Shorter Minimum P-Wave Duration Is Associated with Paroxysmal Lone Atrial Fibrillation

Sex-Specific Changes in Cardiac Function and Electrophysiology During Progression of Adenine-Induced Chronic Kidney Disease in Mice

Chronic kidney disease (CKD) and cardiovascular disease (CVD) often co-exist, with notable sex-dependent differences in manifestation and progression despite both sexes sharing similar risk factors. Identifying sex-specific diagnostic markers in CKD-induced CVD could elucidate why the development and progression of these diseases differ by sex. Adult, C57BL/6J male and female mice were fed a high-adenine diet for 12 weeks to induce CKD, while control mice were given a normal diet. Adenine-treated males showed more severe CKD than females. Cardiac physiology was evaluated using electrocardiogram (ECG) and echocardiogram markers. Only adenine-treated male mice showed markers of left ventricular (LV) hypertrophy. Adenine males showed markers of LV systolic and diastolic dysfunction throughout regimen duration, worsening as the disease progressed. Adenine males had prolonged QTc interval compared to adenine females and control males. We identified a new ECG marker, Speak-J duration, which increased with disease progression and appeared earlier in adenine-treated males than in females. We identified sex-dependent differences in cardiac structure, function, and electrophysiology in a CKD-induced CVD mouse model, with adenine-treated males displaying markers of LV hypertrophy, dysfunction, and electrophysiological changes. This study demonstrates the feasibility of using this model to investigate sex-dependent cardiac differences resulting from CKD.

Prognostic significance of ratio of P-wave duration to P-wave vector magnitude for mortality in acute anterior myocardial infarction

BACKGROUND

The impact of P-wave abnormality in acute anterior MI, where the culprit vessel is the left anterior descending artery, remains undetermined. This study aimed to elucidate the impact of P-wave morphology on clinical outcomes in acute anterior MI.

METHODS

Patients undergoing emergent percutaneous coronary intervention for acute anterior MI were enrolled between September 2014 and April 2019 (derivation cohort) and May 2019 through July 2023 (validation cohort). P-wave duration (Pd) and P-wave vector magnitude (Pvm) were measured. The Pvm was calculated as the square root of the sum of the squared P-wave magnitudes in leads II and V6 and one-half of the P-wave amplitude in V2. The patients were categorized into high and low Pd/Pvm groups using a statistically derived cut-off value. The endpoint comprised the composite of heart failure (HF) hospitalization and all-cause death.

RESULTS

Consecutive 426 patients were enrolled in this study (derivation cohort, 213 patients; validation cohort, 216 patients). The calculated cut-off value of Pd/Pvm for predicting the clinical endpoint, determined through receiver operating curve analysis, was 793.5 ms/mV (area under the curve [AUC] = 0.85, sensitivity of 73.8 %, and specificity of 94.0 %) in the derivation cohort. Kaplan-Meier analyses revealed a significantly higher risk of the endpoint in patients with high Pd/Pvm than those with low Pd/Pvm in derivation and validation cohorts (Log-rank p < 0.001 and p < 0.001, respectively). Multivariate Cox proportional hazards analysis identified advanced age, elevated Pd/Pvm, and reduced left ventricular ejection fraction as independent and significant factors associated with the endpoint in the validation cohort (p = 0.008, p < 0.001, and p < 0.001, respectively).

CONCLUSION

High Pd/Pvm was significantly associated with the composite of HF hospitalization and all-cause death after acute anterior MI.

P-wave duration as a marker of atrial remodeling in patients referred to ablation for atrial fibrillation: A new stratification tool emerging?

