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Koutalas E, Kallergis E, Nedios S, Kochiadakis G, Kanoupakis E. P-wave duration as a marker of atrial remodeling in patients referred to ablation for atrial fibrillation: A new stratification tool emerging? Hellenic J Cardiol 2023; 73:53-60. [PMID: 36863411 DOI: 10.1016/j.hjc.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 03/04/2023] Open
Abstract
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.
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Affiliation(s)
- Emmanuel Koutalas
- Department of Cardiology University Hospital of Heraklion, Crete, Greece.
| | | | - Sotirios Nedios
- Department of Arrhythmology, Leipzig Heart Center, Leipzig, Germany
| | - George Kochiadakis
- Department of Cardiology University Hospital of Heraklion, Crete, Greece
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2
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Bianco F, De Caterina R, Chandra A, Aquila I, Claggett B, Johansen MC, Gonçalves A, Norby FL, Cogswell R, Soliman EZ, Gottesman R, Mosley T, Alonso A, Shah A, Solomon SD, Chen LY. Left Atrial Remodeling and Stroke in Patients With Sinus Rhythm and Normal Ejection Fraction: ARIC-NCS. J Am Heart Assoc 2022; 11:e024292. [PMID: 35491988 PMCID: PMC9238625 DOI: 10.1161/jaha.121.024292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Age-related left atrial (LA) structural and functional abnormalities may be related to subclinical cerebral infarcts (SCIs) and stroke. We evaluated the association of 3-dimensional echocardiographic LA contractility parameters with SCIs and stroke across the spectrum of tertiles of age increment in elderly patients with sinus rhythm, normal ejection fraction, and no history of atrial fibrillation. Methods and Results We enrolled 407 participants (mean age, 76±8 years; 40% men) from ARIC-NCS (Atherosclerosis Risk in Communities Neurocognitive Study) undergoing a brain magnetic resonance imaging and 3-dimensional echocardiographic examinations in 2011 to 2013. The sample was analyzed among age tertiles and subgroups: no cerebral magnetic resonance imaging-detectable infarcts (n=315), magnetic resonance imaging-diagnosed SCIs (n=58), and clinically diagnosed stroke (n=34). The frequency of SCIs significantly increased over age tertiles (P trend 0.023). LA global longitudinal strain-a 3-dimensional echocardiographic index of LA reservoir function-and E/e' divided by LA global longitudinal strain-an index of LA stiffness-worsened across age tertiles (P trend 0.014 and 0.001, respectively), and only in the categories of SCIs (P trend <0.001 and 0.045, respectively) and stroke (P trend 0.001 and 0.011, respectively). LA global longitudinal strain was negatively associated with increased odds of SCIs (P=0.036, P=0.008, and P=0.001, respectively) and strokes (P=0.043, P=0.015, and P=0.001, respectively) over age tertiles, with a significant interaction between age tertiles (interaction P=0.043 and P=0.010, respectively). E/e' divided by LA global longitudinal strain was positively associated with the presence of SCIs (P=0.037, P=0.007, and P=0.001, respectively) and strokes (P=0.045, P=0.007, and P=0.003, respectively) over age tertiles, with a significant interaction only for SCIs (interaction P=0.040) and not for clinical stroke. Conclusions In a large cohort study of elderly patients, among participants with sinus rhythm, normal ejection fraction, and no history of atrial fibrillation, measures of worse age-related LA reservoir function and stiffness are associated with higher odds of SCIs and stroke.
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Affiliation(s)
- Francesco Bianco
- Department of Cardiovascular MedicineBrigham and Women's HospitalBostonMA
| | - Raffaele De Caterina
- Cardio‐Thoracic and Vascular Department, Pisa University Hospital, University of PisaPisaItaly
| | - Alvin Chandra
- Department of Cardiovascular MedicineBrigham and Women's HospitalBostonMA
| | - Iolanda Aquila
- Department of Cardiovascular MedicineBrigham and Women's HospitalBostonMA
| | - Brian Claggett
- Department of Cardiovascular MedicineBrigham and Women's HospitalBostonMA
| | - Michelle C. Johansen
- Department of NeurologyThe Johns Hopkins University School of MedicineBaltimoreMD
| | - Alexandra Gonçalves
- Department of Cardiovascular MedicineBrigham and Women's HospitalBostonMA
- University of Porto Medical SchoolPortoPortugal
| | - Faye L. Norby
- Center for Cardiac Arrest Prevention, Department of Cardiology,Cedars‐Sinai Smidt Heart Institute,Los AngelesCA
| | - Rebecca Cogswell
- Lillehei Heart Institute and Cardiovascular DivisionDepartment of MedicineUniversity of MinnesotaMinneapolisMN
| | | | - Rebecca Gottesman
- Department of NeurologyThe Johns Hopkins University School of MedicineBaltimoreMD
| | - Thomas Mosley
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMS
| | - Alvaro Alonso
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGA
| | - Amil Shah
- Department of Cardiovascular MedicineBrigham and Women's HospitalBostonMA
| | - Scott D. Solomon
- Department of Cardiovascular MedicineBrigham and Women's HospitalBostonMA
| | - Lin Yee Chen
- Lillehei Heart Institute and Cardiovascular DivisionDepartment of MedicineUniversity of MinnesotaMinneapolisMN
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3
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Power DA, Lampert J, Camaj A, Bienstock SW, Kocovic N, Bayes-Genis A, Miller MA, Bayés-de-Luna A, Fuster V. Cardiovascular Complications of Interatrial Conduction Block: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:1199-1211. [PMID: 35331415 DOI: 10.1016/j.jacc.2022.01.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/25/2022] [Indexed: 12/11/2022]
Abstract
Interatrial block (IAB) is an electrocardiographic pattern describing the conduction delay between the right and left atria. IAB is classified into 3 degrees of block that correspond to decreasing conduction in the region of Bachmann's bundle. Although initially considered benign in nature, specific subsets of IAB have been associated with atrial arrhythmias, elevated thromboembolic stroke risk, cognitive impairment, and mortality. As the pathophysiologic relationships between IAB and stroke are reinforced, investigation has now turned to the potential benefit of early detection, atrial imaging, cardiovascular risk factor modification, antiarrhythmic pharmacotherapy, and stroke prevention with oral anticoagulation. This review provides a contemporary overview of the epidemiology, pathophysiology, diagnosis, and management of IAB, with a focus on future directions.
