Counterclockwise and Clockwise Rotation of QRS Transitional Zone: Prospective Correlates of Change and Time‐Varying Associations With Cardiovascular Outcomes

BACKGROUND: A few studies have recently reported clockwise and counterclockwise rotations of QRS transition zone as predictors of mortality. However, their prospective correlates and associations with individual cardiovascular disease (CVD) outcomes are yet to be investigated. METHODS AND RESULTS: Among 13 567 ARIC (Atherosclerosis Risk in Communities) study participants aged 45 to 64 years, we studied key correlates of changes in the status of clockwise and counterclockwise rotation over time as well as the association of rotation status with incidence of coronary heart disease (2408 events), heart failure (2196 events), stroke (991 events), composite CVD (4124 events), 898 CVD deaths, and 3469 non‐CVD deaths over 23 years of follow‐up. At baseline, counterclockwise rotation was most prevalent (52.9%), followed by no (40.5%) and clockwise (6.6%) rotation. Of patients with no rotation, 57.9% experienced counterclockwise or clockwise rotation during follow‐up, with diabetes mellitus and black race significantly predicting clockwise and counterclockwise conversion, respectively. Clockwise rotation was significantly associated with higher risk of heart failure (hazard ratio, 1.20; 95% confidence interval [CI], 1.02–1.41) and non‐CVD death (hazard ratio, 1.28; 95% CI, 1.12–1.46) after adjusting for potential confounders including other ECG parameters. On the contrary, counterclockwise rotation was significantly related to lower risk of composite CVD (hazard ratio, 0.93; 95% CI, 0.87–0.99]), CVD mortality (hazard ratio, 0.76; 95% CI, 0.65–0.88), and non‐CVD deaths (hazard ratio, 0.92; 95% CI, 0.85–0.99 [borderline significance with heart failure]). CONCLUSIONS: Counterclockwise rotation, the most prevalent QRS transition zone pattern, demonstrated the lowest risk of CVD and mortality, whereas clockwise rotation was associated with the highest risk of heart failure and non‐CVD mortality. These results have implications on how to interpret QRS transition zone rotation when ECG was recorded.