Relations Between QRS|T Angle, Cardiac Risk Factors, and Mortality in the Third National Health and Nutrition Examination Survey (NHANES III)

Published:January 05, 2012DOI:
      On the surface electrocardiogram, an abnormally wide QRS|T angle reflects changes in the regional action potential duration profiles and in the direction of the repolarization sequence, which is thought to increase the risk of ventricular arrhythmia. We investigated the relation between an abnormal QRS|T angle and mortality in a nationally representative sample of subjects without clinically evident heart disease. We studied 7,052 participants ≥40 years old in the third National Health and Nutrition Examination Survey with 12-lead electrocardiograms. Those with self-reported or electrocardiographic evidence of a previous myocardial infarction, QRS duration of ≥120 ms, or history of heart failure were excluded. Borderline and abnormal spatial QRS|T angles were defined according to gender-specific 75th and 95th percentiles of frequency distributions. All-cause (1,093 women and 1,191 men) and cardiovascular (462 women and 455 men) mortality during the 14-year period was assessed through linkage with the National Death Index. On multivariate analyses, an abnormal spatial QRS|T angle was associated with an increased hazard ratio (HR) for cardiovascular mortality in women (HR 1.82, 95% confidence interval 1.05 to 3.14) and men (HR 2.21, 95% confidence interval 1.32 to 3.68). Also, the multivariate adjusted HR for all-cause mortality associated with an abnormal QRS|T angle was 1.30 (95% confidence interval 0.95 to 1.78) for women and 1.87 (95% confidence interval 1.29 to 2.7) for men. A borderline QRS|T angle was not associated with an increased risk of all-cause or cardiovascular mortality. In conclusion, an abnormal QRS|T angle, as measured on a 12-lead electrocardiogram, was associated with an increased risk of cardiovascular and all-cause mortality in this population-based sample without known heart disease.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Oikarinen L.
        • Nieminen M.S.
        • Viitasalo M.
        • Toivonen L.
        • Jern S.
        • Dahlöf B.
        • Devereux R.B.
        • Okin P.M.
        • LIFE Study Investigators
        QRS duration and QT interval predict mortality in hypertensive patients with left ventricular hypertrophy: the Losartan Intervention for Endpoint Reduction in Hypertension Study.
        Hypertension. 2004; 43: 1029-1034
        • Okin P.M.
        • Devereux R.B.
        • Fabsitz R.R.
        • Lee E.T.
        • Galloway J.M.
        • Howard B.V.
        Principal component analysis of the T wave and prediction of cardiovascular mortality in American Indians: the strong heart study.
        Circulation. 2002; 105: 714-719
        • Rautaharju P.M.
        • Ge S.
        • Nelson J.C.
        • Marino Larsen E.K.
        • Psaty B.M.
        • Furberg C.D.
        • Zhang Z.M.
        • Robbins J.
        • Gottdiener J.S.
        • Chaves P.H.
        Comparison of mortality risk for electrocardiographic abnormalities in men and women with and without coronary heart disease (from the cardiovascular health study).
        Am J Cardiol. 2006; 97: 309-315
        • Chugh S.S.
        • Reinier K.
        • Singh T.
        • Uy-Evanado A.
        • Socoteanu C.
        • Peters D.
        • Mariani R.
        • Gunson K.
        • Jui J.
        Determinants of prolonged QT interval and their contribution to sudden death risk in coronary artery disease: the Oregon sudden unexpected death study.
        Circulation. 2009; 119: 663-670
        • Voulgari C.
        • Tentolouris N.
        Assessment of the spatial QRS-T angle by vectorcardiography: current data and perspectives.
        Curr Cardiol Rev. 2009; 5: 251-262
        • Zhang Z.M.
        • Prineas R.J.
        • Case D.
        • Soliman E.Z.
        • Rautaharju P.M.
        • ARIC Research Group
        Comparison of the prognostic significance of the electrocardiographic QRS/T angles in predicting incident coronary heart disease and total mortality (from the atherosclerosis risk in communities study).
        Am J Cardiol. 2007; 100: 844-849
        • Kardys I.
        • Kors J.A.
        • van der Meer I.M.
        • Hofman A.
        • van der Kuip D.A.
        • Witteman J.C.
        Spatial QRS-T angle predicts cardiac death in a general population.
        Eur Heart J. 2003; 24: 1357-1364
        • Rautaharju P.M.
        • Kooperberg C.
        • Larson J.C.
        • LaCroix A.
        Electrocardiographic abnormalities that predict coronary heart disease events and mortality in postmenopausal women: the women's health initiative.
