{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T06:19:12Z","timestamp":1787725152301,"version":"build-2784847793"},"reference-count":40,"publisher":"Oxford University Press (OUP)","issue":"3","license":[{"start":{"date-parts":[[2016,6,23]],"date-time":"2016-06-23T00:00:00Z","timestamp":1466640000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"funder":[{"DOI":"10.13039\/100008497","name":"Boston Scientific","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100008497","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100004359","name":"Swedish Research Council","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100004359","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Swedish Heart and Lung Foundation"},{"DOI":"10.13039\/501100004348","name":"Stockholm County Council","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100004348","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2017,3,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>Symptom severity assessed by NYHA functional class and QRS duration are essential criteria for selection of heart failure (HF) patients for CRT. This study assessed the relationship between NYHA class, QRS duration, and survival in a nationwide HF registry.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and results<\/jats:title>\n                    <jats:p>We studied 13 423 patients with HF in NYHA class II\u2013IV and LVEF &amp;lt;40% in the Swedish Heart Failure Registry. Survival was followed via the Swedish Population Registry. Of 12 534 patients without CRT (age 71 \u00b1 12 years, 29% women), 51% and 49% were in NYHA class II and III\u2013IV, respectively. Patients in NYHA class II compared with class III\u2013IV were younger (69 vs. 73 years), and had a better systolic function (49% vs. 58% with LVEF &amp;lt;30%), P &amp;lt;0.001 for all, and a favourable co-morbidity profile. QRS duration was 116 \u00b1 29 ms in NYHA class II and 119 \u00b1 29 ms in NYHA class III\u2013IV with QRS \u2265120 ms found in 37% vs. 44%, and an LBBB in 23% vs. 28% (P &amp;lt; 0.001 for all). Upon multivariable Cox regression adjusting for 40 clinically relevant variables, mortality risk was higher in NYHA class III\u2013IV vs. class II, with a hazard ratio (HR) of 1.31, 95% confidence interval (CI) 1.23\u20131.40. Mortality was also higher with QRS prolongation \u2265120 ms vs. narrow QRS. The HR in NYHA class II patients with non-LBBB was 1.19 (95% CI 1.05 \u2212 1.36) and in those with LBBB it was 1.16 (95% CI 1.03\u20131.41). The corresponding HRs in NYHA class III\u2013IV were 1.33 (95% CI 1.21\u20131.47) and 1.12 (95% CI 1.02\u20131.22). There was no significant interaction between the effects of NYHA class and QRS duration or morphology on mortality. Applying different scenarios to estimate guideline adherence, fewer patients with NYHA class II (range 14.4\u201342.6%) compared with NYHA class III\u2013IV (18.0\u201345.4%) had received a CRT device when indicated.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>In HF with reduced LVEF, QRS prolongation is common and independently linked to worse survival. The increase in mortality risk associated with QRS prolongation of both LBBB and non-LBBB morphology is similar in NYHA class II and III\u2013IV.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/ejhf.563","type":"journal-article","created":{"date-parts":[[2016,6,25]],"date-time":"2016-06-25T10:53:21Z","timestamp":1466852001000},"page":"366-376","source":"Crossref","is-referenced-by-count":34,"title":["New York Heart Association Functional Class, Qrs Duration, and Survival in Heart Failure with Reduced Ejection Fraction: Implications for Cardiac Resychronization Therapy"],"prefix":"10.1093","volume":"19","author":[{"given":"Frieder","family":"Braunschweig","sequence":"first","affiliation":[{"name":"Karolinska Institutet, Department of Medicine , Stockholm ,","place":["Sweden"]},{"name":"Karolinska University Hospital, Department of Cardiology , Stockholm ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cecilia","family":"Linde","sequence":"additional","affiliation":[{"name":"Karolinska Institutet, Department of Medicine , Stockholm ,","place":["Sweden"]},{"name":"Karolinska University Hospital, Department of Cardiology , Stockholm ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lina","family":"Benson","sequence":"additional","affiliation":[{"name":"Karolinska Institutet, Department of Clinical Science and Education, South Hospital , Stockholm ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcus","family":"St\u00e5hlberg","sequence":"additional","affiliation":[{"name":"Karolinska Institutet, Department of Medicine , Stockholm ,","place":["Sweden"]},{"name":"Karolinska University Hospital, Department of Cardiology , Stockholm ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ulf","family":"Dahlstr\u00f6m","sequence":"additional","affiliation":[{"name":"Department of Cardiology and Department of Medicine and Health Sciences, Link\u00f6ping University , Link\u00f6ping ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lars H.","family":"Lund","sequence":"additional","affiliation":[{"name":"Karolinska Institutet, Department of Medicine , Stockholm ,","place":["Sweden"]},{"name":"Karolinska University Hospital, Department of Cardiology , Stockholm ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2016,6,23]]},"reference":[{"key":"2026011721180493800_ejhf563-bib-0001","doi-asserted-by":"crossref","first-page":"1126","DOI":"10.1161\/01.CIR.102.10.1126","article-title":"Evidence of improving prognosis in heart failure: trends in case fatality in 66 547 patients hospitalized between 1986 and 1995","volume":"102","author":"MacIntyre","year":"2000","journal-title":"Circulation"},{"key":"2026011721180493800_ejhf563-bib-0002","doi-asserted-by":"crossref","first-page":"300","DOI":"10.1016\/j.ehj.2003.12.012","article-title":"Decreasing one-year mortality and hospitalization rates for heart failure in Sweden; data from the Swedish Hospital Discharge Registry 1988 to 2000","volume":"25","author":"Schaufelberger","year":"2004","journal-title":"Eur Heart J"},{"key":"2026011721180493800_ejhf563-bib-0003","doi-asserted-by":"crossref","first-page":"208","DOI":"10.1093\/oxfordjournals.eurheartj.a015223","article-title":"The epidemiology of heart failure","volume":"18","author":"Cowie","year":"1997","journal-title":"Eur Heart J"},{"key":"2026011721180493800_ejhf563-bib-0004","doi-asserted-by":"crossref","first-page":"933","DOI":"10.1016\/j.ejheart.2008.08.005","article-title":"ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM)","volume":"10","author":"Dickstein","year":"2008","journal-title":"Eur J Heart Fail"},{"key":"2026011721180493800_ejhf563-bib-0005","first-page":"253","volume-title":"Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels","author":"The Criteria Committee of the New York Heart Association","year":"1994","edition":"9th ed"},{"key":"2026011721180493800_ejhf563-bib-0006","doi-asserted-by":"crossref","first-page":"476","DOI":"10.1136\/hrt.2006.089656","article-title":"Limitations of the New York Heart Association functional classification system and self-reported walking distances in chronic heart failure","volume":"93","author":"Raphael","year":"2007","journal-title":"Heart"},{"key":"2026011721180493800_ejhf563-bib-0007","doi-asserted-by":"crossref","first-page":"S204","DOI":"10.1016\/S0002-8703(98)70251-0","article-title":"Clinical definition and epidemiology of advanced heart failure","volume":"135","author":"Adams","year":"1998","journal-title":"Am Heart J"},{"key":"2026011721180493800_ejhf563-bib-0008","doi-asserted-by":"crossref","first-page":"1236","DOI":"10.1016\/j.healun.2011.05.012","article-title":"Selecting patients for heart transplantation: comparison of the Heart Failure Survival Score (HFSS) and the Seattle Heart Failure Model (SHFM)","volume":"30","author":"Goda","year":"2011","journal-title":"J Heart Lung Transplant"},{"key":"2026011721180493800_ejhf563-bib-0009","doi-asserted-by":"crossref","first-page":"529","DOI":"10.1093\/eurheartj\/ehs305","article-title":"Prevalence, correlates, and