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ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 3  |  Page : 1071-1075

Fragmented QRS: a novel marker of cardiovascular diseases in patients with erectile dysfunction


1 Department of Dermatology and Andrology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Radio-Diagnosis, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Cardiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission26-Jan-2022
Date of Decision09-Apr-2022
Date of Acceptance10-Apr-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Hosna EL-Sayed Ali EL-Nager
Tala, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_38_22

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  Abstract 


Background
The most common cause of erectile dysfunction (ED) is vascular insufficiency. Fragmented QRS (fQRS) is an ECG marker of myocardial ischemia in patients with coronary artery disease.
Objectives
To evaluate if the fQRS by ECG can be detected earlier and if it is possible to track simpler markers of cardiovascular involvement in patients with arteriogenic ED than pharmaco-penile duplex ultrasonography.
Patients and methods
A total of 100 patients with ED were included. They were classified according to International Index of Erectile Function-5 and subjected to detailed history taking, thorough clinical examination, and imaging studies, including pharmaco-penile duplex ultrasonography and ECG, to detect fQRS.
Results
The presence of fQRS was significantly different among the studied groups (P = 0.005), as 66.7% of patients with severe ED and 60% of patients with moderate ED had fQRS, whereas 28.6% of patients with mild–moderate ED and 24% of patients with mild ED had fQRS. fQRS was more specific (83%) than sensitive (56%), with an accuracy of 72% in arteriogenic ED prediction.
Conclusion
fQRS is an efficient specific and simple marker of arteriogenic ED. Absent fQRS can exclude the arteriogenic ED, and the patient could be considered normal or venogenic.

Keywords: cardiovascular diseases, ECG, erectile dysfunction, fragmented QRS, pharmaco-penile duplex ultrasonography


How to cite this article:
Bazid HA, Maree AH, Ali EL-Nager HE, Alghannam MB, Elkersh AM. Fragmented QRS: a novel marker of cardiovascular diseases in patients with erectile dysfunction. Menoufia Med J 2022;35:1071-5

How to cite this URL:
Bazid HA, Maree AH, Ali EL-Nager HE, Alghannam MB, Elkersh AM. Fragmented QRS: a novel marker of cardiovascular diseases in patients with erectile dysfunction. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:1071-5. Available from: http://www.mmj.eg.net/text.asp?2022/35/3/1071/359504




  Introduction Top


Erectile dysfunction (ED) is defined as the inability to initiate or maintain an erection long enough to have a satisfying sexual relationship[1]. Although ED is a multifaceted process, vascular insufficiency is a common cause, accounting for up to 80% of cases[2]. The size of the artery hypothesis explains the association between ED and coronary artery disease (CAD), implying that atherosclerosis damages small vessels more than bigger vessels and that when atherosclerosis affects coronary circulation, the damage to the penile artery is greater[3].

Pharmaco-penile duplex ultrasonography (PPDU) is an effective, minimally invasive approach for individuals with ED who have failed to respond to oral erectogenic medications (ED). PPDU is used as part of the ED evaluation to determine the quality of arterial blood flow and the sufficiency of veno-occlusive mechanisms, both of which are required for a good erection[4].

The most common procedure for diagnosing heart abnormalities is ECG[5]. In patients with CAD, a fragmented QRS (fQRS) is a reliable ECG sign of myocardial ischemia. As a new, useful, and reliable ECG finding, fQRS has sparked a lot of interest.

Das et al.[6] were the first to define it as the presence of notched R or S waves in the original QRS complex that is not followed by a typical branch block or extra spikes akin to the RSR model 120 ms[6]. Therefore, this work aimed to assess if detecting a fQRS on an ECG could be a better and earlier indicator of cardiovascular involvement in patients with arteriogenic ED than PPDU.


  Patients and methods Top


The sample was calculated (to achieve the full potential of the study of 80% and to detect the difference with a significance level of 5% and confidence interval of 95%). It was estimated that 100 participants were recruited in the study[7]. Before the start of the study, all participants provided written informed consent, which was validated by our institute's local ethical committee and was in conformity with the Helsinki Declaration of 1975 (updated in 2000). The exclusion criteria were a history of ischemic cardiac diseases and the presence of any other organic causes of ED such as hormonal causes, neurogenic causes, drug-induced ED, pyronine disease, and psychogenic ED. All patients were subjected to the following: full history taking, including personal history comprising name, age, sex, and specific habits like smoking, alcoholism, and addiction, and also marital history as well as present history, including detailed sexual history regarding onset, course, duration of ED, libido, ejaculation, orgasm, sexual habits, extramarital relationships, and coital frequency. According to the International Index of Erectile Function-5 questionnaire, the severity of ED in all individuals was determined based on sexual activity in the previous 6 months[8]. The patients were divided into four ED groups based on their scores: mild to moderate (score of 5–7), moderate (score of 8–11), severe (score of 5–7) (score of 12–16), and mild (score of 17–21). Psychological history, including depression, anxiety, and marital conflict, was also taken into consideration. Medical history, including diabetes, drug intake, history of trauma and operations, and history of systemic diseases such as atherosclerosis or cardiovascular system affection, was also accounted for. General examination was conducted, accounting for signs of systemic diseases and secondary sex characteristics. The local genital examination also was conducted to assess the presence of any abnormality. Imaging studies included ECG to detect fQRS at the cardiology department. When no bundle branch block was observed in two contiguous leads representing the region of a major coronary artery, the fQRS was characterized as a QRS with varied RSR patterns or notched R or S waves, with a length of 120 ms[6]. PPDU images were taken after the stoppage of oral erectogenic drugs (PDE5Is) for 48 h for sildenafil/vardenafil and 96 h for tadalafil at the radiology department according to the guidelines of the Australasian Society for Ultrasound in Medicine (ASUM)[9].