Ablation of atrial fibrillation is one of the most widely applied invasive procedures in cardiovascular medicine, and populations with atrial fibrillation continuously rise. Recurrence rates are, however, consistently high, even in patients without severe comorbidities. Robust stratification algorithms to distinguish patients suitable for ablation are generally lacking. This is a fact caused by the inability to incorporate evidence of atrial remodeling and fibrosis, e.g., atrial remodeling, in the decision pathways. Cardiac magnetic resonance is a powerful tool in identifying fibrosis; however, it is costly and not routinely used. Electrocardiography has been generally underutilized in clinical practice during pre-ablative screening. One of the characteristics of the electrocardiogram that can give us valuable data depicting the existence and the extent of atrial remodeling and fibrosis is the duration of the P-wave. Currently, many studies support the implementation of P-wave duration in the routine practice of patient evaluation as a surrogate marker of existing atrial remodeling, that in turn predicts recurrence after ablation of atrial fibrillation. Further research is guaranteed to establish this electrocardiographic characteristic in our stratification quiver.

Electrocardiographic Predictors of Atrial Fibrillation

BACKGROUND

Atrial fibrillation (AF) is the most common pathological arrhythmia, and its complications lead to significant morbidity and mortality. However, patients with AF can often go undetected, especially if they are asymptomatic or have a low burden of paroxysms. Identification of those at high risk of AF development may help refine screening and management strategies.

METHODS

PubMed and Embase databases were systematically searched for studies looking at electrocardiographic predictors of AF from inception to August 2021.

RESULTS

A total of 115 studies were reported which examined a combination of atrial and ventricular parameters that could be electrocardiographic predictors of AF. Atrial predictors include conduction parameters, such as the PR interval, p-wave index and dispersion, and partial interatrial or advanced interatrial block, or morphological parameters, such as p-wave axis, amplitude and terminal force. Ventricular predictors include abnormalities in QRS amplitude, morphology or duration, QT interval duration, r-wave progression and ST segment, i.e., t-wave abnormalities.

CONCLUSIONS

There has been significant interest in electrocardiographic prediction of AF, especially in populations at high risk of atrial AF, such as those with an embolic stroke of undetermined source. This review highlights the breadth of possible predictive parameters, and possible pathological bases for the predictive role of each parameter are proposed.

P-wave durations from automated electrocardiogram analysis to predict atrial fibrillation and mortality in heart failure

BACKGROUND

P-wave indices have been used to predict incident atrial fibrillation (AF), stroke, and mortality. However, such indices derived from automated ECG measurements have not been explored for their predictive values in heart failure (HF). We investigated whether automated P-wave indices can predict adverse outcomes in HF.

METHODS

This study included consecutive Chinese patients admitted to a single tertiary centre, presenting with HF but without prior AF, and with at least one baseline ECG, between 1 January 2010 and 31 December 2016, with last follow-up of 31 December 2019.

RESULTS

A total of 2718 patients were included [median age: 77.4, interquartile range (IQR): (66.9-84.3) years; 47.9 males]. After a median follow-up of 4.8 years (IQR: 1.9-9.0 years), 1150 patients developed AF (8.8/year), 339 developed stroke (2.6/year), 563 developed cardiovascular mortality (4.3/year), and 1972 had all-cause mortality (15.1/year). Compared with 101-120 ms as a reference, maximum P-wave durations predicted new-onset AF at ≤90 ms [HR: 1.17(1.11, 1.50), P < 0.01], 131-140 ms [HR: 1.29(1.09, 1.54), P < 0.001], and ≥141 ms [HR: 1.52(1.32, 1.75), P < 0.001]. Similarly, they predicted cardiovascular mortality at ≤90 ms [HR: 1.50(1.08, 2.06), P < 0.001] or ≥141 ms [HR: 1.18(1.15, 1.45), P < 0.001], and all-cause mortality at ≤90 ms [HR: 1.26(1.04, 1.51), P < 0.001], 131-140 ms [HR: 1.15(1.01, 1.32), P < 0.01], and ≥141 ms [HR: 1.31(1.18, 1.46), P < 0.001]. These remained significant after adjusting for significant demographics, past co-morbidities, P-wave dispersion, and maximum P-wave amplitude.

CONCLUSIONS

Extreme values of maximum P-wave durations (≤90 ms and ≥141 ms) were significant predictors of new-onset AF, cardiovascular mortality, and all-cause mortality.