prognostic significance of QRS prolongation in heart failure with reduced and preserved ejection fraction","volume":"34","author":"Lund","year":"2013","journal-title":"Eur Heart J"},{"key":"2026011721180493800_ejhf563-bib-0010","doi-asserted-by":"crossref","first-page":"1539","DOI":"10.1056\/NEJMoa050496","article-title":"The effect of cardiac resynchronization on morbidity and mortality in heart failure","volume":"352","author":"Cleland","year":"2005","journal-title":"N Engl J Med"},{"key":"2026011721180493800_ejhf563-bib-0011","doi-asserted-by":"crossref","first-page":"2140","DOI":"10.1056\/NEJMoa032423","article-title":"Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure","volume":"350","author":"Bristow","year":"2004","journal-title":"N Engl J Med"},{"key":"2026011721180493800_ejhf563-bib-0012","doi-asserted-by":"crossref","first-page":"1834","DOI":"10.1016\/j.jacc.2008.08.027","article-title":"Randomized trial of cardiac resynchronization in mildly symptomatic heart failure patients and in asymptomatic patients with left ventricular dysfunction and previous heart failure symptoms","volume":"52","author":"Linde","year":"2008","journal-title":"J Am Coll Cardiol"},{"key":"2026011721180493800_ejhf563-bib-0013","doi-asserted-by":"crossref","first-page":"1329","DOI":"10.1056\/NEJMoa0906431","article-title":"Cardiac-resynchronization therapy for the prevention of heart-failure events","volume":"361","author":"Moss","year":"2009","journal-title":"N Engl J Med"},{"key":"2026011721180493800_ejhf563-bib-0014","doi-asserted-by":"crossref","first-page":"2385","DOI":"10.1056\/NEJMoa1009540","article-title":"Cardiac-resynchronization therapy for mild-to-moderate heart failure","volume":"363","author":"Tang","year":"2010","journal-title":"N Engl J Med"},{"key":"2026011721180493800_ejhf563-bib-0015","doi-asserted-by":"crossref","first-page":"803","DOI":"10.1093\/eurjhf\/hfs105","article-title":"ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC","volume":"14","author":"McMurray","year":"2012","journal-title":"Eur J Heart Fail"},{"key":"2026011721180493800_ejhf563-bib-0016","doi-asserted-by":"crossref","first-page":"2281","DOI":"10.1093\/eurheartj\/eht150","article-title":"2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA)","volume":"34","author":"Brignole","year":"2013","journal-title":"Eur Heart J"},{"key":"2026011721180493800_ejhf563-bib-0017","doi-asserted-by":"crossref","first-page":"2793","DOI":"10.1093\/eurheartj\/ehv316","article-title":"2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: the Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC) Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC)","volume":"36","author":"Priori","year":"2015","journal-title":"Eur Heart J"},{"key":"2026011721180493800_ejhf563-bib-0018","doi-asserted-by":"crossref","first-page":"260","DOI":"10.1016\/j.ahj.2011.11.014","article-title":"Effect of QRS morphology on clinical event reduction with cardiac resynchronization therapy: meta-analysis of randomized controlled trials","volume":"163","author":"Sipahi","year":"2012","journal-title":"Am Heart J"},{"key":"2026011721180493800_ejhf563-bib-0019","doi-asserted-by":"crossref","first-page":"1454","DOI":"10.1001\/archinternmed.2011.247","article-title":"Impact of QRS duration on clinical event reduction with cardiac resynchronization therapy: meta-analysis of randomized controlled trials","volume":"171","author":"Sipahi","year":"2011","journal-title":"Arch Intern Med"},{"key":"2026011721180493800_ejhf563-bib-0020","doi-asserted-by":"crossref","first-page":"3547","DOI":"10.1093\/eurheartj\/eht290","article-title":"An individual patient meta-analysis of five randomized trials assessing the effects of cardiac resynchronization therapy on morbidity and mortality in patients with symptomatic heart failure","volume":"34","author":"Cleland","year":"2013","journal-title":"Eur Heart J"},{"issue":"Suppl 