Prognostic value of low QRS voltage in patients with acute coronary syndrome

Abstract

I have read the article by Tan et al. [ [1] Tan N.S. Goodman S.G. Yan R.T. et al. GRACE ECG substudy and Canadian ACS I Registry investigators. Prognostic significance of low QRS voltage on the admission electrocardiogram in acute coronary syndromes. Int. J. Cardiol. 2015; 190: 34-39 Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar ] with great interest, recently published in your journal. Authors reported that low QRS voltage was found to be an independent predictor of in-hospital mortality, and there was a consistent trend toward higher 6-month cumulative mortality in patients with acute coronary syndrome (ACS) and low QRS voltage. In the present study of Tan et al. there are no data about patient group medications on admission and at discharge. It is well known that optimal medical therapy significantly reduces in-hospital and long term mortality in ACS patients. According to guidelines, it is recommended to use statins, angiotensin-converting enzyme inhibitors (ACEI)/angiotensin-receptor blockers (ARB), oral beta-blockers, long term acetylsalicylic acid, and dual antiplatelet therapy for at least 12 months to reduce the mortality in ACS patients [ 2 Steg P.G. James S.K. Atar D. et al. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur. Heart J. 2012; 33: 2569-2619 Crossref PubMed Scopus (139) Google Scholar , 3 Hamm C.W. Bassand J.P. Agewall S. et al. ESC Committee for Practice Guidelines. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur. Heart J. 2011; 32: 2999-305 Google Scholar ]. In addition, approximately half of the patients have impaired left ventricle systolic function in the present study of Tan et al. It has been demonstrated that aldosterone antagonists reduce mortality significantly in post-ST elevation myocardial infarction patients with left ventricle systolic dysfunction (ejection fraction <40%) [ [4] Pitt B. Remme W. Zannad F. et al. Eplerenone post-acute myocardial infarction heart failure efficacy and survival study investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N. Engl. J. Med. 2003; 348: 1309-1321 Crossref PubMed Scopus (4028) Google Scholar ]. Therefore, Authors should state the incidence of treatment with statins, dual antiplatelet therapy, beta-blockers, aldosterone antagonists, and ACEI/ARB for both groups and compare the groups regarding their medications. Less medication with optimal medical therapy may be another significant reason for higher mortality rates in patients with low QRS voltage.