Vindiš D, Vítovec J, Widimský P, Číhalík Č, Linhart A, Málek F, Táborský M, Dušek L, Jarkovský J, Fedorco M, Felšöci M, Miklík R, Pařenica J (2014) ECG in patients with acute heart failure can predict in-hospital and long-term mortality. Intern Emerg Med 9(3):283–291. https://doi.org/10.1007/s11739-012-0862-1
Baldasseroni S, Opasich C, Gorini M, Lucci D, Marchionni N, Marini M, Campana C, Perini G, Deorsola A, Masotti G, Tavazzi L, Maggioni AP, Italian Network on Congestive Heart Failure Investigators (2002) Left bundle-branch block is associated with increased 1-year sudden and total mortality rate in 5517 outpatients with congestive heart failure: a report from the Italian network on congestive heart failure. Am Heart J 143(3):398–405. https://doi.org/10.1067/mhj.2002.121264
Baldasseroni S, Gentile A, Gorini M, Marchionni N, Marini M, Masotti G, Porcu M, Maggioni AP, Italian Network on Congestive Heart Failure Investigators (2003) Intraventricular conduction defects in patients with congestive heart failure: left but not right bundle branch block is an independent predictor of prognosis. A report from the Italian Network on Congestive Heart Failure (IN-CHF database). Ital Heart J 4(9):607–613
Wang NC, Maggioni AP, Konstam MA, Zannad F, Krasa HB, Burnett JC Jr, Grinfeld L, Swedberg K, Udelson JE, Cook T, Traver B, Zimmer C, Orlandi C, Gheorghiade M, Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) Investigators (2008) Clinical implications of QRS duration in patients hospitalized with worsening heart failure and reduced left ventricular ejection fraction. JAMA 299(22):2656–2666. https://doi.org/10.1001/jama.299.22.2656
Abdel-Qadir HM, Tu JV, Austin PC, Wang JT, Lee DS (2011) Bundle branch block patterns and long-term outcomes in heart failure. Int J Cardiol 146(2):213–218. https://doi.org/10.1016/j.ijcard.2010.01.012
Lee JH, Park JJ, Cho Y, Oh IY, Yoo BS, Kim JJ, Kim KH, Kang SM, Baek SH, Jeon ES, Cho MC, Chae SC, Oh BH, Choi DJ (2019) Prognostic implication of ventricular conduction disturbance pattern in hospitalized patients with acute heart failure syndrome. Korean Circ J 49(7):602–611. https://doi.org/10.4070/kcj.2018.0290
Tabrizi F, Englund A, Rosenqvist M, Wallentin L, Stenestrand U (2007) Influence of left bundle branch block on long-term mortality in a population with heart failure. Eur Heart J 28(20):2449–2455. https://doi.org/10.1093/eurheartj/ehm262
Barsheshet A, Leor J, Goldbourt U, Garty M, Schwartz R, Behar S, Luria D, Eldar M, Glikson M (2008) Effect of bundle branch block patterns on mortality in hospitalized patients with heart failure. Am J Cardiol 101(9):1303–1308. https://doi.org/10.1016/j.amjcard.2007.12.035
Barsheshet A, Goldenberg I, Garty M, Gottlieb S, Sandach A, Laish-Farkash A, Eldar M, Glikson M (2011) Relation of bundle branch block to long-term (four-year) mortality in hospitalized patients with systolic heart failure. Am J Cardiol 107(4):540–544. https://doi.org/10.1016/j.amjcard.2010.10.007
Hong SJ, Oh J, Kang SM, Youn JC, Han S, Jeon ES, Cho MC, Kim JJ, Yoo BS, Chae SC, Oh BH, Choi DJ, Lee MM, Ryu KH, KorHF Registry (2012) Clinical implication of right bundle branch block in hospitalized patients with acute heart failure: data from the Korean Heart Failure (KorHF) Registry. Int J Cardiol 157(3):416–418. https://doi.org/10.1016/j.ijcard.2012.03.155
Dzudie A, Milo O, Edwards C, Cotter G, Davison BA, Damasceno A, Mayosi BM, Mondo C, Ogah O, Ojji D, Sani MU, Sliwa K (2014) 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 20(1):45–52. https://doi.org/10.1016/j.cardfail.2013.11.005