1","key":"2026011721180493800_ejhf563-bib-0021","doi-asserted-by":"crossref","first-page":"i1","DOI":"10.1093\/europace\/euu300","article-title":"Statistics on the use of cardiac electronic devices and electrophysiological procedures in the European Society of Cardiology countries: 2014 report from the European Heart Rhythm Association","volume":"17","author":"Raatikainen","year":"2015","journal-title":"Europace"},{"key":"2026011721180493800_ejhf563-bib-0022","doi-asserted-by":"crossref","first-page":"2108","DOI":"10.1001\/jama.2012.14785","article-title":"Association between use of renin\u2013angiotensin system antagonists and mortality in patients with heart failure and preserved ejection fraction","volume":"308","author":"Lund","year":"2012","journal-title":"JAMA"},{"key":"2026011721180493800_ejhf563-bib-0023","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1093\/eurjhf\/hfp175","article-title":"Heart failure registry: a valuable tool for improving the management of patients with heart failure","volume":"12","author":"Jonsson","year":"2010","journal-title":"Eur J Heart Fail"},{"key":"2026011721180493800_ejhf563-bib-0024","doi-asserted-by":"crossref","DOI":"10.1007\/978-1-4757-3294-8","volume-title":"Modeling Survival Data: Extending the Cox Model","author":"Therneau","year":"2000"},{"key":"2026011721180493800_ejhf563-bib-0025","doi-asserted-by":"crossref","first-page":"2183","DOI":"10.1016\/j.jacc.2005.01.071","article-title":"Significance of QRS complex duration in patients with heart failure","volume":"46","author":"Kashani","year":"2005","journal-title":"J Am Coll Cardiol"},{"key":"2026011721180493800_ejhf563-bib-0026","doi-asserted-by":"crossref","first-page":"143D","DOI":"10.1016\/S0002-9149(98)01016-9","article-title":"Potential benefit of biventricular pacing in patients with congestive heart failure and ventricular tachyarrhythmia","volume":"83","author":"Stellbrink","year":"1999","journal-title":"Am J Cardiol"},{"key":"2026011721180493800_ejhf563-bib-0027","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1046\/j.1460-9592.2003.00010.x","article-title":"Beneficial effects of biventricular pacing in patients with a \u2018narrow\u2019 QRS","volume":"26","author":"Gasparini","year":"2003","journal-title":"Pacing Clin Electrophysiol"},{"key":"2026011721180493800_ejhf563-bib-0028","doi-asserted-by":"crossref","first-page":"491","DOI":"10.1016\/j.ejheart.2006.11.003","article-title":"Prevalence of ECG abnormalities in an international survey of patients with suspected or confirmed heart failure at death or discharge","volume":"9","author":"Khan","year":"2007","journal-title":"Eur J Heart Fail"},{"key":"2026011721180493800_ejhf563-bib-0029","doi-asserted-by":"crossref","first-page":"398","DOI":"10.1067\/mhj.2002.121264","article-title":"Left bundle-branch block is associated with increased 1-year sudden and total mortality rate in 5517 outpatients with congestive heart failure: a report from the Italian network on congestive heart failure","volume":"143","author":"Baldasseroni","year":"2002","journal-title":"Am Heart J"},{"key":"2026011721180493800_ejhf563-bib-0030","doi-asserted-by":"crossref","first-page":"696","DOI":"10.1016\/j.ejheart.2008.05.001","article-title":"The prevalence and incidence of left bundle branch block in ambulant patients with chronic heart failure","volume":"10","author":"Clark","year":"2008","journal-title":"Eur J Heart Fail"},{"key":"2026011721180493800_ejhf563-bib-0031","doi-asserted-by":"crossref","first-page":"1133","DOI":"10.1161\/01.CIR.0000118502.91105.F6","article-title":"Characterization of left ventricular activation in patients with heart failure and left bundle-branch block","volume":"109","author":"Auricchio","year":"2004","journal-title":"Circulation"},{"key":"2026011721180493800_ejhf563-bib-0032","doi-asserted-by":"crossref","first-page":"956","DOI":"10.1016\/j.ahj.2013.03.013","article-title":"Left ventricular mechanical dyssynchrony by cardiac magnetic resonance is greater in patients with strict vs nonstrict electrocardiogram criteria for