Usefulness of standard electrocardiographic parameters for predicting cardiac events after acute myocardial infarction during modern treatment era

The clinical value of P-wave terminal force in lead V1 in evaluating pericardial thickness in tuberculous constrictive pericarditis

AIM

To investigate the relationship between p wave terminal force (Ptfv1) and pericardial thickness in patients with tuberculous constrictive pericarditis.

METHODS

From January 2018 to October 2022, 95 patients with tuberculous constrictive pericarditis who needed pericarditis dissection in a hospital were collected, and 3 patients who did not meet the criteria were excluded, a total of 92 cases. The absolute value of Ptfv1 in conventional electrocardiogram was tested before surgery, and pericardial thickness was measured by echocardiography and chest CT. Pericardial thickness was measured after pericardial dissection. Pearson correlation analysis was used, R software was used to make scatter plot, and non-parametric square test was used. The correlation of postoperative measurements with echocardiography, chest CT and absolute value of Ptfv1 was analyzed.

RESULTS

Pearson correlation analysis was conducted with postoperative measurements and echocardiography measurements, postoperative measurements and chest CT measurements, and postoperative measurements and absolute value of Ptfv1. Pearson correlation analysis showed that the correlation coefficients between postoperative measurements and echocardiography, chest CT and Ptfv1 values were statistically significant. Scatter plot and nonparametric Chi-square test showed that postoperative measurements were consistent with absolute values of echocardiography, chest CT and Ptfv1 (p < 0.05). And this study found that the distribution of the value of Ptfv1 ≥ 5 was higher than the value of Ptfv1 < 5 after pericardiectomy (0.95:0.05) in the absolute value of Ptfv1 ≥ 0.04 which measured before pericardiectomy. The hypothesis was statistically significant (p < 0.05).

CONCLUSION

The absolute value of Ptfv1 in electrocardiogram can be used as an auxiliary diagnostic index to evaluate pericardial thickness in tuberculous constrictive pericarditis.

Prognostic value of P-wave morphology in general population

AIMS

To evaluate the prognostic significance of novel P-wave morphology descriptors in general population.

METHODS AND RESULTS

Novel P-wave morphology variables were analyzed from orthogonal X-, Y-, Z-leads of the digitized electrocardiogram using a custom-made software in 6906 middle-aged subjects of the Mini-Finland Health Survey. A total of 3747 (54.3%) participants died during the follow-up period of 24.3 ± 10.4 years; 379 (5.5%) of the study population succumbed to sudden cardiac death (SCD), 928 (13.4%) to non-SCD (NSCD) and 2440 (35.3%) patients to non-cardiac death (NCD). In univariate comparisons, most of the studied P-wave morphology parameters had a significant association with all modes of death (P from <0.05 to <0.001). After relevant adjustments in the Cox multivariate hazards model, P-wave morphology dispersion (PMD) still tended to predict SCD [hazard ratio (HR): 1.006, 95% confidence interval (CI): 1.000-1.012, P = 0.05) but not NSCD (HR: 0.999, 95% CI: 0.995-1.003, P = 0.68) or NCD (HR: 0.999, 95% CI: 0.997-1.001, P = 0.44). The P-wave maximum amplitude in the lead Z (P-MaxAmp-Z) predicted SCD even after multivariate adjustments (HR: 1.010, 95% CI: 1.005-1.015, P = 0.0002) but also NSCD (HR: 1.005, 95% CI: 1.002-1.009, P = 0.0005) and NCD (HR: 1.002, 95% CI: 1.000-1.005, P = 0.03).

CONCLUSION

Abnormalities of P-wave morphology are associated with the risk of all modes of death in general population. After relevant adjustments, PMD was still closely associated with the risk of SCD but not with NSCD or NCD. P-MaxAmp-Z predicted SCD even after adjustments, however, it also retained its association with NSCD and NCD.

Association of atrial depolarization variability and cardiac autonomic regulation with sudden cardiac death in coronary artery disease

AIMS

To evaluate the prognostic significance of the temporal variability of P-wave morphology, specifically in relation to cardiac autonomic regulation.