Statistical analysis

Statistical Package for the Social Sciences (SPSS), version 19 was used to aggregate, tabulate, and statistically analyze data on an IBM personal computer (SPSS Inc., Chicago, Illinois, USA). Quantitative data were presented in the form of mean, SD, and range, and qualitative data were presented in the form of numbers and percentages. Analytical statistics were employed to find out the possible link between examined components and the targeted disease. The χ2 test (nonparametric test) was used to investigate the relationship between two qualitative variables, whereas the Kruskal–Wallis test (parametric test) was used to investigate the relationship between two quantitative variables. Mann–Whitney (U) test was used to compare nonparametric data.


  Results Top


This study was conducted on 100 patients with ED. Their age range was 41–66 years, with mean ± SD of 56.1 ± 7.47 years. Cases were classified according to IEEF into the mild group (25 cases), with IEEF within 19–23 and mean ± SD of 21.4 ± 1.65; the mild to moderate group (35 cases), with IEEF within 12–16 and mean ± SD of 14.1 ± 1.47, the moderate group (25 cases), with IEEF within 8–11 and mean ± SD of 10.2 ± 1.19; and the severe group (15 cases), with IEEF within 4–7 and mean ± SD of 6.73 ± 0.88. Regarding clinical data of the studied cases, 57 (57%) of the cases were smokers, whereas 43 (43%) were nonsmokers. There was no history of alcohol intake or addiction in our cases. A total of 38 (38%) cases were diabetic and 34 (34%) were hypertensive. Regarding radiological findings, there were 41 cases with fQRS, whereas the other 59 cases did not have fQRS. According to the penile duplex ultrasonography, 32 cases were normal, 33 cases arteriogenic, and 35 were venogenic.

Regarding the relationship between fQRS and demographic and clinical data, there was a significant relationship between the presence of fQRS and the age of the studied group, smoking, diabetes mellitus, and the duration of the disease (P = 0.021, 0.006, 0.001, and 0.001, respectively). There was a significant relationship between PPDU results of the cases regarding the presence of fQRS (P < 0.001), as 56.1% of the cases with fQRS had arteriogenic Doppler. However, only 22% with fQRS had venogenic, and only 22% with fQRS had normal results [Table 1].
Table 1: Relation between fragmented QRS and demographic and clinical data and pharmaco-penile duplex ultrasonography results of studied cases (n=100)

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Regarding the relationship between PPDU results and demographic and clinical data, there was a significant relationship between PPDU results and the age of the studied patients, smoking, diabetes mellitus, hypertension, and the duration of the disease (P = 0.001, 0.011, 0.001, 0.046, and 0.001, respectively) [Table 2].
Table 2: Relation between Doppler results and demographic and clinical data

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Regarding the ECG results, the presence of fQRS was significantly different among the studied groups (P = 0.005), as 66.7% of patients with severe ED and 60% of patients with moderate ED had fQRS, whereas 28.6% of patients with mild-to-moderate ED and 24% of patients with mild ED had fQRS. Regarding the PPDU results, Doppler results were significantly different among the studied groups (P < 0.001) as 46.7% of the cases with severe ED and 44% of cases with moderate ED had arteriogenic ED. Only 28.6% of mild-to-moderate had arteriogenic ED and 20% of mild cases had arteriogenic ED [Table 3].
Table 3: Comparison between studied groups regarding their fragmented QRS and pharmaco-penile duplex ultrasonography results

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fQRS is more specific (83%) than sensitive (56%) with an accuracy of 72% in the prediction of arteriogenic ED, with a positive predictive value of 70% and a negative predictive value of 73%.


  Discussion Top


The inability to initiate or maintain a sufficient erection to engage in a satisfying sexual relationship is known as ED[1]. ED can be categorized into three kinds, according to the International Society of Impotence Research: organic (which includes iatrogenic, neurogenic, vasculogenic, and hormonal), psychogenic, and mixed ED. To prevent making a mistake during diagnosis, a multi-specialty team should conduct a thorough evaluation[10].

Vascular insufficiency is the most common cause of ED, and vascular assessment has historically played a substantial role in ED estimation[11]. Arterial insufficiency and corporal veno-occlusive dysfunction are two types of vascular insufficiency. Cavernosometry was used to estimate the integrity of the cavernosal artery inflow as well as the veno-occlusive mechanism before the development of PPDU. PPDU, on the contrary, is a beneficial, less intrusive approach that is frequently employed after oral erectogenic medications have failed. It also takes less time and requires fewer specialized tools and equipment than cavernosometry[12].