Short P-Wave Duration Is Associated with Incident Atrial Fibrillation

Atrial fibrillation (AF) is common and increases the risk for stroke and heart failure (HF). The early identification of patients at risk may prevent the development of AF and improve prognosis. This study, therefore, aimed to test the effect of the association between P-wave and PR-interval on the ECG and incident AF.The PIVUS (Prospective Investigation of the Vasculature in Uppsala Seniors) study (1016 individuals all aged 70 years; 50% women) was used to identify whether the ECG variables P-wave duration (Pdur) and PR-duration in lead V1 were related to new-onset AF. Exclusion criteria were prevalent AF, QRS-duration ≥ 130 milliseconds (msec), atrial tachyarrhythmias and implanted pacemaker/defibrillator. Cox proportional-hazards models were used for analyses. Adjustments were made for gender, RR-interval, beta-blocking agents, systolic blood pressure, body mass index, and smoking.Of 877 subjects at risk, 189 individuals developed AF during a 15-year follow-up. There was a U-shaped relationship between the Pdur and incident AF (P = 0.017) following multiple adjustment. Values below 60 msec were significantly associated with incident AF, with a hazard ratio of 1.55 (95% confidence interval 1.15-2.09) for a Pdur ≤ 42 msec. There was no significant relationship between incident AF and the PR-interval.A short Pdur derived from the ECG in V1 may be a useful marker for new-onset AF, enabling the early identification of at-risk patients.

P Wave Parameters and Indices: A Critical Appraisal of Clinical Utility, Challenges, and Future Research-A Consensus Document Endorsed by the International Society of Electrocardiology and the International Society for Holter and Noninvasive Electrocardiology

Atrial cardiomyopathy, characterized by abnormalities in atrial structure and function, is associated with increased risk of adverse cardiovascular and neurocognitive outcomes, independent of atrial fibrillation. There exists a critical unmet need for a clinical tool that is cost-effective, easy to use, and that can diagnose atrial cardiomyopathy. P wave parameters (PWPs) reflect underlying atrial structure, size, and electrical activation; alterations in these factors manifest as abnormalities in PWPs that can be readily ascertained from a standard 12-lead ECG and potentially be used to aid clinical decision-making. PWPs include P wave duration, interatrial block, P wave terminal force in V₁, P wave axis, P wave voltage, P wave area, and P wave dispersion. PWPs can be combined to yield an index (P wave index), such as the morphology-voltage-P-wave duration ECG risk score. Abnormal PWPs have been shown in population-based cohort studies to be independently associated with higher risks of atrial fibrillation, ischemic stroke, sudden cardiac death, and dementia. Additionally, PWPs, either individually or in combination (as a P wave index), have been reported to enhance prediction of atrial fibrillation or ischemic stroke. To facilitate translation of PWPs to routine clinical practice, additional work is needed to standardize measurement of PWPs (eg, via semiautomated or automated measurement), confirm their reliability and predictive value, leverage novel approaches (eg, wavelet analysis of P waves and machine learning algorithms), and finally, define the risk-benefit ratio of specific interventions in high-risk individuals. Our ultimate goal is to repurpose the ubiquitous 12-lead ECG to advance the study, diagnosis, and treatment of atrial cardiomyopathy, thus overcoming critical challenges in prevention of cardiovascular disease and dementia.

P-wave indices in Japanese patients with ischemic stroke: Implication of atrial myopathy in subtype of ischemic stroke

BACKGROUND

P-wave indices have been not fully studied in subtypes of ischemic stroke. We compared P-wave indices among embolic stroke, lacunar stroke and the control.

METHODS

P-wave duration, advanced interatrial block (aIAB) defined as P-wave duration ≥120 ms and biphasic (positive negative) morphology in inferior leads, and P-terminal force in lead V1 (PTFV1) were measured at the time of the first episode of cardioembolic stroke in 81 patients with paroxysmal atrial fibrillation (PAF), and in 64 patients with lacunar stroke, and compared with 100 control subjects. The latter two groups had no episode of PAF.

