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The available prognostic studies have differing results but some suggest that end QRS notching and slurring, particularly when occurring in the inferior leads or accompanied by downward sloping ST segments, have associated risk. The differences in the studies appear to be due to terminology and methodology issues as well as design shortcomings.
The available prognostic studies have differing results but some suggest that end QRS notching and slurring, particularly when occurring in the inferior leads or accompanied by downward sloping ST segments, have associated risk. The differences in the studies appear to be due to terminology and methodology issues as well as design shortcomings.


A total of 8 prognostic studies are available as on February 2013 (summarized on the [https://docs.google.com/spreadsheet/pub?hl=en&hl=en&key=0AhMCIH0M0pLYdGFhMVlGQ2RpX3VVUnJlYk1DRzlnU2c&single=true&gid=2&output=html Prognostic ''ER'' studies] spreadsheet).
A total of 8 prognostic studies are available as on February 2013. These are summarized in the table below.
 
{| class="wikitable" border="0" cellpadding="0" cellspacing="0"
|-
!style="background:#D9F0F4;" colspan="16"|''Prognostic ER Studies''
|-
|
|
|
|
|
|
|
|
|
|
!''Prevalence''
|
|
|
!''Include in Criteria*''
|
|-
!Lead Author
!Year, Journal
!Population Size
!Female (%)
!African Descent (%)
!Mean age (SD)
!FU yrs
!End Points
!Design
!Nationality
!''ERP''
!CVD* Hazard
!Measurement (1mm)
!Leads
!J waves /slurs
!ST elevation
|-
|Tikkannen
|2009, NEJM
|10,864
|48
|0
|44 ± 8
|30
|CV mortality, arrythmic deaths
|community based, prospective
|Finnish
|5.8%
|2-3x inferior only
|vis*, 2 contig*
|Inf*, Lat*
|yes
|no
|-
|Sinner
|2010, PLOS
|1,945
|51
|0
|35-54
|18.9
|CV mortality
|MONICA, case control, enhanced with deaths*
|German
|13%
|2-4X
|vis, 2 contig
|Inf, Lat
|yes
|no
|-
|Uberio 
|2011, Circ
|29,281
|13
|13
|55 ±14
|7.6
|CV mortality
|clinic based, prospective
|USA
|14%
|none
|GE12L* ST0* /vis
|Inf, Lat
|yes
|yes
|-
|Haruta
|2011, Circ
|5,976
|56
|0
|45
|24
|CV mortality, unexpected deaths
|atomic bomb survivors
|Japan
|24%
|none, unexplained deaths only
|vis, 2 contig
|Inf, Lat
|yes
|yes
|-
|Olson
|2011, EHJ
|15,141
|56
|27
|54 ± 6
|17
|Sudden Cardiac Death
|ARIC population based, prospective
|USA
|STE 12.3%
|1.2x (white females 2x )
|GE12L ST0 (J-pt)
|Ant*, Inf, Lat
|no
|yes
|-
|Stavrakis
|2012, ANEC
|825ER, 255controls
|1
|40
|49 ± 12
|6.4
|all-cause mortality
|clinic based, case control
|USA
|NA
|NA, 1.5x all cause
|vis, 2 contig
|Inf, Lat
|yes
|no
|-
|Rollin
|2012, AJC
|1,161
|48
|0
|50 ± 9
|14.2
|CV mortality
|MONICA, prospective
|French
|13%
|3 to 8x inf and lat
|vis, 2 contig
|Inf, Lat
|yes
|no*
|-
|Hisamatsu
|2013, Circ Japan
|7,630
|59
|0
|52 ± 4
|15
|CV mortality
|National Circ Survey
|Japan
|STE* 3.5%
|2.5x, anterior leads (>2mm)
|vis, any lead
|Ant, Inf, Lat
|no
|yes
|-
|bgcolor="D9F0F4" colspan="16"|'''Key:'''
|-
|bgcolor="EEE8AA" colspan="16"|
*'''''Include in Criteria = no if not at all or only considered ST slope or level in ECGs with J waves/slurs'''''
|-
|bgcolor="F5F9FA" colspan="16"|
*'''CVD''' = ''cardiac death''
|-
|bgcolor="FFFFE0" colspan="16"|
*'''STE''' = ''ST elevation only''
|-
|bgcolor="FFFFE0" colspan="16"|
*'''vis''' = ''visual''
*'''contig''' = ''contiguous''
*'''GE12 L''' = ''general electric MUSE program''
*'''ST0''' = ''ST at zero msec, beginning of ST segment [J-point]''
|-
|bgcolor="FFFFE0" colspan="16"|
*'''Inf''' = ''inferior III, aVF, II''
*'''Lat''' = ''lateral (V456, I, aVL)''
*'''Ant''' = ''anterior (V123)''
|}


