Acute effect of cigarette smoking on frontal planar QRS-T angle in apparently healthy subjects with habitual smoking



Cigarette smoking, Frontal planar QRS-T angle, Electrocardiography, Nicotine


Aim: It has been well recognized that smoking exerts various detrimental cardiovascular effects. Although the effect of chronic smoking on cardiac electrophysiology is well known, little is known about the effect of acute smoking on surface ECG. Previous reports suggested that frontal planar QRS-T angle (fpQRS-Ta), measured by surface ECG, may be associated with ventricular arrhythmias and cardiac death. Hence, we primarily aimed to assess the effect of acute smoking on fpQRS-Ta.
Methods: A total of 92 apparently healthy subjects [44 female, 48 male, mean age 38.7(8.02) years] with smoking habit were enrolled in this prospective cohort study between May-July 2019. Demographic and clinical characteristics were recorded, and fpQRS-Ta together with some ECG parameters were noted before and 10 minutes after smoking for comparison. Spearman’s analysis was implemented to seek the probable correlation of the difference between pre- and post-smoking ECG parameters.
Results: Ten minutes after smoking, median heart rate, QRS duration and fpQRS-Ta increased significantly (72.6 beats/min vs 81.5 beats/min, P<0.001; 84 ms vs 86 ms, P=0.012; 14.5° vs 25°, P<0.001; respectively), while PR and QTc duration did not significantly change (150.0 ms vs 150.0 ms, P=0.774; and, 423.5 ms vs 429.5 ms, P=0.372). In Spearman’s correlation analysis, the difference between pre- and post-smoking fpQRS-Ta significantly and negatively correlated with C-reactive protein (CRP) levels (r: -0.272, P=0.027).
Conclusion: Acute smoking may widen fpQRS-Ta in healthy habitual smokers, and serum CRP negatively correlates with the degree of fpQRS-Ta widening. Our observation may further enlighten the pathophysiological mechanism of smoking in cardiac arrhythmias and sudden death.


Download data is not yet available.


Akşit E, Bakar C, Özerdogan Ö, Yıldırım ÖT, Aydın F, Aydın AH, et al. The effect of health warning labels on cigarette packages on patients who applied to cardiology clinic. J Surg Med. 2018;2(3):303-9. Doi: 10.28982/josam.435234.

Ambrose JA, Barua RS. The pathophysiology of cigarette smoking and cardiovascular disease: an update. J Am Coll Cardiol. 2004;43(10):1731-7. Doi: 10.1016/j.jacc.2003.12.047.

Bullen C. Impact of tobacco smoking and smoking cessation on cardiovascular risk and disease. Expert Review of Cardiovascular Therapy. 2008;6(6):883-95. Doi: 10.1586/14779072.6.6.883.

D'Alessandro A, Boeckelmann I, Hammwhoner M, Goette A. Nicotine, cigarette smoking and cardiac arrhythmia: an overview. Eur J Prev Cardiol. 2012;19(3):297-305. Doi: 10.1177/1741826711411738.

Akbarzadeh MA, Yazdani S, Ghaidari ME, Asadpour-Piranfar M, Bahrololoumi-Bafruee N, Golabchi A, et al. Acute effects of smoking on QT dispersion in healthy males. ARYA Atherosclerosis. 2014;10(2):89-93.

Karakaya O, Barutcu I, Kaya D, Esen AM, Saglam M, Melek M, et al. Acute effect of cigarette smoking on heart rate variability. Angiology. 2007;58(5):620-4. Doi: 10.1177/0003319706294555.

Wang H, Shi H, Zhang L, Pourrier M, Yang B, Nattel S, et al. Nicotine is a potent blocker of the cardiac A-type K (+) channels. Effects on cloned Kv4.3 channels and native transient outward current. Circulation. 2000;102(10):1165-71. Doi: 10.1161/01.CIR.102.10.1165.

Aronow WS, Stemmer EA, Wood B, Zweig S, Tsao KP, Raggio L. Carbon monoxide and ventricular fibrillation threshold in dogs with acute myocardial injury. Am Heart J. 1978;95(6):754-6. Doi: 10.1016/0002-8703(78)90506-9.