METHODS AND RESULTS

We analyzed the standard deviation of P-wave residuum (PWRSD) from five consecutive beats of the standard 12-lead ECG in 1236 patients with angiographically verified coronary artery disease (CAD). We evaluated the prognostic value of PWRSD, of PWRSD and PWR in relation to the 24 h standard deviation of normal-to-normal intervals (PWRSD/SDNN and PWR/SDNN). After 8.7 ± 2.2 years of follow-up on average, 43 patients (3.5%) experienced sudden cardiac death (SCD) or were resuscitated from sudden cardiac arrest (SCA), 34 (2.8%) succumbed to non-sudden cardiac death (NSCD) and 113 (9.1%) to non-cardiac death (NCD). In the Cox regression analysis, PWRSD (≥0.002727) had a significant univariate (uv) [hazard ratio (HR): 4.27, 95% confidence interval (CI): 2.26-8.08, P = 0.000008] and multivariate (mv) (HR: 2.58, 95% CI: 1.31-5.08, P = 0.006) association with SCD/SCA but not with NSCD (uv P = 0.76, mv P = 0.33) or NCD (uv P = 0.57, mv P = 0.66). All the studied P-morphology parameters retained a significant association with the risk of SCD/SCA after relevant adjustment (mv P-values from 0.00003 to <0.05) but not with NSCD or NCD. When dichotomized PWRSD, PWR, PWRSD/SDNN, and PWR/SDNN were added to the clinical risk model for SCD/SCD, the C-index increased from 0.799 to 0.834 and integrated discrimination index and net reclassification index improved significantly (P < 0.001).

CONCLUSION

Variability of P-morphology representing temporo-spatial heterogeneity of atrial depolarization, specifically when combined with cardiac autonomic regulation, independently predicts the risk of SCD in patients with CAD.

Increased Beat-to-Beat Variability of T-Wave Heterogeneity Measured From Standard 12-Lead Electrocardiogram Is Associated With Sudden Cardiac Death: A Case-Control Study

Introduction

The prognostic significance of beat-to-beat variability of spatial heterogeneity of repolarization measured from standard 12-lead ECG is not well-understood.

Methods

We measured the short-term variability of repolarization parameters, such as T-wave heterogeneity in leads V4–V6 (TWH) and QT interval (QT), from five consecutive beats of previously recorded standard 12-lead ECG in 200 victims of unexpected sudden cardiac death (SCD) confirmed to be due to complicated atherosclerotic coronary artery disease (CAD) in medico-legal autopsy and 200 age- and sex-matched controls with angiographically confirmed CAD. The short-term variability of repolarization heterogeneity was defined as the standard deviation (SD) of the measured repolarization parameters. All ECGs were in sinus rhythm, and no premature ventricular contractions were included in the measured segment.

Results

TWH-SD and QT-SD were significantly higher in SCD victims than in subjects with CAD (6.9 ± 5.6 μV vs. 3.8 ± 2.6 μV, p = 1.8E-11; 8.3 ± 13.1 ms vs. 3.8 ± 7.1 ms, p = 0.00003, respectively). After adjusting in the multivariate clinical model with factors, such as diabetes, RR interval, and beta blocker medication, TWH-SD and QT-SD retained their significant power in discriminating between the victims of SCD and the patients with CAD (p = 0.00003, p = 0.006, respectively). TWH-SD outperformed QT-SD in identifying the SCD victims among the study subjects (area under the curve in the receiver operating characteristics curve 0.730 vs. 0.679, respectively).

Conclusion

Increased short-term variability of repolarization heterogeneity measured from standard 12-lead ECG is associated with SCD.

