Factors influencing P terminal force in lead V1 of the ECG in hemodialysis patients

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.

The predictive value of abnormal P-wave axis for the detection of incident atrial fibrillation: A systematic review with meta-analysis

INTRODUCTION

There is growing interest in the prediction of incident atrial fibrillation (AF). The 12-lead electrocardiogram (ECG) has been a particularly rich target for possible prediction strategies.

PURPOSE

The P-wave axis is an ECG parameter that reflects the dominant vector of atrial depolarisation and is usually 0° -75°. There is a large body of literature suggesting that AF reflects structural and conduction abnormalities of the atria, and thus the P-wave axis may represent a sensitive parameter to detect such changes.

METHODS

A systematic review and meta-analysis of published literature associating abnormal P-wave axis and the development of incident AF was performed. Electronic databases were systematically searched from inception to October 2021. A random-effects model with generic inverse variance weights was utilised to pool the most adjusted effect measure from each paper. A funnel plot was used to assess publication bias.

RESULTS

After excluding duplicate studies, 568 studies were screened. A total of eleven studies were identified that associated an abnormal P-wave axis with the subsequent detection of AF. The eight studies that considered abnormal P-wave axis as being <0° or >75° were pooled for meta-analysis. In the pooled studies a total of 78,222 patients were included with 5656 cases of incident atrial fibrillation identified. The meta-analysis of the studies suggested that an abnormal P-wave axis was associated with a pooled risk ratio of 2.12 (95% CI 1.49 to 3.01) for the detection of incident atrial fibrillation.

CONCLUSION

This comprehensive systematic review and meta-analysis, indicates the positive association of abnormal P wave axis and future detection of AF. Utilisation of abnormal P-wave axis, alongside other parameters, may allow clinicians to better risk-stratify individuals at increased risk of AF, and thus identify those who may benefit most from prolonged cardiac monitoring or targeted anticoagulation.

Usefulness of P-wave peak time as an electrocardiographic parameter in predicting left ventricular diastolic dysfunction in patients with mitral regurgitation

INTRODUCTION

Conventional Doppler measurements have limitations in predicting left ventricular diastolic dysfunction (LVDD) in patients with mitral regurgitation (MR). Recently, electrocardiographic P-wave peak time (PWPT) has been proposed as a parameter of detecting LVDD. This study aimed to evaluate the association between PWPT and left ventricular end-diastolic pressure (LVEDP) in patients with MR.

METHODS

We performed echocardiography and cardiac catheterization in 82 patients with moderate or severe MR. We classified patients into two groups: low LVEDP group (L-LVEDP) (LVEDP <16 mmHg, n = 40) and high LVEDP group (H-LVEDP) (LVEDP ≥16 mmHg, n = 42). We evaluated LVDD and PWPT based on echocardiographic and electrocardiographic findings in both groups.

RESULTS

The PWPT in lead II (PWPT_II ) was significantly longer in patients in the H-LVEDP group than in those in the L-LVEDP group (67 vs. 47 ms, p < .001). Using correlation analysis, LVEDP was positively correlated with PWPT_II (r = .577, p < .001). Using multivariate analysis, PWPT_II was found to be an independent predictor of increased LVEDP (95% CI: 0.1030-0.110; p < .001). Using receiver operating characteristic (ROC) curve analysis, the optimal cutoff value of PWPT_II for predicting elevated LVEDP was 58.9 ms, with a sensitivity of 80.0% and a specificity of 73.8% (area under curve: 0.809, 95% CI: 0.713-0.905).

CONCLUSION

To the best of our knowledge, this is the first study to assess the effect of a significant valvular disease on PWPT in lead II. These findings suggest that prolonged PWPT_II may be an independent predictor of increased LVEDP in patients with moderate or severe MR.