Clearly the best follow up study and one unlikely to be duplicated is that by Tikkannen et al. This classic study was only ''limited'' by non-computerized ECG acquisition; the paper ECG recordings from over 30 years ago (requiring using the ''adjacent lead'' criteria for accuracy unlike modern ECG analyses that rely on waveforms averaged over 10 seconds).  
Clearly the best follow up study and one unlikely to be duplicated is that by Tikkannen et al. This classic study was only ''limited'' by non-computerized ECG acquisition; the paper ECG recordings from over 30 years ago (requiring using the ''adjacent lead'' criteria for accuracy unlike modern ECG analyses that rely on waveforms averaged over 10 seconds).  
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A 5th study was that of Rollins et al with the French participants in the Monica Study. It was a retrospective study of 1,161 southwestern French subjects 35 to 64 years old. This relatively small study without isolating risk to the inferior leads is hard to reconcile with the larger Finnish study. Some of the examples they provide of high risk ECGs puts their conclusions in doubt.  
A 5th study was that of Rollins et al with the French participants in the Monica Study. It was a retrospective study of 1,161 southwestern French subjects 35 to 64 years old. This relatively small study without isolating risk to the inferior leads is hard to reconcile with the larger Finnish study. Some of the examples they provide of high risk ECGs puts their conclusions in doubt.  
A sixth and seventh studies by Olson et al and Hisamatsu et al were excellent population studies but did not consider R wave downslope phenomena (Haïssaguerre Pattern) but only ST elevation and included the anterior leads. Uberoi et al from the Veterans Affairs was one of the largest multi-ethnic population studies and considered R wave downslope phenomena (Haïssaguerre Pattern) as well as ST elevation.


[[Image:projects_repolarization_2.svg|300px|right|thumbnail|The figure shows where the CSE experts indicated that these measurements be made.]]
[[Image:projects_repolarization_2.svg|300px|right|thumbnail|The figure shows where the CSE experts indicated that these measurements be made.]]


These eight studies are summarized in this spreadsheet [https://docs.google.com/spreadsheet/pub?hl=en&hl=en&key=0AhMCIH0M0pLYdGFhMVlGQ2RpX3VVUnJlYk1DRzlnU2c&single=true&gid=2&output=html Prognostic ''ER'' studies].
A sixth and seventh studies by Olson et al and Hisamatsu et al were excellent population studies but did not consider R wave downslope phenomena (Haïssaguerre Pattern) but only ST elevation and included the anterior leads. Uberoi et al from the Veterans Affairs was one of the largest multi-ethnic population studies and considered R wave downslope phenomena (Haïssaguerre Pattern) as well as ST elevation.
   
   
Studies that have used the same population as a study summarized but considered confounders are not listed but worthy of mention is the study of Perez which found a risk in non-African Americans as opposed to African Americans and a Finnish sub-study which found risk isolated to those with downsloping ST depression. Also of mention, is the study of Uberoi demonstrating any risk of R wave downslope phenomena to be dependent on accompanying Q waves and/or T wave inversion.
Studies that have used the same population as a study summarized but considered confounders are not listed but worthy of mention is the study of Perez which found a risk in non-African Americans as opposed to African Americans and a Finnish sub-study which found risk isolated to those with downsloping ST depression. Also of mention, is the study of Uberoi demonstrating any risk of R wave downslope phenomena to be dependent on accompanying Q waves and/or T wave inversion.
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===ECG Measuement Issues===
===ECG Measuement Issues===
Before the prognostic significance of the Haïssaguerre Pattern can be demonstrated, there must be agreement on what measurments should be made. It appears that for stable ECG patterns with a QRS duration (including an end QRS slur J wave/slur) less than 120 msec, we should follow the CSE Measurement statement (1985)and consider the J point (also known as QRS end, J-junction, ST0[zero msec] or ST beginning) to occur after the R wave downslope notch/slur/or J wave as determined across all 12 leads. And that the measurement baseline be set in an interval immediately preceding QRS onset as per the CSE Measurement statement. Some of the bizarre and dynamic ECGs may require other rules for measurments but for now the CSE statement should be followed.
Before the prognostic significance of the Haïssaguerre Pattern can be demonstrated, there must be agreement on what measurments should be made. It appears that for stable ECG patterns with a QRS duration (including an end QRS slur J wave/slur) less than 120 msec, we should follow the CSE Measurement statement (1985)and consider the J point (also known as QRS end, J-junction, ST0[zero msec] or ST beginning) to occur after the R wave downslope notch/slur/or J wave as determined across all 12 leads. And that the measurement baseline be set in an interval immediately preceding QRS onset as per the CSE Measurement statement. Some of the bizarre and dynamic ECGs may require other rules for measurments but for now the CSE statement should be followed.


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