Physiological Changes in QRS Fragmentation in Athletes and Nonathletes without Cardiac Disease

Background/Objectives: QRS fragmentation has not been linked with increased mortality in individuals without known cardiac disease. We aimed to investigate the physiological determinants of QRS fragmentation in individuals without cardiac disease. Methods: Study participants were 163 (54 athletes, 109 nonathletes) asymptomatic individuals with QRS fragmentation but without cardiac disease. QRS fragmentation was assessed in the supine position after deep inspiration or standing up and during exercise. The changes in QRS fragmentation were evaluated over a median follow-up period of 2.3 (0.8-4.9) years. Results: The most common lead with QRS fragmentation was III (63.0% in athletes, 61.5% in nonathletes), immediately followed by V1 (50.0%) and aVF (42.6%) in athletes and aVF (55.0%) in nonathletes. QRS fragmentation in V1 was more frequent in athletes compared to nonathletes (p < 0.001). Among athletes, the presence of QRS fragmentation in V1 could be independently predicted by increased RVOTproxi (right ventricular outflow tract proximal diameter indexed to body surface area) (p < 0.001). Among individuals with QRS fragmentation in V1, deep inspiration resulted in disappearance of QRS fragmentation more frequently in nonathletes compared to athletes (100% vs. 20%, p = 0.003). Deep inspiration resulted in disappearance of QRS fragmentation in aVF (p < 0.001). The presence of QRS fragmentation in II or aVF was associated with increased body mass index (BMI) (p = 0.003). Among athletes without QRS fragmentation in V1 at baseline, the appearance of QRS fragmentation in V1 at the end of follow-up was associated with greater training age (p = 0.034). Among individuals with QRS fragmentation in aVF at baseline, the disappearance of QRS fragmentation in aVF at the end of follow-up was associated with greater reduction in BMI (p = 0.008). Conclusions: The characteristic feature of QRS fragmentation in athletes was the presence of QRS fragmentation in V1, which was associated with RVOTproxi. The persistence of QRS fragmentation in V1 after deep inspiration could serve as a specific marker of exercise-training-related cardiac adaptation. The presence of QRS fragmentation in the leads of the frontal plane was influenced by BMI and respiration phase.