P-Wave Terminal Force V1 Is Associated with Left Ventricular Diastolic Function in Patients with No Significant Perfusion Abnormality

P-wave terminal force in lead V1 (PTFV1) is a marker of increased left atrial (LA) overload. Whether PTFV1 is associated with left ventricular (LV) diastolic function remains undetermined. We tested the hypothesis that PTFV1 is associated with LV diastolic parameters derived from gated myocardial perfusion single-photon emission computed tomography (SPECT) in patients with no significant perfusion abnormalities.The study population included 158 patients with preserved ejection fraction and no significant perfusion abnormalities. The amplitude and duration of the P-wave negative phase in lead V1 were measured using an electrocardiogram, and PTFV1 was calculated. The peak filling rate (PFR) and one-third mean filling rate (1/3 MFR) were obtained as LV diastolic parameters using gated SPECT.PTFV1 showed a weak correlation with the LA volume index (r = 0.31; P < 0.001). Significant associations were observed between PTFV1 and PFR (r = -0.27; P < 0.001) and 1/3 MFR (r = -0.26; P = 0.001). A multivariate linear regression analysis showed that age (β = -0.26; P < 0.001), LV end-diastolic volume index (β = -0.27; P = 0.001), and PTFV1 (β = -0.15; P = 0.036) were significant factors associated with PFR. Moreover, male gender (β = -0.16; P = 0.041), LV mass index (β = -0.17; P = 0.046), and PTFV1 (β = -0.17; P = 0.022) were significant factors associated with the 1/3 MFR.PTFV1 is associated with LV diastolic function, as derived from gated SPECT in patients with no significant perfusion abnormalities.

Serum microRNA profiles in patients with autosomal dominant polycystic kidney disease show systematic dysregulation partially reversible by hemodialysis

INTRODUCTION

The impact of autosomal dominant polycystic kidney disease (ADPKD) on serum microRNAs (miRNA) is unknown.

MATERIAL AND METHODS

For profiling experiment we recruited 30 patients from three equinumerous groups: controls, ADPKD and ADPKD on hemodialysis. From the last group extra samples were collected for in pre-/postdialysis analysis. Additionally, 23 healthy volunteers were used for selected biomarker verification. Real-time PCR arrays were used for quantification of 752 miRNAs. Validation of selected miRNAs was performed in total RNA extracted from the serum and the exosomal fraction in pre-/postdialysis samples.

RESULTS

In total, 37 significant circulating miRNAs were found to differ between ADPKD patients and controls. In validation, 3 miRNAs with the highest fold change in comparison of dialyzed vs non-dialyzed patients (miR-532-3p, miR-320b, miR-144-5p) were not significantly altered by hemodialysis and from the top down-regulated ones, miR-27a-3p was significantly lower after dialysis in both total and exosomal fractions, miR-20a-5p was down-regulated in the exosomal fraction and miR-16-5p was unaltered by hemodialysis. MiR-16-5p was selected as the best circulating biomarker of ADPKD. Circulating representatives of the miR-17 family sharing the same seed region (miR-20a-5p, miR-93-5p and miR-106a-5p) showed significantly lower expression among dialyzed vs. non-dialyzed patients and their exosomal fraction dropped after hemodialysis.

CONCLUSIONS

The serum miRNAs among ADPKD patients differ substantially depending on the stage of CKD. The exosomal fraction of miRNA was more affected by dialysis than the total one. There was a common pattern of down-regulation for circulating miR-17 family members sharing the same seed region.

Interatrial block, P terminal force or fragmented QRS do not predict new-onset atrial fibrillation in patients with severe chronic kidney disease

Background

The prevalence of left atrial enlargement (LAE) and fragmented QRS (fQRS) diagnosed using ECG criteria in patients with severe chronic kidney disease (CKD) is unknown. Furthermore, there is limited data on predicting new-onset atrial fibrillation (AF) with LAE or fQRS in this patient group.

Methods

We enrolled 165 consecutive non-dialysis patients with CKD stage 4–5 without prior AF diagnosis between 2013 and 2017 in a prospective follow-up cohort study. LAE was defined as total P-wave duration ≥120 ms in lead II ± > 1 biphasic P-waves in leads II, III or aVF; or duration of terminal negative portion of P-wave > 40 ms or depth of terminal negative portion of P-wave > 1 mm in lead V₁ from a baseline ECG, respectively. fQRS was defined as the presence of a notched R or S wave or the presence of ≥1 additional R waves (R’) or; in the presence of a wide QRS complex (> 120 ms), > 2 notches in R or S waves in two contiguous leads corresponding to a myocardial region, respectively.