Electrocardiographic predictors of mortality in patients after percutaneous coronary interventions - a nested case-control study

Background: The outcome of patients undergoing percutaneous coronary interventions (PCIs) varies considerably. Several ECG parameters have recently emerged (PQ interval, P-wave, T-peak-to-T-end interval, T-wave, T/R ratio, J-wave) beyond traditional markers (rhythm, QRS, Q-wave, QT interval, ST segment) and were attributed important prognostic value in the setting of coronary artery disease. The present study integrated for the first time these ECG parameters altogether with the aim to determine their role in predicting patients' outcome after a PCI. Methods: A total of 3342 patients were enrolled in the present study between 2009 and 2013. In a nested case-control design, 644 patients who died within a year post-PCI (cases) were matched 1:4 with patients alive at that particular date (controls). Results: Our data showed that only the presence of a longer QT interval (heart rate-corrected using Bazett formula) was associated with increased risk of death after adjusting for multiple clinical and angiographic risk factors (adjusted OR 1.07; 95%CI 1.01-1.12, p = .022). Conclusion: Our study emphasises the prognostic importance of the QT interval in identifying patients at increased risk of death during the first year after PCI. Clinical Trial Registration - URL: https://www.clinicaltrials.gov . Unique identifier: NCT02241291.

Prognostic significance of P-wave morphology in patients with coronary artery disease

INTRODUCTION

The prognostic significance of P-wave morphology in patients with coronary artery disease (CAD) is not well-known.

METHODS

A total of 1946 patients with angiographically verified CAD were included in the Innovation to reduce Cardiovascular Complications of Diabetes at the Intersection (ARTEMIS) study. The P-wave morphology could be analyzed in 1797 patients.

RESULTS

During 7.4 ± 2.0 years, a total of 168 (9.3%) patients died or experienced resuscitation from sudden cardiac arrest (SCA), 43 (2.4%) patients experienced sudden cardiac death (SCD) or were resuscitated from SCA, 37 (2.1%) patients succumbed to non-SCD (NSCD), and 88 (4.9%) patients to noncardiac death (NCD). Of the P-wave parameters, the absolute P-wave residuum (PWR), the heterogeneity of the P-wave morphology (PWH), and the P-wave duration (Pdur) had the closest univariate association with the risk of SCD/SCA (0.0038 ± 0.0026 vs 0.0022 ± 0.0017, P < .001; 11.0 ± 5.2 vs 8.6 ± 3.6, P < .01; 142.7 ± 16.9 vs 134.8 ± 14.3 milliseconds, P < .01; SCD/SCA vs no SCD/SCA, respectively). After adjustments with factors that were associated with the risk of SCD/SCA, such as diabetes, smoking, left bundle branch block, high-sensitivity C-reactive protein, and high-sensitivity troponin T, PWR (P < .001), PWH (P < .05), and Pdur (P < 0.01) still predicted SCD/SCA but not non-sudden cardiac death. When these parameters were added to the SCD/SCA clinical risk model, the discrimination and reclassification accuracy of the risk model increased significantly (P < .05, P < .001) and the C-index increased from 0.745 to 0.787.

CONCLUSION

The P-wave morphology parameters independently predict SCD/SCA in patients with CAD.

P-wave terminal force in lead V1 is a predictive indicator for the diagnosis of tuberculous constrictive pericarditis

OBJECTIVES

The purpose of this study is to explore the value of P-wave terminal force in lead V1 (PTFV1) in the clinical diagnosis of tuberculous constrictive pericarditis (TCP).

METHODS

A total of 53 patients with TCP and 64 patients with tuberculous exudative pericarditis were enrolled in this retrospective study. The demographic and clinical characteristics were collected, including gender, age, the course of disease and New York Heart Association (NYHA) classification. Besides, echocardiography data also were obtained, including left atrial diameter, left ventricular end-diastolic diameter and left ventricular ejection fraction. In addition, the parameters of electrocardiogram (ECG) were obtained, such as heart rate, the time from the corrected ORS wave origin to T-wave terminal, atrial fibrillation, right bundle branch block, atrial premature beat, and PTFV1 value.

RESULTS

No significant differences were found in age, gender, the course of disease, echocardiography results, ECG parameters (in addition to PTFV1) between patients with TCP and patients with tuberculous exudative pericarditis. The percentage of patients located in NYHA class IV in the patients with TCP was significantly higher than those of patients with tuberculous exudative pericarditis (p = 0.041). Moreover, the incidence rate of abnormal PTFV1 (≤ -0.04 mm·s) was obviously higher in patients with TCP than those of patients with tuberculous exudative pericarditis (64.2% vs 9.4%, p < 0.001).