left bundle-branch block","volume":"165","author":"Andersson","year":"2013","journal-title":"Am Heart J"},{"key":"2026011721180493800_ejhf563-bib-0033","doi-asserted-by":"crossref","first-page":"438","DOI":"10.1016\/j.jacc.2008.04.036","article-title":"Predicting the long-term effects of cardiac resynchronization therapy on mortality from baseline variables and the early response a report from the CARE-HF (Cardiac Resynchronization in Heart Failure) Trial","volume":"52","author":"Cleland","year":"2008","journal-title":"J Am Coll Cardiol"},{"key":"2026011721180493800_ejhf563-bib-0034","doi-asserted-by":"crossref","first-page":"604","DOI":"10.1002\/clc.22454","article-title":"The prognostic significance of right bundle branch block: a meta-analysis of prospective cohort studies","volume":"38","author":"Xiong","year":"2015","journal-title":"Clin Cardiol"},{"key":"2026011721180493800_ejhf563-bib-0035","doi-asserted-by":"crossref","first-page":"2022","DOI":"10.1161\/CIRCULATIONAHA.110.956011","article-title":"Bundle-branch block morphology and other predictors of outcome after cardiac resynchronization therapy in Medicare patients","volume":"122","author":"Bilchick","year":"2010","journal-title":"Circulation"},{"key":"2026011721180493800_ejhf563-bib-0036","doi-asserted-by":"crossref","first-page":"873","DOI":"10.1056\/NEJM200103223441202","article-title":"Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay","volume":"344","author":"Cazeau","year":"2001","journal-title":"N Engl J Med"},{"key":"2026011721180493800_ejhf563-bib-0037","doi-asserted-by":"crossref","first-page":"1845","DOI":"10.1056\/NEJMoa013168","article-title":"Cardiac resynchronization in chronic heart failure","volume":"346","author":"Abraham","year":"2002","journal-title":"N Engl J Med"},{"key":"2026011721180493800_ejhf563-bib-0038","doi-asserted-by":"crossref","first-page":"2450","DOI":"10.1093\/eurheartj\/ehp359","article-title":"The European cardiac resynchronization therapy survey","volume":"30","author":"Dickstein","year":"2009","journal-title":"Eur Heart J"},{"key":"2026011721180493800_ejhf563-bib-0039","doi-asserted-by":"crossref","first-page":"1694","DOI":"10.1056\/NEJMoa1401426","article-title":"Survival with cardiac-resynchronization therapy in mild heart failure","volume":"370","author":"Goldenberg","year":"2014","journal-title":"N Engl J Med"},{"key":"2026011721180493800_ejhf563-bib-0040","doi-asserted-by":"crossref","first-page":"2592","DOI":"10.1093\/eurheartj\/eht160","article-title":"Long-term impact of cardiac resynchronization therapy in mild heart failure: 5-year results from the REsynchronization reVErses Remodeling in Systolic left vEntricular dysfunction (REVERSE) study","volume":"34","author":"Linde","year":"2013","journal-title":"Eur Heart J"}],"container-title":["European Journal of Heart Failure"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.wiley.com\/onlinelibrary\/tdm\/v1\/articles\/10.1002%2Fejhf.563","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/api.wiley.com\/onlinelibrary\/tdm\/v1\/articles\/10.1002%2Fejhf.563","content-type":"unspecified","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/academic.oup.com\/eurjhf\/article-pdf\/19\/3\/366\/66331030\/eurjhf_19_3_366.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/eurjhf\/article-pdf\/19\/3\/366\/66331030\/eurjhf_19_3_366.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,18]],"date-time":"2026-01-18T02:19:24Z","timestamp":1768702764000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/eurjhf\/article\/19\/3\/366\/8418836"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2016,6,23]]},"references-count":40,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2016,6,23]]},"published-print":{"date-parts":[[2017,3,1]]}},"URL":"https:\/\/doi.org\/10.1002\/ejhf.563","relation":{},"ISSN":["1388-9842","1879-0844"],"issn-type":[{"value":"1388-9842","type":"print"},{"value":"1879-0844","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2017,3]]},"published":{"date-parts":[[2016,6,23]]}}}