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Affiliation(s)
- David A Power
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Joshua Lampert
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anton Camaj
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Solomon W Bienstock
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nikola Kocovic
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitario Germans Trias I Pujol, Badalona, Spain
| | - Marc A Miller
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Antoni Bayés-de-Luna
- Cardiovascular Research Foundation, Cardiovascular ICCC-Program, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Valentin Fuster
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
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4
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Moore U, Fernandez-Torron R, Jacobs M, Gordish H, Diaz-Manera J, James MK, Mayhew AG, Harris E, Guglieri M, Rufibach LE, Feng J, Blamire AM, Carlier PG, Spuler S, Day JW, Jones KJ, Bharucha-Goebel DX, Salort-Campana E, Pestronk A, Walter MC, Paradas C, Stojkovic T, Mori-Yoshimura M, Bravver E, Pegoraro E, Lowes LP, Mendell JR, Bushby K, Bourke J, Straub V. Cardiac and pulmonary findings in dysferlinopathy: a 3-year, longitudinal study. Muscle Nerve 2022; 65:531-540. [PMID: 35179231 PMCID: PMC9311426 DOI: 10.1002/mus.27524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 02/05/2022] [Accepted: 02/12/2022] [Indexed: 11/15/2022]
Abstract
Introduction/Aims There is debate about whether and to what extent either respiratory or cardiac dysfunction occurs in patients with dysferlinopathy. This study aimed to establish definitively whether dysfunction in either system is part of the dysferlinopathy phenotype. Methods As part of the Jain Foundation's International Clinical Outcome Study (COS) for dysferlinopathy, objective measures of respiratory and cardiac function were collected twice, with a 3‐y interval between tests, in 188 genetically confirmed patients aged 11–86 y (53% female). Measures included forced vital capacity (FVC), electrocardiogram (ECG), and echocardiogram (echo). Results Mean FVC was 90% predicted at baseline, decreasing to 88% at year 3. FVC was less than 80% predicted in 44 patients (24%) at baseline and 48 patients (30%) by year 3, including ambulant participants. ECGs showed P‐wave abnormalities indicative of delayed trans‐atrial conduction in 58% of patients at baseline, representing a risk for developing atrial flutter or fibrillation. The prevalence of impaired left ventricular function or hypertrophy was comparable to that in the general population. Discussion These results demonstrate clinically significant respiratory impairment and abnormal atrial conduction in some patients with dysferlinopathy. Therefore, we recommend that annual or biannual follow‐up should include FVC measurement, enquiry about arrhythmia symptoms and peripheral pulse palpation to assess cardiac rhythm. However, periodic specialist cardiac review is probably not warranted unless prompted by symptoms or abnormal pulse findings.
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Affiliation(s)
- Ursula Moore
- The John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Central Parkway, Newcastle upon Tyne, UK
| | - Roberto Fernandez-Torron
- The John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Central Parkway, Newcastle upon Tyne, UK.,Neurology Department, Biodonostia Health Research Institute, Neuromuscular Area, Hospital Donostia, Basque Health Service, Doctor Begiristain, Donostia-San Sebastian, Spain
| | - Marni Jacobs
- Center for Translational Science, Division of Biostatistics and Study Methodology, Children's National Health System, Washington, DC, USA.,Pediatrics, Epidemiology and Biostatistics, George Washington University, Washington, DC, USA
| | - Heather Gordish
- Center for Translational Science, Division of Biostatistics and Study Methodology, Children's National Health System, Washington, DC, USA.,Pediatrics, Epidemiology and Biostatistics, George Washington University, Washington, DC, USA
| | - Jordi Diaz-Manera
- Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Barcelona, Spain.,Neuromuscular Disorders Unit, Neurology Department, Hospital de la Santa Creu i Sant Pau
| | - Meredith K James
- The John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Central Parkway, Newcastle upon Tyne, UK
| | - Anna G Mayhew
- The John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Central Parkway, Newcastle upon Tyne, UK
| | - Elizabeth Harris
- The John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Central Parkway, Newcastle upon Tyne, UK
| | - Michela Guglieri
- The John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Central Parkway, Newcastle upon Tyne, UK
| | | | - Jia Feng
- Center for Translational Science, Division of Biostatistics and Study Methodology, Children's National Health System, Washington, DC, USA
| | - Andrew M Blamire
- Translational and Clinical Research Institute, Newcastle University, UK
| | - Pierre G Carlier
- University Paris-Saclay, CEA, DRF, Service Hospitalier Frederic Joliot, Orsay, France
| | - Simone Spuler
- Charite Muscle Research Unit, Experimental and Clinical Research Center, a joint cooperation of the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - John W Day
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine; Stanford, CA, USA
| | - Kristi J Jones
- The Children's Hospital at Westmead, and The University of Sydney, Australia
| | - Diana X Bharucha-Goebel
- Department of Neurology Children's National Health System, Washington, DC, USA.,National Institutes of Health (NINDS), Bethesda, MD, USA
| | | | - Alan Pestronk
- Department of Neurology Washington University School of Medicine, St. Louis, MO, USA
| | - Maggie C Walter
- Friedrich-Baur-Institute, Dept. of Neurology, Ludwig-Maximilians-University of Munich, Germany
| | - Carmen Paradas
- Neuromuscular Unit, Department of Neurology, Hospital U. Virgen del Rocío/Instituto de Biomedicina de Sevilla, Sevilla, Spain
| | - Tanya Stojkovic
- Centre de référence des maladies neuromusculaires, Institut de Myologie, AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Madoka Mori-Yoshimura
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry Tokyo, Japan
| | - Elena Bravver
- Neuroscience Institute, Carolinas Neuromuscular/ALS-MDA Center, Carolinas HealthCare System, Charlotte, NC, USA
| | | | - Linda Pax Lowes
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jerry R Mendell
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kate Bushby
- The John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Central Parkway, Newcastle upon Tyne, UK
| | | | - John Bourke
- Department of Cardiology, Freeman Hospital, NUTH NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Volker Straub
- The John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Central Parkway, Newcastle upon Tyne, UK
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5
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Bhat A, Mahajan V, Chen HHL, Gan GCH, Pontes-Neto OM, Tan TC. Embolic Stroke of Undetermined Source: Approaches in Risk Stratification for Cardioembolism. Stroke 2021; 52:e820-e836. [PMID: 34706562 DOI: 10.1161/strokeaha.121.034498] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Ischemic stroke is a leading cause of morbidity and mortality worldwide. Embolic stroke of undetermined source has been recently proposed to categorize nonlacunar ischemic strokes without confirmed etiology after adequate investigation with a likely embolic stroke mechanism. A strategy of empirical anticoagulation for embolic stroke of undetermined source patients is attractive but may only be beneficial in a select subset of patients. Strategies which would help identify the subset of embolic stroke of undetermined source patients most likely to have cardioembolic origin of stroke, and hence benefit from anticoagulation, are needed. This article will review current evidence which may be useful in the development of a risk stratification approach based on arrhythmia monitoring, cardiac imaging, and clinical risk stratification. This approach may be beneficial in clinical practice in improving patient outcomes and reducing stroke recurrence in this population; however, further work is required with active trials underway.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Vipul Mahajan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Medicine (G.C.H.G.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Octavio M Pontes-Neto
- Stroke Service, Neurology Division, Department of Neuroscience and Behavior, Ribeirão Preto Medical School, University of São Paulo, Brazil (O.M.P.-N.)
