Inter- and intra-observer variability of visual fragmented QRS scoring in ischemic and non-ischemic cardiomyopathy

Fragmented QRS (fQRS) on a 12-lead ECG has been linked with adverse outcome. However, the visual scoring of ECGs is prone to inter- and intra-observer variability.

Five observers, two experienced and three novel, assessed fQRS in 712 digital ECGs, 100 were re-evaluated to assess intra-observer variability. Fleiss and Cohen's Kappa were calculated and compared between subgroups.

The inter-observer variability for assessing fQRS in all leads combined was substantial with a Kappa of 0.651. Experienced observers only had a better agreement with a Kappa of 0.823. Intra-observer variability ranged from 0.736 to 0.880. In the subgroup with ventricular pacing the inter-observer variability was even significantly larger when compared to ECGs with normal QRS duration (Kappa 0.493 vs 0.664, p<0.001).

The visual assessment of QRS fragmentation is prone to inter- and intra-observer variability, mainly influenced by the experience of the observers, the underlying rhythm and QRS morphology.