RESULTS

The age of participants was 76 ± 11 years. Age, sex distribution, body mass index and CHADS2 score were comparable among three groups. Maximum P-wave duration, the longest across 12 leads, was significantly prolonged in cardioembolic and lacuna stroke compared to the control; 118 ± 12 ms and 118 ± 11 ms vs. 110 ± 11 ms, respectively (P < 0.0001). P-wave duration ≥120 ms and aIAB were more prevalent in ischemic stroke groups than the control, and associated with a higher Odds ratio for stroke, more so in cardioembolic stroke. However, PTFV1 value and the prevalence of PTFV1 ≥ 4.0 ms·mV were significantly not different among the three groups. Abnormal P-wave duration and aIAB indicating the presence of atrial myopathy were present in cardioembolic and lacuna stroke.

CONCLUSION

Atrial myopathy was present in cardioembolic and lacunar stroke, but it can't be the direct cause of small vessel occlusion in lacunar stroke. Roles of atrial myopathy in each subtype of ischemic stroke should be studied.

Short P-Wave Duration is a Marker of Higher Rate of Atrial Fibrillation Recurrences after Pulmonary Vein Isolation: New Insights into the Pathophysiological Mechanisms Through Computer Simulations

Background Short ECG P-wave duration has recently been demonstrated to be associated with higher risk of atrial fibrillation (AF). The aim of this study was to assess the rate of AF recurrence after pulmonary vein isolation in patients with a short P wave, and to mechanistically elucidate the observation by computer modeling. Methods and Results A total of 282 consecutive patients undergoing a first single-pulmonary vein isolation procedure for paroxysmal or persistent AF were included. Computational models studied the effect of adenosine and sodium conductance on action potential duration and P-wave duration (PWD). About 16% of the patients had a PWD of 110 ms or shorter (median PWD 126 ms, interquartile range, 115 ms-138 ms; range, 71 ms-180 ms). At Cox regression, PWD was significantly associated with AF recurrence (P=0.012). Patients with a PWD <110 ms (hazard ratio [HR], 2.20; 95% CI, 1.24-3.88; P=0.007) and patients with a PWD ≥140 (HR, 1.87, 95% CI, 1.06-3.30; P=0.031) had a nearly 2-fold increase in risk with respect to the other group. In the computational model, adenosine yielded a significant reduction of action potential duration 90 (52%) and PWD (7%). An increased sodium conductance (up to 200%) was robustly accompanied by an increase in conduction velocity (26%), a reduction in action potential duration 90 (28%), and PWD (22%). Conclusions One out of 5 patients referred for pulmonary vein isolation has a short PWD which was associated with a higher rate of AF after the index procedure. Computer simulations suggest that shortening of atrial action potential duration leading to a faster atrial conduction may be the cause of this clinical observation.

P wave dispersion in patients with erectile dysfunction

Background and aims

P wave dispersion (PWD) has been reported to be a non-invasive electrocardiographic predictor for atrial fibrillation. The aim of this study is to evaluate PWD between men with erectile dysfunction (ED) and healthy controls in order to investigate whether PWD was prolonged in patients with ED and related to severity of the disease.

Methods

This study included a total of 72 men (42 patients with ED and 30 healthy controls). Demographic data and clinical features were recorded on admission. An electrocardiographic evaluation was obtained to measure PWD values for both patients and controls.

Results

Maximum P wave duration was 108.5 ± 4.7 and 108.3 ± 4.3 in ED group and control group, respectively (p = 0.748). Minumum P wave duration was significantly higher in the control group than in the ED group. PWD was 48.1 ± 5.9 in the ED group. As a result, PWD was prolonged in patients with ED (48.1 ± 5.9 vs. 38.0 ± 3.9, p < 0.05). A significant negative correlation was observed between IIEF score and PWD values (p < 0.05, r = −0.662).

Conclusions

Patients with ED exhibited prolonged PWD values compared with normal controls. In addition, PWD was found to be associated with severity of the disease.