Aguiló O, Trullàs JC, Wussler D, Llorens P, Conde-Martel A, López-Ayala P, Jacob J, Roca-Villanueva B, Gil V, Belkin M, Satué-Bartolomé JÁ, Mueller C, Miró Ò, INVESTIGATORS OF THE EAHFE, RICA AND BASEL-V REGISTRIES (2022) Prevalence, related factors and association of left bundle branch block with prognosis in patients with acute heart failure: a simultaneous analysis in 3 independent cohorts. J Card Fail. https://doi.org/10.1016/j.cardfail.2021.11.022
Huvelle E, Fay R, Alla F, Cohen Solal A, Mebazaa A, Zannad F (2010) Left bundle branch block and mortality in patients with acute heart failure syndrome: a substudy of the EFICA cohort. Eur J Heart Fail 12(2):156–163. https://doi.org/10.1093/eurjhf/hfp180
Tolppanen H, Siirila-Waris K, Harjola VP, Marono D, Parenica J, Kreutzinger P, Nieminen T, Pavlusova M, Tarvasmaki T, Twerenbold R, Tolonen J, Miklik R, Nieminen MS, Spinar J, Mueller C, Lassus J (2016) Ventricular conduction abnormalities as predictors of long-term survival in acute de novo and decompensated chronic heart failure. ESC Heart Fail 3(1):35–43. https://doi.org/10.1002/ehf2.12068
Mueller C, Laule-Kilian K, Klima T, Breidthardt T, Hochholzer W, Perruchoud AP, Christ M (2006) Right bundle branch block and long-term mortality in patients with acute congestive heart failure. J Intern Med 260(5):421–428. https://doi.org/10.1111/j.1365-2796.2006.01703.x
Trullàs JC, Aguiló O, Mirò Ó, Díez-Manglano J, Carrera-Izquierdo M, Quesada-Simón MA, Álvarez-Rocha P, Llorens P, González-Franco Á, Montero-Pérez-Barquero M, RICA registry researchers (2022) Prevalence and impact on prognosis of right-bundle branch block in patients with acute heart failure: findings from the RICA registry. Rev Clin Esp (Barc). 222(5):272–280. https://doi.org/10.1016/j.rceng.2021.10.002
McCullough PA, Hassan SA, Pallekonda V, Sandberg KR, Nori DB, Soman SS, Bhatt S, Hudson MP, Weaver WD (2005) Bundle branch block patterns, age, renal dysfunction, and heart failure mortality. Int J Cardiol 102(2):303–308. https://doi.org/10.1016/j.ijcard.2004.10.008
Hawkins NM, Wang D, McMurray JJ, Pfeffer MA, Swedberg K, Granger CB, Yusuf S, Pocock SJ, Ostergren J, Michelson EL, Dunn FG, CHARM Investigators and Committees (2007) Prevalence and prognostic impact of bundle branch block in patients with heart failure: evidence from the CHARM programme. Eur J Heart Fail 9(5):510–517. https://doi.org/10.1016/j.ejheart.2006.11.006
Surawicz B, Childers R, Deal BJ, Gettes LS, Bailey JJ, Gorgels A, Hancock EW, Josephson M, Kligfield P, Kors JA, Macfarlane P, Mason JW, Mirvis DM, Okin P, Pahlm O, Rautaharju PM, van Herpen G, Wagner GS, Wellens H, American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology 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. J Am Coll Cardiol 53(11):976–981. https://doi.org/10.1016/j.jacc.2008.12.013
Willems JL, Robles de Medina EO, Bernard R, Coumel P, Fisch C, Krikler D, Mazur NA, Meijler FL, Mogensen L, Moret P (1985) Criteria for intraventricular conduction disturbances and pre-excitation. World Health Organizational/International Society and Federation for Cardiology Task Force Ad Hoc. J Am Coll Cardiol 5(6):1261–1275. https://doi.org/10.1016/s0735-1097(85)80335-1
Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C, Ioannidis JP, Straus S, Thorlund K, Jansen JP, Mulrow C, Catalá-López F, Gøtzsche PC, Dickersin K, Boutron I, Altman DG, Moher D (2015) The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 162(11):777–784. https://doi.org/10.7326/M14-2385