Results

Mean age of the patients was 59 (SD 14) years, 56/165 (33.9%) were female and the mean estimated glomerular filtration rate was 12.8 ml/min/1.73m². Altogether 29/165 (17.6%) patients were observed with new-onset AF within median follow-up of 3 [IQR 3, range 2–6] years. At baseline, 137/165 (83.0%) and 144/165 (87.3%) patients were observed with LAE and fQRS, respectively. Furthermore, LAE and fQRS co-existed in 121/165 (73.3%) patients. Neither findings were associated with the risk of new-onset AF within follow-up.

Conclusion

The prevalence of LAE and fQRS at baseline in this study on CKD stage 4–5 patients not on dialysis was very high. However, LAE or fQRS failed to predict occurrence of new-onset AF in these patients.

The influence of cognitive-behavioral therapy on depression in dialysis patients - meta-analysis

INTRODUCTION

Depressive disorders are the most common mental health problem among patients undergoing dialysis. Furthermore, depression is an independent factor increasing the mortality and frequency of hospitalization in this group of patients, yet psychological intervention programs aimed at improving the mental health of dialysis patients have still not been developed. This meta-analysis aimed to assess the effects of cognitive-behavioral therapy on depressive symptoms in dialysis patients. The main hypothesis of this study is that cognitive-behavioral therapy is an effective psychological method of reducing the severity of depression symptoms among patients undergoing dialysis.

MATERIAL AND METHODS

A systematic search was conducted using Medline, PubMed, Web of Science, Scopus and Google Scholar. Data extraction was carried out by two independent researchers. The severity of depression symptoms in the included studies was measured by the Beck Depression Inventory. A random-effects model was used to estimate the pooled mean difference of these values between patients undergoing CBT and the controls.

RESULTS

Four of the 1841 search results met the inclusion criteria with data from 226 patients who had undergone dialysis therapy due to renal disorders and psychological intervention based on cognitive-behavioral therapy. This therapy significantly reduced the level of depression symptoms in all studies included in the meta-analysis (mean difference = -5.3, p = 0.001; 95% CI: -7.95 to -2.66).

CONCLUSIONS

The study showed that the use of psychological intervention based on cognitive- behavioral therapy was an effective method of decreasing the severity of depressive symptoms in hemodialyzed patients. For the sake of patient well-being, it seems reasonable to extend renal replacement therapy with psychological intervention such as cognitive-behavioral therapy.

Risk factors for ischemic stroke in patients with non-valvular atrial fibrillation and therapeutic international normalized ratio range

INTRODUCTION

Atrial fibrillation (AF) is the most common cause of ischemic stroke (IS). Atrial fibrillation patients are recommended to use oral anticoagulants (OACs) as part of prevention against IS. However, despite having a therapeutic intensity of OAC therapy, IS can still occur in such patients. The aim of our study was to examine the configuration of IS risk factors in patients with non-valvular atrial fibrillation (NVAF) and within the therapeutic INR range (TINR).

MATERIAL AND METHODS

Our retrospective study involved 1835 patients with a recent IS. The experimental group consisted of 154 patients with acute IS, NVAF and TINR. The control group consisted of 1681 patients with acute IS but without AF.

RESULTS

Patients with IS, NVAF and TINR were significantly older and more often female than patients with IS without NVAF (p < 0.001 and p < 0.001, respectively). In these patients, diabetes mellitus, dyslipidemia, hypertension, coronary heart disease, smoking and previous IS were significantly more frequent than in the patients with IS without NVAF (p = 0.036, p = 0.002, p < 0.001, p < 0.001, p < 0.001, p = 0.003). Based on a univariable and multivariable logistic regression model, we found that in the group of patients who suffered a stroke despite TINR compared to patients with IS without AF there were more smokers (OR = 20.337; OR = 147.589) and patients with previous stroke (OR = 6.556; OR = 11.094), hypertension (OR = 3.75; OR = 2.75) and dyslipidemia (OR = 2.318; OR = 2.294).

CONCLUSIONS

The group of patients with NVAF and TINR is significantly more burdened by other independent common risk factors for stroke.