Electrocardiogram (ECG) for the Prediction of Incident Atrial Fibrillation: An Overview

Electrocardiograms (ECGs) have been employed to medically evaluate participants in population-based studies, and ECG-derived predictors have been reported for incident atrial fibrillation (AF). Here, we reviewed the status of ECG in predicting new-onset AF. We surveyed population-based studies and revealed ECG variables to be risk factors for incident AF. When available, the predictive values of each ECG risk marker were calculated. Both the atrium-related and ventricle-related ECG variables were risk factors for incident AF, with significant hazard risks (HRs) even after multivariate adjustments. The risk factors included P-wave indices (maximum P-wave duration, its dispersion or variation and P-wave morphology) and premature atrial contractions (PACs) or runs. In addition, left ventricular hypertrophy (LVH), ST-T abnormalities, intraventricular conduction delay, QTc interval and premature ventricular contractions (PVCs) or runs were a risk of incident AF. An HR of greater than 2.0 was observed in the upper 5th percentile of the P-wave durations, P-wave durations greater than 130 ms, P-wave morpholyg, PACs (PVCs) or runs, LVH, QTc and left anterior fascicular blocks. The sensitivity , specificity and the positive and negative predictive values were 3.6-53.8%, 61.7-97.9%, 2.9-61.7% and 77.4-97.7%, respectively. ECG variables are risk factors for incident AF. The correlation between the ECG-derived AF predictors, especially P-wave indices, and underlying diseases and the effects of the reversal of the ECG-derived predictors on incident AF by treatment of comorbidities require further study.

Levels of uric acid and increased diastolic blood pressure: Risk factors for atrial fibrillation in patients older than 60 years

Summary Objective: To characterize the maximum P-wave duration (Pmax) and P-wave dispersion (PWD) according to blood pressure (BP) and uric acid (UA) levels in geriatric patients. Method: An analytical study was performed in 83 patients aged over 60 years treated at the Family Medical Office 5 of the Aracelio Rodríguez Castellón Polyclinic, in Cienfuegos, Cuba between January and December 2015. The sample was divided into two groups (patients with hyperuricemia and patients with normal UA levels). Results: We found a linear and significant correlation between diastolic BP and Pmax in patients with hyperuricemia (r=0.695; p=0.026), but not in patients with normal UA (r=0.048; p=0.757). A linear and significant correlation was demonstrated between diastolic BP and PWD in patients with hyperuricemia (r=0.657; p=0.039), but not in patients with normal UA (r=0.054; p=0.730). Conclusion: There is correlation between diastolic BP and Pmax plus PWD in elderly patients with hyperuricemia.

P-wave duration in lead aVR and the risk of atrial fibrillation in hypertension

BACKGROUND

Hypertension entails atrial remodeling that affect P-wave (PW) duration on electrocardiogram (ECG). PW indices (e.g., variance, dispersion, and terminal force) are associated with a higher risk for atrial fibrillation (AF), but their calculation requires multiple measurements of PW duration, limiting their use in clinical practice. We evaluated whether PW duration in specific ECG leads may identify patients with increased susceptibility to AF in a population of hypertensive patients.

METHODS

In a case-control study, AF and control subjects were matched for age, sex, and left atrial (LA) dimensions. PW duration was measured from digitally stored ECGs. Logistic regression was used to assess the association of PW duration and indices with AF.

RESULTS

We enrolled 44 hypertensive AF patients (16 paroxysmal and 28 persistent) and 44 hypertensive controls. AF and control subjects were matched for sex (males, n = 27), age (67 ± 8 years), LA diameter (40 ± 5 mm), and were comparable for left ventricular mass (45 ± 11 g/m(2.7) vs 48 ± 12 g/m(2.7) , P = 0.19), ejection fraction (58 ± 7% in both groups), and prevalence of mild valvular heart disease (7% vs 5%; P = 0.64). PW duration in lead aVR was significantly higher in AF patients as compared with controls (115 ± 18 ms vs 101 ± 14 ms; P < 0.0001) and was the best independent predictor of AF in multivariable logistic regression (PW ≥ 100 ms: RR = 3.7; 95% CI: 1.3-10.3; P = 0.02).

CONCLUSIONS

Simple measurement of PW duration in lead aVR allows effective identification of AF patients in a population of hypertensives. Confirmation of this finding in a larger population would provide a simple and effective risk marker of AF in hypertensive patients.