CONCLUSIONS

Abnormal PTFV1 (≤ -0.04 mm·s) is associated with TCP, and PTFV1 may be a potential novel diagnostic indicator for TCP diagnosis.

Electrocardiographic left atrial abnormalities predict cardiovascular mortality

OBJECTIVE

Clinical utilization of electrocardiography for diagnosis of left atrial abnormalities is hampered by variable P-wave morphologies, multiple empiric criteria, and lack of an imaging "gold standard". Our aim was to determine the prevalence of P-wave patterns and demonstrate which components have associations with cardiovascular death (CVD).

METHODS

This is a retrospective analysis of 20,827 veterans <56 years of age who underwent electrocardiograms at a Veteran's Affairs Medical Center from 1987 to 1999, followed for a median duration of 17.8 years for CVD. Receiver Operating Characteristic, Kaplan-Meier and Cox Hazard analyses were applied, the latter with adjustment for age, gender and electrocardiography abnormalities.

RESULTS

The mean age was 43.3 ± 8 years, and 888 CVD (4.3%) occurred. A single positive deflection of the P-wave (Pattern 1) was present in 29% for V1 and 81% for V2. A singular negative P-wave (Pattern 2) was present in 4.6% for V1 and 1.6% in V2. A P-wave with an upward component followed by downward component (Pattern 3) was present in 64.5% for V1 and 17.5% for V2. When the downward component in Patterns 2 and/or 3 is at least -100 μV, a significant association is observed with CVD (adjusted hazard ratios [HRs] 2.9-4.1, P < 0.001). Total P-wave duration ≥140 ms was also associated with CVD (adjusted HR 2.2, P < 0.001).

CONCLUSIONS

A negative P-wave in V1 or V2 ≤-100 μV, and P-wave with a duration of ≥140 ms, all have independent and significant associations with CVD, with HRs comparable to other electrocardiography abnormalities.

Prognostic value of standard electrocardiographic parameters for predicting major adverse cardiac events after acute myocardial infarction

BACKGROUND

The prognostic value of electrocardiographic (ECG) variables in predicting major adverse cardiac events (MACEs) after acute myocardial infarction (AMI) in the era of modern therapy is unclear. This study was conducted to evaluate the prognostic significance of ECG parameters in predicting 1-year MACEs for AMI patients.

METHODS

Between January 2006 and January 2008, 529 AMI patients were included. ECG variables were analyzed from the ECG taken on discharge day. The 1-year MACEs were defined as death, nonfatal MI, and revascularization including repeat percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Mean follow-up duration was 360 ± 119 days.

RESULTS

Of these patients, 497 (94%) patients provided complete follow-up data (355 males; 67 ± 12 years old). The rate of 1-year MACEs was 16%. In univariate analysis, heart rate, corrected QT interval, left ventricular (LV) hypertrophy, voltage (SV(1) + RV(5) ), lateral ST-depression (V(5-6) or I, aVL), pathologic Q wave (V(1-4) , V(5-6) ), ST-elevation (V(1-4) , V(5-6) or I, aVL), and T-wave inversion (V(1-4) , V(5-6) , or I, aVL) had a significant association with 1-year MACEs. In the Cox regression hazard model, lateral ST-depression (hazard ratio [HR] 2.260, 95% confidence interval [CI] 1.204 to 4.241, P = 0.011) and corrected QT interval (HR 1.007, 95% CI 1.002 to 1.011, P = 0.004) were independent predictors of 1-year MACEs. After adjustment for all risk variables, lateral ST-depression (HR 3.781, 95% CI 1.047 to 13.656, P = 0.042) was the only ECG variable that independently predicted 1-year MACEs.

CONCLUSION

Lateral ST-depression on discharge day ECG is an independent predictor of 1-year MACEs after AMI.

The prognostic importance of isolated P-Wave abnormalities

BACKGROUND

While certain P-Wave morphologies have been associated with abnormal atrial size and either pulmonary or cardiovascular (CV) disease, their relationship to mortality and specific cause of death has not been reported.

