{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T14:05:44Z","timestamp":1789740344811,"version":"4.0.1"},"reference-count":25,"publisher":"BMJ","issue":"9","license":[{"start":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T00:00:00Z","timestamp":1789689600000},"content-version":"unspecified","delay-in-days":17,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,8,21]]},"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To provide an updated and methodologically rigorous assessment of the association of fragmented QRS (fQRS) on ECG with mortality and other clinical outcomes in patients with pulmonary embolism (PE).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Systematic review and meta-analysis of observational studies using a DerSimonian-Laird random-effects model for all pooled analyses. Heterogeneity was assessed using the I\u00b2 statistic, with I\u00b2&gt;50% indicating substantial heterogeneity. Study quality was evaluated using the Newcastle-Ottawa Scale (NOS), and publication bias was assessed by funnel plot inspection.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>A systematic search of PubMed, Embase, Web of Science and Cochrane Library was conducted up to 13 August 2025. Observational studies investigating the association between fQRS and outcomes (mortality, cardiogenic shock, treatment escalation) in adults with confirmed PE were included. Patients were classified based on the presence or absence of fQRS on admission ECG.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Primary and secondary outcome measures<\/jats:title>\n                    <jats:p>The primary outcome was all-cause mortality (in-hospital and long-term). Secondary outcomes included cardiogenic shock and treatment escalation (thrombolysis, surgical embolectomy or mechanical ventilation).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Five studies involving 1383 patients were included. All included studies scored \u22657 on the NOS, indicating moderate-to-high methodological quality. The presence of fQRS was significantly associated with an increased risk of in-hospital mortality (OR 3.40; 95%\u2009CI 1.72 to 6.71; p=0.0004; I\u00b2=51%), long-term mortality (OR 3.90; 95%\u2009CI 1.80 to 8.47; p=0.0006; I\u00b2=47%) and cardiogenic shock (OR 4.88; 95%\u2009CI 1.70 to 14.01; p=0.003; I\u00b2=65%). No significant association was found with the use of thrombolysis, surgical embolectomy or mechanical ventilation. Funnel plot inspection revealed asymmetry, suggesting potential publication bias; however, formal testing was limited by the small number of included studies. Sensitivity analysis confirmed the robustness of the primary findings. All pooled estimates were derived from unadjusted effect sizes extracted from the primary studies.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>In this updated meta-analysis, fQRS was a robust and readily available risk marker for early and late mortality and cardiogenic shock in patients with PE. Standardised ECG interpretation may enhance risk stratification and guide early, intensive management. Further large-scale, prospective studies are warranted to validate these findings across diverse populations and to establish standardised criteria for fQRS assessment in this setting.<\/jats:p>\n                    <jats:p>CRD420251127962.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2026-120177","type":"journal-article","created":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T13:30:46Z","timestamp":1789738246000},"page":"e120177","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Association of fragmented QRS complex with mortality and clinical outcomes in patients with pulmonary embolism: an updated meta-analysis"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1148-0404","authenticated-orcid":false,"given":"Shangbo","family":"Xu","sequence":"first","affiliation":[{"name":"Department of Cardiology, Jieyang People\u2019s Hospital, Jieyang, Guangdong Province, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Weibiao","family":"Ji","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Jieyang People\u2019s Hospital, Jieyang, Guangdong Province, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yangbo","family":"Chen","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Jieyang People\u2019s Hospital, Jieyang, Guangdong Province, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Weihan","family":"Lin","sequence":"additional","affiliation":[{"name":"Department of Respiratory and Critical Care Medicine, Jieyang People\u2019s Hospital, Jieyang, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,9,18]]},"reference":[{"key":"2026091806301503000_16.9.e120177.1","doi-asserted-by":"crossref","first-page":"1336","DOI":"10.1001\/jama.2022.16815","article-title":"Acute Pulmonary Embolism: A Review","volume":"328","author":"Freund","year":"2022","journal-title":"JAMA"},{"key":"2026091806301503000_16.9.e120177.2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(11)61904-1"},{"key":"2026091806301503000_16.9.e120177.3","doi-asserted-by":"crossref","DOI":"10.1161\/JAHA.120.016784","article-title":"Time Trends in Pulmonary Embolism Mortality Rates in the United States, 1999 to 2018","volume":"9","author":"Martin","year":"2020","journal-title":"J Am Heart Assoc"},{"key":"2026091806301503000_16.9.e120177.4","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehz405"},{"key":"2026091806301503000_16.9.e120177.5","doi-asserted-by":"publisher","DOI":"10.1378\/chest.11-2301"},{"key":"2026091806301503000_16.9.e120177.6","doi-asserted-by":"crossref","DOI":"10.3390\/jcm14134750","article-title":"Prevalence of Electrocardiographic Abnormalities in Patients with Acute Pulmonary Embolism: A Systematic Review and Meta-Analysis","volume":"14","author":"Krintratun","year":"2025","journal-title":"J Clin Med"},{"key":"2026091806301503000_16.9.e120177.7","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9149(94)90237-2"},{"key":"2026091806301503000_16.9.e120177.8","doi-asserted-by":"publisher","DOI":"10.1183\/09031936.05.00119704"},{"key":"2026091806301503000_16.9.e120177.9","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1111\/anec.12278","article-title":"The value of electrocardiographic abnormalities in the prognosis of pulmonary embolism: a consensus paper","volume":"20","author":"Digby","year":"2015","journal-title":"Ann Noninvasive Electrocardiol"},{"key":"2026091806301503000_16.9.e120177.10","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.105.595892"},{"key":"2026091806301503000_16.9.e120177.11","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1159\/000522427","article-title":"Relationship between Fragmented QRS and Microvascular Dysfunction in Masked Hypertension","volume":"10","author":"Mahfouz","year":"2022","journal-title":"Pulse (Basel)"},{"key":"2026091806301503000_16.9.e120177.12","doi-asserted-by":"crossref","unstructured":"Jain R , Singh R , Yamini S , et al . . 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