McInnes MDF, Moher D, Thombs BD, McGrath TA, Bossuyt PM, the PRISMA-DTA Group, Clifford T, Cohen JF, Deeks JJ, Gatsonis C, Hooft L, Hunt HA, Hyde CJ, Korevaar DA, Leeflang MMG, Macaskill P, Reitsma JB, Rodin R, Rutjes AWS, Salameh JP, Stevens A, Takwoingi Y, Tonelli M, Weeks L, Whiting P, Willis BH (2018) Preferred reporting items for a systematic review and meta-analysis of diagnostic test accuracy studies: the PRISMA-DTA statement. JAMA 319(4):388–396. https://doi.org/10.1001/jama.2017.19163
Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327(7414):557–560. https://doi.org/10.1136/bmj.327.7414.557
Xiong Y, Wang L, Liu W, Hankey GJ, Xu B, Wang S (2015) The prognostic significance of right bundle branch block: a meta-analysis of prospective cohort studies. Clin Cardiol 38(10):604–613. https://doi.org/10.1002/clc.22454
Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM, ESC Scientific Document Group (2022) ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: Developed by the Task Force on cardiac pacing and cardiac resynchronization therapy of the European Society of Cardiology (ESC) With the special contribution of the European Heart Rhythm Association (EHRA). Rev Esp Cardiol (Engl Ed). 75(5):430. https://doi.org/10.1016/j.rec.2022.04.004
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland J, Coats A, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M et al (2021) 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 42(36):3599–3726. https://doi.org/10.1093/eurheartj/ehab368
Funding
No funding was received for the present study.
Author information
Authors and Affiliations
Contributions
The corresponding author guarantees that all authors meet each of the following characteristics defined by the International Committee of Medical Journal Editors in the criteria for authorship of scientific articles: Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; Drafting the work or revising it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical standards
The manuscript does not contain clinical studies or patient data.
Supplementary Information
Below is the link to the electronic supplementary material.
392_2022_2105_MOESM2_ESM.tif
Supplemental Figure 1. Cumulative meta-analysis shows that the association of Bundle Branch Block with an increased risk of all-cause mortality was not statistically significant until 2008. Afterwards the effect was consistent over time being the increasing statistical significance the only effect of the progressive accumulation of evidence (TIF 61 kb)
392_2022_2105_MOESM3_ESM.tif
Supplemental Figure 2. Sensitivity analysis (in which one study at a time was excluded and the rest analysed) showed that the HR ranged from 1.11 to 1.12, indicating that the calculated effect was not unduly caused by the contribution of a single study (TIF 61 kb)
392_2022_2105_MOESM4_ESM.tif
Supplemental Figure 3A, 3B, 3C and 3D. Forest plots of hazard risks (HRs) with 95% confidence intervals (CIs) of other outcomes for Bundle Branch Block (BBB) (TIF 77 kb)
Rights and permissions
Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Aguiló, O., Castells, X., Miró, Ò. et al. The prognostic significance of bundle branch block in acute heart failure: a systematic review and meta-analysis. Clin Res Cardiol 112, 1020–1043 (2023). https://doi.org/10.1007/s00392-022-02105-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00392-022-02105-z