METHODS

Analyses were performed on the first digitally recorded electrocardiogram (ECG) on 43 903 patients at the Palo Alto Veterans Administration Medical Center since 1987. After appropriate exclusions, 40 020 patients remained. Using computerized algorithms, P-wave amplitude and duration in 12 leads as well as several standardized ECG interpretations were extracted. The main outcome measures were pulmonary and CV mortality.

RESULTS

During a mean follow-up of 6 years there were 3417 CV and 1213 pulmonary deaths. After adjusting for age and heart rate in a Cox regression model, P-wave amplitude in the inferior leads was the strongest predictor of pulmonary death (hazard ratio [HR]: 3.0, 95% confidence interval [CI]: 2.3-3.9, P < .0001 for an amplitude > 2.5 mm), outperforming all other ECG criteria. The depth of P-wave inversion in leads V(1) or V(2) and P-wave duration were strong predictors of CV death (HR: 1.7, 95% CI: 1.5-2.0, P < 0.0001 for a P-wave inversion deeper than 1 mm), outperforming many previously established ECG predictors of CV death.

CONCLUSIONS

P-wave amplitude in the inferior leads is the strongest independent predictor of pulmonary death while P-wave duration and the depth of P-wave inversion in leads V(1) or V(2) significantly predict CV death. These measurements can be obtained easily and should be considered as part of clinical risk stratification.

Comparison of acute electrocardiographic presentation in patients with diastolic vs systolic heart failure

There are limited data comparing admission electrocardiograms (ECGs) in patients with acute diastolic (DHF) vs systolic heart failure (SHF) and their ability to predict cardiac events (CEs). Admission ECGs were evaluated in 241 acute heart failure patients (88 DHF; 153 SHF). DHF was defined as left ventricular ejection fraction >45%. End points consisted of rehospitalization for CEs or death during a 30-day follow-up. DHF patients had more atrial fibrillation (AF) while SHF patients had faster heart rates and longer QRS and QTc duration. There were 68 CEs: 26 (30%) in DHF and 42 (27%) in SHF patients ( P=.728). Multivariate logistic regression analysis revealed that in DHF patients, CEs were associated with nonischemic heart failure, blood urea nitrogen >28 mg/dL, and AF. In the SHF group, CEs were associated with AF. Admission ECG differs between acute DHF and SHF patients. CE rates are similar in both groups; AF is the only ECG parameter predictive of CEs.

Gender-related differences in electrocardiographic parameters and their association with cardiac events in patients after myocardial infarction

There are limited data regarding gender-related differences in electrocardiographic (ECG) presentation in patients after myocardial infarction (MI) and the prognostic value of ECG variables in women. A series of ECG parameters were analyzed in 838 patients (216 women, 622 men) using standard electrocardiography performed 5 to 7 days after first MI, and their associations with gender and risk for cardiac events, defined as cardiac death, nonfatal MI, or unstable angina, were evaluated. Heart rate was faster and QTc duration was longer, whereas QRS duration was shorter in women compared with men. Women had more lateral ST depressions and more T-wave inversions in the anterior and lateral regions. During mean 2-year follow-up, there were 138 events in men and 65 in women; women had a 38% greater risk for recurrent events (adjusted hazard ratio [HR] 1.38, p = 0.031). In multivariate Cox regression analysis, ST-segment elevation in leads V(1) to V(4) on the fifth to seventh day after MI was associated with increased risk for recurrent events in women (adjusted HR 2.16, p = 0.003) but not in men (adjusted HR = 0.81, p = 0.32). ST depressions in leads V(5), V(6), I, or aVL (adjusted HR 1.70, p = 0.006) in men but not in women (adjusted HR 0.98, p = 0.93) were identified as a risk factor for recurrent events. In conclusion, there are gender-related differences in ECG presentation and the prognostic significance of ECG findings after MI. ST-segment elevation in anterior leads is a significant predictor of events in women, whereas ST depression in lateral leads is a significant predictor in men.