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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.

journal of the american heart association

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