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
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6
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Abstract
Interatrial blocks like other types of block may be of first degree or partial second degree, also named transient atrial block or atrial aberrancy, and third degree or advanced. In first degree, partial interatrial block (P-IAB), the electrical impulse is conducted to the left atrium, through the Bachmann’s region, but with delay. The ECG shows a P-wave ≥ 120 ms. In third-degree, advanced interatrial block (A-IAB), the electrical impulse is blocked in the upper part of the interatrial septum (Bachmann region); the breakthrough to LA has to be performed retrogradely from the AV junction zone. This explains the p ± in leads II, III and aVF. In typical cases of A-IAB, the P-wave morphology is biphasic (±) in leads II, III and aVF, because the left atrium is activated retrogradely and, therefore, the last part of the atrial activation falls in the negative hemifield of leads II, III and aVF. Recently, some atypical cases of A-IAB have been described. The presence of A-IAB is a risk factor for atrial fibrillation, stroke, dementia, and premature death.
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7
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Kulkarni K, Singh JP, Parks KA, Katritsis DG, Stavrakis S, Armoundas AA. Low-Level Tragus Stimulation Modulates Atrial Alternans and Fibrillation Burden in Patients With Paroxysmal Atrial Fibrillation. J Am Heart Assoc 2021; 10:e020865. [PMID: 34075778 PMCID: PMC8477868 DOI: 10.1161/jaha.120.020865] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Low‐level tragus stimulation (LLTS) has been shown to significantly reduce atrial fibrillation (AF) burden in patients with paroxysmal AF. P‐wave alternans (PWA) is believed to be generated by the same substrate responsible for AF. Hence, PWA may serve as a marker in guiding LLTS therapy. We investigated the utility of PWA in guiding LLTS therapy in patients with AF. Methods and Results Twenty‐eight patients with AF were randomized to either active LLTS or sham (earlobe stimulation). LLTS was delivered through a transcutaneous electrical nerve stimulation device (pulse width 200 μs, frequency 20 Hz, amplitude 10–50 mA), for 1 hour daily over a 6‐month period. AF burden over 2‐week periods was assessed by noninvasive continuous ECG monitoring at baseline, 3 months, and 6 months. A 5‐minute control ECG for PWA analysis was recorded during all 3 follow‐up visits. Following the control ECG, an additional 5‐minute ECG was recorded during active LLTS in all patients. At baseline, acute LLTS led to a significant rise in PWA burden. However, active patients receiving chronic LLTS demonstrated a significant reduction in both PWA and AF burden after 6 months (P<0.05). Active patients who demonstrated an increase in PWA burden with acute LLTS showed a significant drop in AF burden after 6 months of chronic LLTS. Conclusions Chronic, intermittent LLTS resulted in lower PWA and AF burden than did sham control stimulation. Our results support the use of PWA as a potential marker for guiding LLTS treatment of paroxysmal AF.
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Affiliation(s)
- Kanchan Kulkarni
- Cardiovascular Research Center Massachusetts General Hospital Boston MA
| | - Jagmeet P Singh
- Cardiology Division Cardiac Arrhythmia Service Massachusetts General Hospital Boston MA
| | | | | | - Stavros Stavrakis
- Heart Rhythm Institute University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Antonis A Armoundas
- Cardiovascular Research Center Massachusetts General Hospital Boston MA.,Institute for Medical Engineering and Science Massachusetts Institute of TechnologyCambridge MA
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8
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Bae TW, Kwon KK. ECG PQRST complex detector and heart rate variability analysis using temporal characteristics of fiducial points. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2020.102291] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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9
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Ortigosa N, Ayala G, Cano Ó. Variation of P-wave indices in paroxysmal atrial fibrillation patients before and after catheter ablation. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102500] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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10
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Usefulness of computer-assisted ECG analysis in the pre-operative evaluation of noncardiac surgery. Eur J Anaesthesiol 2020; 37:1075-1077. [PMID: 33027228 DOI: 10.1097/eja.0000000000001256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Jacobsson J, Carlson J, Reitan C, Borgquist R, Platonov PG. Interatrial Block Predicts Atrial Fibrillation and Total Mortality in Patients with Cardiac Resynchronization Therapy. Cardiology 2020; 145:720-729. [PMID: 33022672 DOI: 10.1159/000509916] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/17/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Interatrial block (IAB) and abnormal P-wave terminal force in lead V1 (PTFV1) are electrocardiographic (ECG) abnormalities that have been shown to be associated with new-onset atrial fibrillation (AF) and death. However, their prognostic importance has not been proven in cardiac resynchronization therapy (CRT) recipients. OBJECTIVE To assess if IAB and abnormal PTFV1 are associated with new-onset AF or death in CRT recipients. METHODS CRT recipients with sinus rhythm ECG at CRT implantation and no AF history were included (n = 210). Automated analysis of P-wave duration (PWD) and morphology classified patients as having either no IAB (PWD <120 ms), partial IAB (pIAB: PWD ≥120 ms, positive P waves in leads II and aVF), or advanced IAB (aIAB: PWD ≥120 ms and biphasic or negative P wave in leads II or aVF). PTFV1 >0.04 mm•s was considered abnormal. Adjusted Cox regression analyses were performed to assess the impact of IAB and abnormal PTFV1 on the primary endpoint new-onset AF, death, or heart transplant (HTx) and the secondary endpoint death or HTx at 5 years of follow-up. RESULTS IAB was found in 45% of all patients and independently predicted the primary endpoint with HR 1.9 (95% CI 1.2-2.9, p = 0.004) and the secondary endpoint with HR 2.1 (95% CI 1.2-3.4, p = 0.006). Abnormal PTFV1 was not associated with the endpoints. CONCLUSIONS IAB is associated with new-onset AF and death in CRT recipients and may be helpful in the risk stratification in the context of heart failure management. Abnormal PTFV1 did not demonstrate any prognostic value.
