What is the clinical evidence from this study?

Study design: Observational. Population: Patients with immune checkpoint inhibitor-associated myocarditis hospitalized at Peking Union Medical College Hospital (n=60). Intervention: Admission electrocardiographic assessment including conduction and repolarization abnormalities with ECG burden scoring vs. No ECG abnormalities or low ECG burden score. Primary outcome: In-hospital occurrence of major adverse cardiovascular events (MACE) defined as myocarditis-related cardiogenic shock, high-degree atrioventricular block requiring pacing, or sustained ventricular tachycardia/fibrillation (HR not explicitly provided but ECG burden score improved model C-index from 0.726 to 0.941, p=<0.05 for multiple ECG abnormalities).

What question did this study set out to answer?

The study aimed to identify electrocardiographic predictors of major adverse cardiovascular events in patients with immune checkpoint inhibitor–associated myocarditis.

February 22, 2026Cardio-Oncology1 citationsOpen Access

Electrocardiographic predictors of major adverse cardiovascular events in immune checkpoint inhibitor–associated myocarditis

Q: What are the key findings of this study?

Admission ECG abnormalities including QTc prolongation, atrioventricular block, QRS ≥120 ms, ST-segment and T-wave changes independently predicted MACE in ICI-associated myocarditis, with ECG burden score improving risk model C-index from 0.726 to 0.941.

Q: What does this research mean for the field?

Admission electrocardiographic abnormalities, including QTc prolongation, atrioventricular block, QRS ≥120 ms, and ST-T changes, independently predict major adverse cardiovascular events in immune checkpoint inhibitor-associated myocarditis and significantly improve risk stratification models. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

The study aimed to identify electrocardiographic predictors of major adverse cardiovascular events in patients with immune checkpoint inhibitor–associated myocarditis.

KZKanghao ZhouChinese Academy of Medical Sciences & Peking Union Medical College GLGuangcheng LiuChinese Academy of Medical Sciences & Peking Union Medical College BZBin ZhangChinese Academy of Medical Sciences & Peking Union Medical College

Key Result

Admission ECG abnormalities including QTc prolongation, atrioventricular block, QRS ≥120 ms, ST-segment and T-wave changes independently predicted MACE in ICI-associated myocarditis, with ECG burden score improving risk model C-index from 0.726 to 0.941.

Key Points

The study aimed to identify electrocardiographic predictors of major adverse cardiovascular events in patients with immune checkpoint inhibitor–associated myocarditis.
Retrospective analysis of 60 patients with immune checkpoint inhibitor myocarditis.
Patients stratified by occurrence of major adverse cardiovascular events defined by specific cardiac events.
Systematic adjudication of admission ECGs for conduction and repolarization abnormalities.
Use of multivariable Firth penalized Cox regression models to identify predictors of MACE.
Evaluation of model performance using C-index and reclassification metrics.
Major adverse cardiovascular events occurred in 21 out of 60 patients (35%).
ECG abnormalities such as QTc prolongation, QRS ≥ 120 ms, and atrioventricular block were significantly more common in the MACE group.
In multivariable analysis, several ECG parameters independently predicted MACE.
Adding ECG data significantly improved model performance (C-index values increased from 0.726 to 0.941).
Systematic ECG assessment greatly enhances risk stratification in high-risk myocarditis patients.

Study Design

Type

Observational (n=60)

Multicenter

Structured PICO

Do admission ECG abnormalities and a cumulative ECG burden score predict major adverse cardiovascular events in patients with immune checkpoint inhibitor-associated myocarditis?

Population

60 patients with immune checkpoint inhibitor (ICI)-associated myocarditis, median age 67.5 years, 71.7% male, treated at Peking Union Medical College Hospital (China).

Intervention

Admission electrocardiographic (ECG) parameters (QTc prolongation, QRS ≥120 ms, atrioventricular block, bundle branch block, ST-segment abnormalities, T-wave changes) and a derived ECG burden score (0-6).