Sheps DS, Herbst MC, Hinderliter AL, Adams KF, Ekelund LG, O'Neil JJ, et al. Production of arrhythmias by elevated carboxyhemoglobin in patients with coronary artery disease. Annals of Internal Medicine. 1990;113(5):343-51. Doi: 10.7326/0003-4819-113-5-343.

Narkiewicz K, van de Borne PJ, Hausberg M, Cooley RL, Winniford MD, Davison DE, et al. Cigarette smoking increases sympathetic outflow in humans. Circulation. 1998;98(6):528-34. Doi: 10.1161/01.cir.98.6.528.

Oehler A, Feldman T, Henrikson CA, Tereshchenko LG. QRS-T angle: a review. Ann Noninvasive Electrocardiol. 2014;19(6):534-42. Doi: 10.1111/anec.12206.

Zhang ZM, Prineas RJ, Case D, Soliman EZ, Rautaharju PM. Comparison of the prognostic significance of the electrocardiographic QRS/T angles in predicting incident coronary heart disease and total mortality (from the atherosclerosis risk in communities study). Am J Cardiol. 2007;100(5):844-9. Doi: 10.1016/j.amjcard.2007.03.104.

Tanriverdi Z, Unal B, Eyuboglu M, Bingol Tanriverdi T, Nurdag A, Demirbag R. The importance of frontal QRS-T angle for predicting non-dipper status in hypertensive patients without left ventricular hypertrophy. Clin Exp Hypertens. 2018;40(4):318-23. Doi: 10.1080/10641963.2017.1377214.

Lazzeroni D, Bini M, Camaiora U, Castiglioni P, Moderato L, Ugolotti PT, et al. Prognostic value of frontal QRS-T angle in patients undergoing myocardial revascularization or cardiac valve surgery. J Electrocardiol. 2018;51(6):967-72. Doi: 10.1016/j.jelectrocard.2018.08.028.

Aro AL, Huikuri HV, Tikkanen JT, Junttila MJ, Rissanen HA, Reunanen A, et al. QRS-T angle as a predictor of sudden cardiac death in a middle-aged general population. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2012;14(6):872-6. Doi: 10.1093/europace/eur393.

Chua KC, Teodorescu C, Reinier K, Uy-Evanado A, Aro AL, Nair SG, et al. Wide QRS-T Angle on the 12-Lead ECG as a Predictor of Sudden Death Beyond the LV Ejection Fraction. J Cardiovasc Electrophysiol. 2016;27(7):833-9. Doi: 10.1111/jce.12989.

May O, Graversen CB, Johansen MO, Arildsen H. The prognostic value of the frontal QRS-T angle is comparable to cardiovascular autonomic neuropathy regarding long-term mortality in people with diabetes. A population based study. Diabetes Research and Clinical Practice. 2018;142:264-8. Doi: 10.1016/j.diabres.2018.05.018.

Borleffs CJ, Scherptong RW, Man SC, van Welsenes GH, Bax JJ, van Erven L, et al. Predicting ventricular arrhythmias in patients with ischemic heart disease: clinical application of the ECG-derived QRS-T angle. Circ Arrhythm Electrophysiol. 2009;2(5):548-54. Doi: 10.1161/CIRCEP.109.859108.

Castro-Torres Y, Carmona-Puerta R, Katholi RE. Ventricular repolarization markers for predicting malignant arrhythmias in clinical practice. World J Clin Cases. 2015;3(8):705-20. Doi: 10.12998/wjcc.v3.i8.705.

Bazett H. An analysis of the time relations of electrocardiograms. Heart. 1920;7:353-70.

Kurisu S, Nitta K, Sumimoto Y, Ikenaga H, Ishibashi K, Fukuda Y, et al. Effects of deep inspiration on QRS axis, T-wave axis and frontal QRS-T angle in the routine electrocardiogram. Heart Vessels. 2019;34(9):1519-23. Doi: 10.1007/s00380-019-01380-7.

Middlekauff HR, Park J, Moheimani RS. Adverse effects of cigarette and noncigarette smoke exposure on the autonomic nervous system: mechanisms and implications for cardiovascular risk. J Am Coll Cardiol. 2014;64(16):1740-50. Doi: 10.1016/j.jacc.2014.06.1201.