        Circulation. 2006; 113: 473-480
        • Yamazaki T.
        • Froelicher V.F.
        • Myers J.
        • Chun S.
        • Wang P.
        Spatial QRS-T angle predicts cardiac death in a clinical population.
        Heart Rhythm. 2005; 2: 73-78
        • Selvin E.
        • Manzi J.
        • Stevens L.A.
        • Van Lente F.
        • Lacher D.A.
        • Levey A.S.
        • Coresh J.
        Calibration of serum creatinine in the national health and nutrition examination surveys (NHANES) 1988–1994, 1999–2004.
        Am J Kidney Dis. 2007; 50: 918-926
        • Levey A.S.
        • Stevens L.A.
        • Schmid C.H.
        • Zhang Y.L.
        • Castro 3rd, A.F.
        • Feldman H.I.
        • Kusek J.W.
        • Eggers P.
        • Van Lente F.
        • Greene T.
        • Coresh J.
        • CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)
        A new equation to estimate glomerular filtration rate.
        Ann Intern Med. 2009; 150: 604-612
        • Blackburn H.
        • Keys A.
        • Simonson E.
        • Rautaharju P.
        • Punsar S.
        The electrocardiogram in population studies: a classification system.
        Circulation. 1960; 21: 1160-1175
        • Rautaharju P.M.
        • Park L.P.
        • Chaitman B.R.
        • Rautaharju F.
        • Zhang Z.-M.
        The novacode criteria for classification of ECG abnormalities and their clinically significant progression and regression.
        J Electrocardiol. 1998; 31: 157-187
        • Rautaharju P.M.
        • Prineas R.J.
        • Zhang Z.M.
        A simple procedure for estimation of the spatial QRS/T angle from the standard 12-lead electrocardiogram.
        J Electrocardiol. 2007; 40: 300-304
        • Atsma F.
        • Bartelink M.L.
        • van der Schouw Y.T.
        • Kors J.A.
        • Grobbee D.E.
        Elevated blood pressure and electrocardiographic frontal T axis and spatial QRS-T angle changes in postmenopausal women.
        J Electrocardiol. 2008; 41: 360-364
        • Dilaveris P.
        • Gialafos E.
        • Pantazis A.
        • Synetos A.
        • Triposkiadis F.
        • Gialafos J.
        The spatial QRS-T angle as a marker of ventricular repolarisation in hypertension.
        J Hum Hypertens. 2001; 15: 63-70
        • Voulgari Ch.
        • Tentolouris N.
        • Moyssakis I.
        • Dilaveris P.
        • Gialafos E.
        • Papadogiannis D.
        • Votteas V.
        • Cokkinos D.V.
        • Stefanadis C.
        • Katsilambros N.
        Spatial QRS-T angle: association with diabetes and left ventricular performance.
        Eur J Clin Invest. 2006; 36: 608-613
        • Dilaveris P.
        • Pantazis A.
        • Gialafos E.
        • Triposkiadis F.
        • Gialafos J.
        The effects of cigarette smoking on the heterogeneity of ventricular repolarization.
        Am Heart J. 2001; 142: 833-837
        • Borleffs C.J.
        • Scherptong R.W.
        • Man S.C.
        • van Welsenes G.H.
        • Bax J.J.
        • van Erven L.
        • Swenne C.A.
        • Schalij M.J.
        Predicting ventricular arrhythmias in patients with ischemic heart disease: clinical application of the ECG-derived QRS-T angle.
        Circ Arrhythm Electrophysiol. 2009; 2: 548-554
        • Brown R.A.
        • Schlegel T.T.
        Diagnostic utility of the spatial versus individual planar QRS-T angles in cardiac disease detection.
        J Electrocardiol. 2011; 44: 404-409
        • Schreurs C.A.
        • Algra A.M.
        • Man S.C.
        • Cannegieter S.C.
        • van der Wall E.E.
        • Schalij M.J.
        • Kors J.A.
        • Swenne C.A.
        The spatial QRS-T angle in the Frank vectorcardiogram: accuracy of estimates derived from the 12-lead electrocardiogram.
        J Electrocardiol. 2010; 43: 294-301
        • Pavri B.B.
        • Hillis M.B.
        • Subacius H.
        • Brumberg G.E.
        • Schaechter A.
        • Levine J.H.
        • Kadish A.
        • Defibrillators in Nonischemic Cardiomyopathy Treatment Evaluation (DEFINITE) Investigators
        Prognostic value and temporal behavior of the planar QRS-T angle in patients with nonischemic cardiomyopathy.
        Circulation. 2008; 117: 3181-3186