However, unfortunately, multiple conditions could affect the result of the PPDU, including the psychogenic condition of the patients, such as anxiety, which causes excessive sympathetic discharge, reducing the effect of intracavernous injection of vasoactive drugs. This could eventually lead to a false diagnosis. Moreover, variation of the patient anatomy of the cavernosal artery in position, number, or its abnormal branching could lead to a false diagnosis. A narrowed segment of the artery forces blood to increase velocity, which leads to a false impression of normal velocity (stenosis acceleration). Variation of the timing of the test and its technique, which depend on the experience of the operator, position of the probe, or angle of application, could also affect the result of the test[13]. Besides, the complications of intracavernous injection of vasoactive drugs such as prolonged erection, priapism, pain, fibrosis, and faulty injection may occur. Moreover, a systemic complication may occur such as hypotension owing to systemic absorption of the drug, and hepatic toxicity; in addition, psychological complications may occur[14].

ECG is becoming the most commonly used cardiac diagnostic test. Over the last two centuries, ECG technology and clinical utility have progressed steadily[6]. fQRS is an ECG-based diagnostic parameter of myocardial ischemia in patients with CAD. It has gotten a lot of attention as it is a simple, cost-effective, practical, dependable, easy-to-understand, and non-invasive ECG parameter for doctors. It is defined as the existence of either notched R or S waves not accompanied with a typical branch block or additional spikes similar to the RSR model in the original QRS complex, which was found to be shorter than 120 ms[15]. This study aimed to evaluate whether the presence of a fQRS on an ECG could be a better, faster, and easier prediction tool of cardiovascular involvement in individuals with arteriogenic ED rather than using the PPDU.

There was a significant relationship between PPDU results and ED severity, as 46.7% of the cases with severe ED and 44% of cases with moderate ED had arteriogenic ED, whereas only 28.6% of mild-to-moderate ED and 20% of mild ED cases had arteriogenic ED. Our result is supported by the previous study performed by Kendirci et al.[16], which showed that patients with CAD had severe ED with immensely poor blood flow parameters. They showed that the number of vascular risk factors was connected with an increased likelihood of having abnormal penile vascular parameters.

There was a significant relationship between PPDU results and cardiovascular risks, as 16 (48.5%) of the arteriogenic patients were smokers and 19 (57.6%) of them were diabetic. On the contrary, 16 (48.5of arteriogenic patients were hypertensive. This agrees with Rodriguez et al.[17], who stated that for ED, smoking is a separate risk factor. Tobacco smoking damages endothelial cells directly, including decreased eNOS activity, increased adhesion expression, and impaired regulation of thrombotic factors. Moreover, Nehra[18] and Ibrahim et al.[19] showed that ED is a common diabetic adverse effect, and diabetics are also more likely to experience cardiovascular problems.

Regarding the ECG findings, fQRS was present in 41 (41%) of the cases. There was a significant relationship between the presence of fQRS and ED severity, as 66.7% of patients with severe ED and 60% of patients who had moderate ED had fQRS, whereas only 28.6% of patients with mild-to-moderate and 24% of patients with mild ED had fQRS. Our results were supported by a previous study performed by Karabakan et al.[7]. Their findings revealed a substantial difference in the existence of fQRS between the severe, moderate, and mild-to-moderate ED groups (P ≤ 0.05). However, they stated that one of the study limitations was the absence of PPDU evaluation of the patients. Our results are also supported by a previous study performed by Bektaş et al.[20], who showed that despite the absence of overt CAD, the frequency of fQRS was greater in patients with ED. Furthermore, as the severity of ED increased, so did the frequency of fQRS.

There was a significant difference between fQRS and cardiovascular risks, as 30 (73.2%) of the cases with positive fQRS were smokers and 25 (61%) of them were diabetic. Our results are supported also by previous studies that showed the link between left ventricular failure and fQRS complexes in smokers[21] and with microalbuminuria in patients with type 2 diabetes mellitus[22]. To our knowledge, this is the first study to find a link between fQRS and PPDU outcomes, with 56% of those with fQRS having arteriogenic complex results, whereas only 22% with fQRS venogenic and only 22% with fQRS had normal results. Moreover, this study showed that fQRS had 83% specificity and 56% of sensitivity as a predictive tool of arteriogenic ED with a value of 72% for accuracy.


  Conclusion Top


Finally, we have concluded that fQRS is a good specific, simple marker of arteriogenic ED. Absent fQRS can exclude the arteriogenic ED and the patient could be considered normal or venogenic. Although its presence suggested that the patient may be arteriogenic, further cardiovascular workouts and PPDU should be carried out. According to our findings, we believe that including an ECG record in routine ED evaluation, even if the patient has no cardiologic complaints, will provide valuable information for assessing their cardiovascular health state and allowing for the early detection of CAD. As a result, incorporating a simple ECG parameter into clinical decision making for patients with ED may pave the way for a more thorough diagnosis of their underlying cardiovascular issues.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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