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Affiliation(s)
- Jonatan Jacobsson
- Lund University, Department of Cardiology, Clinical Sciences, Skane University Hospital, Lund, Sweden, .,Department of Medicine, Sahlgrenska University Hospital, Mölndal, Sweden,
| | - Jonas Carlson
- Lund University, Department of Cardiology, Clinical Sciences, Skane University Hospital, Lund, Sweden
| | - Christian Reitan
- Lund University, Department of Cardiology, Clinical Sciences, Skane University Hospital, Lund, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institute, Solna, Sweden
| | - Rasmus Borgquist
- Lund University, Department of Cardiology, Clinical Sciences, Skane University Hospital, Lund, Sweden.,Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Pyotr G Platonov
- Lund University, Department of Cardiology, Clinical Sciences, Skane University Hospital, Lund, Sweden
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12
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Istolahti T, Eranti A, Huhtala H, Lyytikäinen LP, Kähönen M, Lehtimäki T, Eskola M, Anttila I, Jula A, Bayés de Luna A, Nikus K, Hernesniemi J. The prevalence and prognostic significance of interatrial block in the general population. Ann Med 2020; 52:63-73. [PMID: 32077319 PMCID: PMC7877939 DOI: 10.1080/07853890.2020.1731759] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Introduction: Partial and advanced interatrial block (IAB) in the electrocardiographic (ECG) represents inter-atrial conduction delay. IAB is associated with atrial fibrillation (AF) and stroke in the general population.Material and methods: A representative sample of Finnish subjects (n = 6354) aged over 30 years (mean: 52.2 years, standard deviation: 14.6) underwent a health examination including a 12-lead ECG. Five different IAB groups based on automatic measurements were compared to normal P waves using multivariate-adjusted Cox proportional hazard model. Follow-up lasted up to 15 years.Results: The prevalence of advanced and partial IAB was 1.0% and 9.7%, respectively. In the multivariate model, both advanced (hazard ratio (HR): 1.63 (95% confidence interval (CI): 1.00-2.65)) and partial IAB (HR: 1.39 (1.09-1.77)) were associated with increased risk of AF. Advanced IAB was associated with increased risk of stroke or transient ischaemic attack (TIA) independently of associated AF (HR: 2.22 (1.20-4.13)). Partial IAB was also associated with increased risk of being diagnosed with coronary heart disease (HR: 1.26 (1.01-1.58)).Discussion: IAB is a rather frequent finding in the general population. IAB is a risk factor for AF and is associated with an increased risk of stroke or TIA independently of associated AF.Key messagesBoth partial and advanced interatrial block are associated with increased risk of atrial fibrillation in the general population.Advanced interatrial block is an independent risk factor for stroke and transient ischaemic attack.The clinical significance of interatrial block is dependent on the subtype classification.
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Affiliation(s)
- Tiia Istolahti
- Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Tampere, Finland.,Department of Internal Medicine, Vaasa Central Hospital, Vaasa, Finland
| | - Antti Eranti
- Heart Center, Central Hospital of North Karelia, Joensuu, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Leo-Pekka Lyytikäinen
- Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Tampere, Finland.,Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland.,Department of Clinical Chemistry, Fimlab Laboratories, Tampere, Finland
| | - Mika Kähönen
- Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Tampere, Finland.,Department of Clinical Physiology, Tampere University Hospital, Tampere, Finland
| | - Terho Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Tampere, Finland.,Department of Clinical Chemistry, Fimlab Laboratories, Tampere, Finland
| | - Markku Eskola
- Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Tampere, Finland.,Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | - Ismo Anttila
- Department of Emergency Services, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Antti Jula
- National Institute for Health and Welfare, Helsinki, Finland
| | - Antoni Bayés de Luna
- Cardiovascular Research Foundation, Cardiovascular ICCC-Program, Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | - Kjell Nikus
- Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Tampere, Finland.,Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | - Jussi Hernesniemi
- Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Tampere, Finland.,Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
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13
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Centurión OA. Role of Interatrial Block Recognition: A closer look to the Bayés Syndrome. J Atr Fibrillation 2019; 12:2246. [PMID: 32002117 PMCID: PMC6990053 DOI: 10.4022/jafib.2246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 05/14/2019] [Accepted: 06/26/2019] [Indexed: 11/14/2023]
Affiliation(s)
- Osmar Antonio Centurión
- Cardiology Department, Clinic Hospital, Faculty of Medical Sciences,Asunción National University (UNA). San Lorenzo. Paraguay
- Departament of Health Sciences Investigation, Sanatorio Metropolitano. Fernando de la Mora. Paraguay
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14
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Nortamo S, Laitinen I, Passi J, Tulppo M, Ukkola OH, Junttila MJ, Kiviniemi AM, Kenttä T, Huikuri HV, Perkiömäki JS. Prognostic significance of P-wave morphology in patients with coronary artery disease. J Cardiovasc Electrophysiol 2019; 30:2051-2060. [PMID: 31310355 DOI: 10.1111/jce.14066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Santeri Nortamo
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Idamaria Laitinen
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Jussi Passi
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Mikko Tulppo
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Antti M Kiviniemi
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuomas Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
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15
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Baturova MA, Lindgren A, Shubik YV, Carlson J, Platonov PG. Interatrial block in prediction of all-cause mortality after first-ever ischemic stroke. BMC Cardiovasc Disord 2019; 19:37. [PMID: 30744701 PMCID: PMC6371419 DOI: 10.1186/s12872-019-1015-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/04/2019] [Indexed: 12/25/2022] Open
Abstract
Background Interatrial block (IAB) is an ECG indicator of atrial fibrosis related to atrial remodeling and thrombus formation thus leading to embolic stroke and increasing mortality. We aimed to assess weather IAB predicted all-cause mortality during 10 years after ischemic stroke. Methods The study sample comprised 235 patients (median age 74 (interquartile range 25–75% 65–81) years, 95 female) included in the Lund Stroke Register in 2001–2002, who had sinus rhythm ECGs at stroke admission. IAB was defined as a P-wave duration ≥120 ms without = partial IAB (n = 56) or with = advanced IAB (n = 41) biphasic morphology (±) in the inferior ECG leads. All-cause mortality was assessed via linkage with the Swedish Causes of Death Register. Results During follow-up 126 patients died (54%). Advanced IAB, but not partial, was associated with all-cause mortality in univariate Cox regression analysis (hazard ratio (HR) 1.98, 95% CI 1.27–3.09, p = 0.003). After adjustment for age, gender, severity of stroke measured by NIHSS scale and smoking status in patients without additional comorbidities advanced IAB independently predicted all-cause mortality (HR 7.89, 95% CI 2.01–30.98, p = 0.003), while in patients with comorbidities it did not (HR 1.01 95% CI 0.59–1.72, p = 0.966). Conclusion Advanced IAB predicted all-cause mortality after ischemic stroke, but mostly in patients without additional cardiovascular comorbidities.
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Affiliation(s)
- M A Baturova
- Department of Cardiology, Clinical Sciences, Lund University, SE-221 85, Lund, Sweden. .,Research Park, St Petersburg State University, Peterhof, Botanicheskaya, 17, St Petersburg, Russia.
| | - A Lindgren
- Department of Cardiology, Clinical Sciences, Lund University, SE-221 85, Lund, Sweden.,Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - Y V Shubik
- Cardiology research, clinical and educational center, St. Petersburg State University, Universitetskaya Embankment, 7/9, St. Petersburg, Russia
| | - J Carlson
- Department of Cardiology, Clinical Sciences, Lund University, SE-221 85, Lund, Sweden
| | - P G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, SE-221 85, Lund, Sweden.,Arrythmia Clinic, Skåne University Hospital, SE-221 85, Lund, Sweden
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16
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Anees MA, Ahmad MI, Chevli PA, Li Y, Soliman EZ. Association of vitamin D deficiency with electrocardiographic markers of left atrial abnormalities. Ann Noninvasive Electrocardiol 2019; 24:e12626. [PMID: 30659705 DOI: 10.1111/anec.12626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 11/03/2018] [Accepted: 11/28/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE Electrocardiographic markers of left atrial (LA) abnormalities are linked to increased risk of cardiovascular disease (CVD). We examined the relationship of vitamin D deficiency with prolonged P wave duration and PR interval as markers of LA abnormalities. METHODS This analysis included 5,894 participants (58.12 ± 12.9 years; 54.7% women; 49.8% non-Hispanic Whites) without clinical CVD from NHANES III. A multivariable logistic regression model was used to examine the association of vitamin D categories (<20 ng/ml, 20-29 ng/ml and >30 ng/ml (reference) with prolonged P wave duration (≥120 ms) and PR interval (≥200 ms). RESULTS There was an incremental increase in the prevalence of prolonged P wave duration and PR interval across vitamin D categories with the highest prevalence in study participants with vitamin D levels <20 ng/ml, followed by 20-29 ng/ml and then >30 ng/ml (trend p-value < 0.0001). Vitamin D deficiency (<20 ng/ml) was associated with prolonged P wave duration (OR [95% CI]: 1.22 [1.03-1.45], p = 0.02) and prolonged PR interval (OR [95% CI]: 1.48 [1.12-1.97], p = 0.006) in multivariable logistic regression models adjusted for demographics, CVD risk factors, and other potential confounders. These associations were consistent across subgroups stratified by age, sex, and race. CONCLUSIONS Vitamin D deficiency is associated with an increased risk of LA abnormalities. This association elucidates an alternate pathway through which vitamin D deficiency may increase CVD risk. Whether vitamin D supplementation would improve LA abnormalities requires further investigation.
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Affiliation(s)
| | - Muhammad Imtiaz Ahmad
- Section on Hospital Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Parag A Chevli
- Section on Hospital Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Yabing Li
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Epidemiological Cardiology Research Center (EPICARE), Winston Salem, North Carolina
| | - Elsayed Z Soliman
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Epidemiological Cardiology Research Center (EPICARE), Winston Salem, North Carolina.,Section on Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina
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17
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Aizawa Y, Watanabe H, Okumura K. Electrocardiogram (ECG) for the Prediction of Incident Atrial Fibrillation: An Overview. J Atr Fibrillation 2017; 10:1724. [PMID: 29487684 DOI: 10.4022/jafib.1724] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/19/2017] [Accepted: 12/14/2017] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Yoshifusa Aizawa
- Research and Development, Tachikawa Medical Center and Niigata University,Nagaoka and Niigata,Japan
| | - Hiroshi Watanabe
- Department of Cardiology, Graduate School of Medical and Dental Science,Niigata University, Niigata, Japan
| | - Ken Okumura
- Arrhythmia Center,Saiseikai Hospital Kumamoto, Kumamoto, Japan
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18
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Petersson R, Smith JG, Larsson DA, Reitan Ö, Carlson J, Platonov P, Holmqvist F. Orthogonal P-wave morphology is affected by intra-atrial pressures. BMC Cardiovasc Disord 2017; 17:288. [PMID: 29212469 PMCID: PMC5719760 DOI: 10.1186/s12872-017-0724-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 11/28/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND It has previously been shown that the morphology of the P-wave neither depends on atrial size in healthy subjects with physiologically enlarged atria nor on the physiological anatomical variation in transverse orientation of the left atrium. The present study aimed to investigate if different pressures in the left and right atrium are associated with different P-wave morphologies. METHODS 38 patients with isolated, increased left atrial pressure, 51 patients with isolated, increased right atrial pressure and 76 patients with biatrially increased pressure were studied. All had undergone right heart catheterization and had 12-lead electrocardiographic recordings, which were transformed into vectorcardiograms for detailed P-wave morphology analysis. RESULTS Normal P-wave morphology (type 1) was more common in patients with isolated increased pressure in the right atrium while abnormal P-wave morphology (type 2) was more common in the groups with increased left atrial pressure (P = 0.032). Moreover, patients with increased left atrial pressure, either isolated or in conjunction with increased right atrial pressure, had significantly more often a P-wave morphology with a positive deflection in the sagittal plane (P = 0.004). CONCLUSION Isolated elevated right atrial pressure was associated with normal P-wave morphology while left-sided atrial pressure elevation, either isolated or in combination with right atrial pressure elevation, was associated with abnormal P-wave morphology.
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Affiliation(s)
- Richard Petersson
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Center for Integrative Electrocardiology, Lund University, Lund, Sweden
| | - J. Gustav Smith
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Heart Failure and Valvular Disease Clinic, Skåne University Hospital, Lund, Sweden
| | - David A. Larsson
- Department of Internal and Emergency Medicine, Skåne University Hospital, Lund, Sweden
| | - Öyvind Reitan
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Heart Failure and Valvular Disease Clinic, Skåne University Hospital, Lund, Sweden
| | - Jonas Carlson
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Center for Integrative Electrocardiology, Lund University, Lund, Sweden
| | - Pyotr Platonov
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Center for Integrative Electrocardiology, Lund University, Lund, Sweden
- Arrhythmia Clinic, Skåne University Hospital, Lund, Sweden
| | - Fredrik Holmqvist
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Center for Integrative Electrocardiology, Lund University, Lund, Sweden
- Arrhythmia Clinic, Skåne University Hospital, Lund, Sweden
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19
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Affiliation(s)
- Manuel Martínez-Sellés
- Hospital General Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, Madrid, Spain
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20
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Bayés de Luna A, Baranchuk A, Martínez-Sellés M, Platonov PG. Anticoagulation in patients at high risk of stroke without documented atrial fibrillation. Time for a paradigm shift? Ann Noninvasive Electrocardiol 2016; 22. [PMID: 27982498 DOI: 10.1111/anec.12417] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Atrial fibrillation (AF) is currently considered a risk factor for stroke. Depending on the severity of clinical factors (risk scores) a recommendation for full anticoagulation is made. Although AF is most certainly a risk factor for ischemic stroke, it is not necessarily the direct cause of it. The causality of association between AF and ischemic stroke is questioned by the reported lack of temporal relation between stroke events and AF paroxysms (or atrial high-rate episodes detected by devices). In different studies, only 2% of patients had subclinical AF > 6 minutes in duration at the time of stroke or systemic embolism. Is it time to consider AF only one more factor of endothelial disarray rather than the main contributor to stroke? In this "opinion paper" we propose to consider not only clinical variables predicting AF/stroke but also electrocardiographic markers of atrial fibrosis, as we postulate this as a strong indicator of risk of AF/stroke. We ask if it is time to change the paradigm and to consider, in some special situations, to protect patients (preventing stroke) who have no evidence of AF.
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Affiliation(s)
- Antoni Bayés de Luna
- Catalan Institute of Cardiovascular Sciences, St. Pau Hospital, Barcelona, Spain
| | - Adrian Baranchuk
- Heart Rhythm Service, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Manuel Martínez-Sellés
- Cardiology Department, Hospital Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Pyotr G Platonov
- Center for Integrative Electrocardiology at Lund University (CIEL), and Arrhythmia Clinic Sweden, Skåne University Hospital, Lund, Sweden
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21
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Abstract
P-wave morphology and duration reveals several aspects of the atria: Proper function, fibrosis, dyssynchrony, and activation paths can be inferred from the surface P-wave analysis. Surface electrocardiogram (ECG) can help differentiating enlargements of the atria from conduction defects including intra- and interatrial block.The purpose of this paper is to review normal atrial morphology and the most relevant abnormal patterns.
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Affiliation(s)
- Adrian Baranchuk
- Division of Cardiology, Cardiac Electrophysiology and Pacing, Kingston General Hospital, Queen's University, K7L 2V7, Kingston, ON, Canada,
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22
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Baturova MA, Sheldon SH, Carlson J, Brady PA, Lin G, Rabinstein AA, Friedman PA, Platonov PG. Electrocardiographic and Echocardiographic predictors of paroxysmal atrial fibrillation detected after ischemic stroke. BMC Cardiovasc Disord 2016; 16:209. [PMID: 27809773 PMCID: PMC5093933 DOI: 10.1186/s12872-016-0384-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 10/25/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Detection of atrial fibrillation after ischemic stroke is challenging due to its paroxysmal nature. We aimed to assess predictors of paroxysmal atrial fibrillation using non-invasive surface ECG and transthoracic echocardiography to select candidates for atrial fibrillation screening. METHODS Ischemic stroke patients without documented atrial fibrillation (n = 110, 67 ± 10 years, 40 female) and a control group of age- and gender-matched patients with history of paroxysmal atrial fibrillation prior to stroke (n = 55, 67 ± 10 years, 19 female) comprised the study sample. Using non-invasive ECG monitoring for three weeks, short episodes of paroxysmal atrial fibrillation were detected in 24 of 110 patients (22 %). The standard 12-lead ECG with sinus rhythm at stroke onset was digitally processed and analyzed. Transthoracic echocardiography data were reviewed for these patients. RESULTS Atrial fibrillation history was independently associated with P terminal force in lead V 1 > 40 mm*ms (OR 4.04 95 % CI 1.34-12.14, p = 0.013) and left atrial volume index (OR 1.08 95 % CI 1.03-1.13, p = 0.002; for LAVI > 40 mL/m2 OR 6.40 95 % CL 1.47-27.91, p = 0.013). Among patients without atrial fibrillation history, no ECG characteristics were predictive of atrial fibrillation detected after stroke. Left atrial volume index remained an independent predictor of atrial fibrillation detected after stroke (OR 1.09 95 % CI 1.02-1.16, p = 0.017). A cutoff of <40 mL/m2 had an 84 % negative predictive value for ruling out atrial fibrillation on ambulatory monitoring with a sensitivity of 50 % and a specificity of 86 %. CONCLUSION In a post hoc analysis, left atrial dilatation assessed by left atrial volume index independently predicted atrial fibrillation after stroke in patients without prior atrial fibrillation history, while the other clinical or ECG markers were not predictive of atrial fibrillation detected early after ischemic stroke. TRIAL REGISTRATION This study is a post hoc analysis from the prospective case-control study registered in December 2011, ClinicalTrials.gov ID: NCT01325545 .
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Affiliation(s)
- Maria A Baturova
- Department of Cardiology, Clinical Science, Lund University, Lund, SE-221 85, Sweden. .,University Clinic, St. Petersburg State University, Kadetskaya Line 13-15, St. Petersburg, 199004, Russia.
| | - Seth H Sheldon
- Department of Cardiology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55902, USA
| | - Jonas Carlson
- Department of Cardiology, Clinical Science, Lund University, Lund, SE-221 85, Sweden
| | - Peter A Brady
- Department of Cardiology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55902, USA
| | - Grace Lin
- Department of Cardiology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55902, USA
| | - Alejandro A Rabinstein
- Department of Neurology, Mayo Clinic, Mayo West 8B, 200 First Street SW, Mayo Clinic, Rochester, Minnesota, 55905, USA
| | - Paul A Friedman
- Department of Cardiology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55902, USA
| | - Pyotr G Platonov
- Department of Cardiology, Clinical Science, Lund University, Lund, SE-221 85, Sweden.,Arrhythmia Clinic, Skåne University Hospital, Lund, SE-221 85, Sweden
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23
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Martínez-Sellés M, Fernández Lozano I, Baranchuk A, Bayes-Genis A, Bayés de Luna A. ¿Debemos anticoagular a pacientes en alto riesgo de sufrir fibrilación auricular? Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2016.01.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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24
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Martínez-Sellés M, Fernández Lozano I, Baranchuk A, Bayes-Genis A, Bayés de Luna A. Should We Anticoagulate Patients at High Risk of Atrial Fibrillation? ACTA ACUST UNITED AC 2016; 69:374-6. [PMID: 26944349 DOI: 10.1016/j.rec.2016.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 01/11/2016] [Indexed: 12/31/2022]
Affiliation(s)
- Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Europea y Universidad Complutense, Madrid, Spain.
| | | | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Antoni Bayes-Genis
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
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25
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Baturova MA, Lindgren A, Carlson J, Shubik YV, Olsson SB, Platonov PG. Predictors of new onset atrial fibrillation during 10-year follow-up after first-ever ischemic stroke. Int J Cardiol 2015. [PMID: 26209828 DOI: 10.1016/j.ijcard.2015.07.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Paroxysmal atrial fibrillation (AF) may be underdiagnosed in ischemic stroke patients but may be pivotal for initiation of oral anticoagulation therapy. We assessed clinical and ECG predictors of new-onset AF during 10-year follow-up (FU) in ischemic stroke patients. METHODS The study sample comprised of 227 first-ever ischemic stroke patients without AF (median age 73, interquartile range 25%-75% 63-80years, 92 female) and 1:1 age- and gender-matched controls without stroke and AF enrolled in the Lund Stroke Register from March 2001 to February 2002. New-onset AF during FU was assessed by screening through regional ECG database and by record linkage with Swedish National Patient Register. The standard 12-lead sinus rhythm ECGs at stroke admission were retrieved from electronic database and digitally processed. Clinical baseline characteristics were studied using medical records. RESULTS During FU, AF was found in 39 stroke patients and 30 controls, p=0.296. In stroke patients in multivariate Cox regression analysis AF was associated with hypertension (HR 3.45 CI 95% 1.40-3.49, p=0.007) and QRS duration (HR 1.02 CI 95% 1.00-1.03, p=0.049). High cardiovascular risk was predictive for AF development: for CHADS2≥4 HR 2.46 CI 95% 1.45-4.18, p=0.001 and for CHA2DS2-VASc≥5 HR 2.29 CI 95% 1.43-3.68, p=0.001. New onset AF was not associated with baseline ischemic stroke: HR 1.46 95% CI 0.90-2.35, p=0.121. CONCLUSION High CHADS2 and CHA2DS2-VASc scores, but not baseline ischemic stroke, predict new onset AF in FU. QRS duration might be considered a potential risk marker for prediction of AF after ischemic stroke.