Outcome

Major adverse cardiovascular events (MACE) during hospitalization, defined as myocarditis-related cardiogenic shock, high-degree atrioventricular block requiring temporary or permanent pacing, or sustained ventricular tachycardia (VT)/ventricular fibrillation (VF).composite

Admission ECG abnormalities and a cumulative ECG burden score are powerful, independent predictors of MACE in ICI-associated myocarditis, providing incremental prognostic value over clinical and biomarker features.

Main Result

Effect estimate: HR not explicitly provided but ECG burden score improved model C-index from 0.726 to 0.941

p-value: p=<0.05 for multiple ECG abnormalities

Limitations

Retrospective single-center design limits generalizability.
Small sample size (n=60) limits power and may introduce bias.
Lack of randomized control and potential confounding variables.
MACE definition restricted to in-hospital events; longer-term outcomes may differ.
Potential circularity in severity grading including ECG abnormalities, thus excluded from predictive models.

Abstract

Immune checkpoint inhibitor (ICI)–associated myocarditis carries a high risk of mortality, yet electrocardiographic (ECG) predictors of adverse outcomes remain unclear. The present study aimed to evaluate the predictive value of clinical and admission ECG parameters for major adverse cardiovascular events (MACE). We retrospectively analyzed 60 consecutive patients with ICI myocarditis. Patients were stratified according to the occurrence of major adverse cardiovascular events (MACE), defined as myocarditis-related cardiogenic shock, high-degree atrioventricular block requiring temporary or permanent pacing, or sustained ventricular tachycardia(VT)/ventricular fibrillation(VF). Admission ECGs were systematically adjudicated for conduction and repolarization abnormalities, and an ECG burden score (0–6) was derived. Univariable and multivariable Firth penalized Cox regression models were used to identify predictors of MACE. Model performance was evaluated using discrimination and reclassification metrics across nested models: M1 (clinical variables), M2 (M1 + biomarkers and echocardiography), and M3 (M2 + ECG burden score). Among the 60 patients with myocarditis, MACE occurred in 21 patients (35%) patients. Compared with the non-MACE group, QTc prolongation (p = 0.011), QRS ≥ 120 ms((p = 0.002), Atrioventricular block (p = 0.007), bundle branch block (p = 0.005), ST-segment abnormalities (p = 0.003), and T-wave changes (p = 0.004) at the time of admission were more common in the MACE group. In multivariable Firth penalized Cox analysis, severe myocarditis, QTc prolongation, Atrioventricular block, QRS ≥ 120 ms, ST-segment abnormalities, T-wave changes, and higher ECG burden score independently predicted MACE. Sensitivity analyses excluding early MACE or in-hospital deaths confirmed robustness of results. Addition of ECG variables significantly improved model performance (C-index 0.726 M1 vs. 0.860 M2 vs. 0.941 M3), with significant net reclassification and integrated discrimination gains. Admission ECG abnormalities are powerful, independent predictors of adverse outcomes in ICI myocarditis and provide substantial incremental prognostic value beyond clinical and biomarker/echocardiographic features. Systematic ECG assessment and integration into risk stratification should be prioritized for early triage and monitoring in this high-risk population.

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Cite This Study

Zhou et al. (Fri,) conducted a observational in Patients with immune checkpoint inhibitor-associated myocarditis hospitalized at Peking Union Medical College Hospital (n=60). Admission electrocardiographic assessment including conduction and repolarization abnormalities with ECG burden scoring vs. No ECG abnormalities or low ECG burden score was evaluated on In-hospital occurrence of major adverse cardiovascular events (MACE) defined as myocarditis-related cardiogenic shock, high-degree atrioventricular block requiring pacing, or sustained ventricular tachycardia/fibrillation (HR not explicitly provided but ECG burden score improved model C-index from 0.726 to 0.941, p=<0.05 for multiple ECG abnormalities). Admission ECG abnormalities including QTc prolongation, atrioventricular block, QRS ≥120 ms, ST-segment and T-wave changes independently predicted MACE in ICI-associated myocarditis, with ECG burden score improving risk model C-index from 0.726 to 0.941.

synapsesocial.com/papers/699a9cc6482488d673cd2858 https://doi.org/https://doi.org/10.1186/s40959-026-00455-5

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