Benowitz NL, Jacob P, 3rd, Jones RT, Rosenberg J. Interindividual variability in the metabolism and cardiovascular effects of nicotine in man. The Journal of Pharmacology and Experimental Therapeutics. 1982;221(2):368-72.

Karakaya O SM, Metin Esen A, Barutcu I, Ozdemir N, Yaymaci B, et al. Acute effect of cigarette smoking on ventricular repolarization paramaters. Kosuyolu Heart Journal. 2005;9(1):1-7.

Ari H, Ari S, Cosar S, Celiloglu N, Aktas I, Camci S, et al. The effect of varenicline on Tp-e interval, Tp-e/QT ratio and Tp-e/QTc ratio in healthy smokers and nonsmokers. Cardiol J. 2015;22(5):551-6. Doi: 10.5603/CJ.a2015.0038.

Ilgenli TF, Tokatli A, Akpinar O, Kilicaslan F. The Effects of Cigarette Smoking on the Tp-e Interval, Tp-e/QT Ratio and Tp-e/QTc Ratio. Advances in clinical and experimental medicine: official organ Wroclaw Medical University. 2015;24(6):973-8.

Singh K. Effect of smoking on QT interval, QT dispersion and rate pressure product. Indian Heart J. 2004;56(2):140-2.

Khosropanah Sh BM. The Acute Effect of Cigarette Smoking on QT Dispersion. Iran J Med Sci. 2002;27(2):56-9.

Brown RA, Schlegel TT. Diagnostic utility of the spatial versus individual planar QRS-T angles in cardiac disease detection. J Electrocardiol. 2011;44(4):404-9. Doi: 10.1016/j.jelectrocard.2011.01.001.

Scherptong RW, Henkens IR, Man SC, Le Cessie S, Vliegen HW, Draisma HH, et al. Normal limits of the spatial QRS-T angle and ventricular gradient in 12-lead electrocardiograms of young adults: dependence on sex and heart rate. J Electrocardiol. 2008;41(6):648-55. Doi: 10.1016/j.jelectrocard.2008.07.006.

Draisma HH, Schalij MJ, van der Wall EE, Swenne CA. Elucidation of the spatial ventricular gradient and its link with dispersion of repolarization. Heart rhythm. 2006;3(9):1092-9. Doi: 10.1016/j.hrthm.2006.05.025.

Saya S, Hennebry TA, Lozano P, Lazzara R, Schechter E. Coronary slow flow phenomenon and risk for sudden cardiac death due to ventricular arrhythmias: a case report and review of literature. Clin Cardiol. 2008;31(8):352-5. Doi: 10.1002/clc.20266.

Tracy RP, Psaty BM, Macy E, Bovill EG, Cushman M, Cornell ES, et al. Lifetime smoking exposure affects the association of C-reactive protein with cardiovascular disease risk factors and subclinical disease in healthy elderly subjects. Arterioscler Thromb Vasc Biol. 1997;17(10):2167-76. Doi: 10.1161/01.atv.17.10.2167.

Bermudez EA, Rifai N, Buring JE, Manson JE, Ridker PM. Relation between markers of systemic vascular inflammation and smoking in women. Am J Cardiol. 2002;89(9):1117-9. Doi: 10.1016/s0002-9149(02)02284-1.

Ugur MG, Kutlu R, Kilinc I. The effects of smoking on vascular endothelial growth factor and inflammation markers: A case-control study. The Clinical Respiratory Journal. 2018;12(5):1912-8. Doi: 10.1111/crj.12755.

Haass M, Kubler W. Nicotine and sympathetic neurotransmission. Cardiovascular Drugs and Therapy. 1997;10(6):657-65. Doi: 10.1007/bf00053022.

Gungor M, Celik M, Yalcinkaya E, Polat AT, Yuksel UC, Yildirim E, et al. The Value of Frontal Planar QRS-T Angle in Patients without Angiographically Apparent Atherosclerosis. Medical principles and practice. International Journal of the Kuwait University, Health Science Centre. 2017;26(2):125-31. Doi: 10.1159/000453267.






Research Article

How to Cite

Ozdemir L. Acute effect of cigarette smoking on frontal planar QRS-T angle in apparently healthy subjects with habitual smoking. J Surg Med [Internet]. 2020 Mar. 1 [cited 2024 Jul. 15];4(3):190-4. Available from: