Abnormal electrocardiographic QRS transition zone and risk of mortality in individuals free of cardiovascular disease

Aims We examined the prognostic significance of abnormal electrocardiographic QRS transition zone (clockwise and counterclockwise horizontal rotations) in individuals free of cardiovascular disease (CVD). Methods and results A total of 5541 adults (age 53 +/- 10.4 years, 54% women, 24% non-Hispanic black, 25% Hispanic) without CVD or any major electrocardiogram (ECG) abnormalities from the US Third National Health and Nutrition Examination Survey were included in this analysis. Clockwise and counterclockwise horizontal rotations were defined from standard 12-lead ECG using Minnesota ECG Classification. Mortality and cause of death were assessed through 2006. At baseline, 282 participants had clockwise rotation and 3500 had counterclockwise rotation. During a median follow of 14.6 years, 1229 deaths occurred of which 415 were due to CVD. In multivariable-adjusted Cox proportional hazard analysis and compared with normal rotation, clockwise rotation was significantly associated with increased risk of all-cause mortality {hazard ratio (HR) [95% confidence interval (CI)]: 1.43 (1.15-1.78); P = 0.002} and CVD mortality [HR (95% CI): 1.61 (1.09, 2.37) P = 0.016]. In contrast, counterclockwise rotation was associated with significantly lower risk of all-cause mortality [HR (95% CI): 0.86 (0.76, 0.97); P = 0.017] and non-significant association with CVD mortality [HR (95% CI): 1.07 (0.86, 1.33); P = 0.549]. These results were consistent in subgroup analysis stratified by age, sex, and race. Conclusion In a diverse community-based population free of CVD and compared with normal rotation, clockwise rotation was associated with increased risk of all-cause and CVD mortality while counterclockwise rotation was associated with lower risk of all-cause mortality and non-significant association with CVD mortality. These findings call for attention to these often neglected ECG markers, and probably call for revising the current definition of normal rotation.