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Affiliation(s)
- Maria A Baturova
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden; St. Petersburg University Clinic, St. Petersburg, Russia; Cardiology Research, Clinical and Educational Center, St. Petersburg State University, St. Petersburg, Russia.
| | - Arne Lindgren
- Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences Lund, Neurology, Lund University, Sweden
| | - Jonas Carlson
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Yuri V Shubik
- St. Petersburg University Clinic, St. Petersburg, Russia; Cardiology Research, Clinical and Educational Center, St. Petersburg State University, St. Petersburg, Russia
| | - S Bertil Olsson
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Pyotr G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden; Arrythmia Clinic, Skåne University Hospital, Lund, Sweden
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26
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de Luna AB, Massó-van Roessel A, Robledo LAE. The Diagnosis and Clinical Implications of Interatrial Block. Eur Cardiol 2015; 10:54-59. [PMID: 30310424 PMCID: PMC6159419 DOI: 10.15420/ecr.2015.10.01.54] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 07/16/2015] [Indexed: 11/04/2022] Open
Abstract
Impaired interatrial conduction or interatrial block is now well-documented but is not described as an individual electrocardiographic (ECG) pattern in the majority of ECG literature. In fact the term atrial abnormality has been adopted to encompass both left atrial enlargement (LAE) and interatrial block. In this paper, we maintain that interatrial blocks and atrial enlargement are separate entities, and that interatrial blocks, similar to other types of blocks at sinoatrial, AV junctional, and ventricular level, exhibit a specific ECG pattern that may present first, second, and third degree types of conduction block. The third degree or advanced interatrial block (A-IAB) is frequently associated with atrial fibrillation/atrial flutter (AF/AFl), and constitutes a true newly-described syndrome.
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Conde D, Baranchuk A, Bayés de Luna A. Advanced interatrial block as a substrate of supraventricular tachyarrhythmias: a well recognized syndrome. J Electrocardiol 2015; 48:135-40. [DOI: 10.1016/j.jelectrocard.2014.12.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Indexed: 11/29/2022]
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Sadiq Ali F, Enriquez A, Conde D, Redfearn D, Michael K, Simpson C, Abdollah H, Bayés de Luna A, Hopman W, Baranchuk A. Advanced Interatrial Block Predicts New Onset Atrial Fibrillation in Patients with Severe Heart Failure and Cardiac Resynchronization Therapy. Ann Noninvasive Electrocardiol 2015; 20:586-91. [PMID: 25639950 DOI: 10.1111/anec.12258] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Advanced interatrial block (aIAB) on the surface electrocardiogram (ECG), defined as a P-wave duration ≥120 milliseconds with biphasic (±) morphology in inferior leads, is frequently associated with atrial fibrillation (AF). The aim of this study was to determine whether preoperative aIAB could predict new-onset AF in patients with severe congestive heart failure (CHF) requiring cardiac resynchronization therapy (CRT). METHODS Retrospective analysis of consecutive patients with CHF and no prior history of AF undergoing CRT for standard indications. A baseline 12-lead ECG was obtained prior to device implantation and analyzed for the presence of aIAB. ECGs were scanned at 300 DPI and maximized 8×. Semiautomatic calipers were used to determine P-wave onset and offset. The primary outcome was the occurrence of AF identified through analyses of intracardiac electrograms on routine device follow-up. RESULTS Ninety-seven patients were included (74.2% male, left atrial diameter 45.5 ± 7.8 mm, 63% ischemic). Mean P-wave duration was 138.5 ± 18.5 milliseconds and 37 patients (38%) presented aIAB at baseline. Over a mean follow-up of 32 ± 18 months, AF was detected in 29 patients (30%) and the incidence was greater in patients with aIAB compared to those without it (62% vs 28%; P < 0.003). aIAB remained a significant predictor of AF occurrence after multivariate analysis (OR 4.1; 95% CI, 1.6-10.7; P < 0.003). CONCLUSION The presence of aIAB is an independent predictor of new-onset AF in patients with severe CHF undergoing CRT.
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Affiliation(s)
- Fariha Sadiq Ali
- Division of Cardiology, Department of Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Andres Enriquez
- Division of Cardiology, Department of Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Diego Conde
- Cardiovascular Institute of Buenos Aires, Buenos Aires, Argentina
| | - Damian Redfearn
- Division of Cardiology, Department of Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Kevin Michael
- Division of Cardiology, Department of Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Christopher Simpson
- Division of Cardiology, Department of Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Hoshiar Abdollah
- Division of Cardiology, Department of Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Antoni Bayés de Luna
- Division of Cardiology, Department of Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada.,Hospital of Santa Creu i Sant Pau, Cardiovascular Research Center, CSIC-ICCC, Barcelona, Spain
| | - Wilma Hopman
- Division of Cardiology, Department of Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Division of Cardiology, Department of Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
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Eranti A, Aro AL, Kerola T, Anttonen O, Rissanen HA, Tikkanen JT, Junttila MJ, Kenttä TV, Knekt P, Huikuri HV. Prevalence and Prognostic Significance of Abnormal P Terminal Force in Lead V
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of the ECG in the General Population. Circ Arrhythm Electrophysiol 2014; 7:1116-21. [DOI: 10.1161/circep.114.001557] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Antti Eranti
- From the Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (A.E., T.K., O.A.); Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital (A.L.A.) and Department of Health, Functional Capacity and Welfare, National Institute of Health and Welfare (H.A.R., P.K.), Helsinki, Finland; and Department on Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital & University of Oulu, Oulu, Finland (J.T.T., M
| | - Aapo L. Aro
- From the Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (A.E., T.K., O.A.); Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital (A.L.A.) and Department of Health, Functional Capacity and Welfare, National Institute of Health and Welfare (H.A.R., P.K.), Helsinki, Finland; and Department on Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital & University of Oulu, Oulu, Finland (J.T.T., M
| | - Tuomas Kerola
- From the Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (A.E., T.K., O.A.); Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital (A.L.A.) and Department of Health, Functional Capacity and Welfare, National Institute of Health and Welfare (H.A.R., P.K.), Helsinki, Finland; and Department on Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital & University of Oulu, Oulu, Finland (J.T.T., M
| | - Olli Anttonen
- From the Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (A.E., T.K., O.A.); Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital (A.L.A.) and Department of Health, Functional Capacity and Welfare, National Institute of Health and Welfare (H.A.R., P.K.), Helsinki, Finland; and Department on Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital & University of Oulu, Oulu, Finland (J.T.T., M
| | - Harri A. Rissanen
- From the Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (A.E., T.K., O.A.); Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital (A.L.A.) and Department of Health, Functional Capacity and Welfare, National Institute of Health and Welfare (H.A.R., P.K.), Helsinki, Finland; and Department on Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital & University of Oulu, Oulu, Finland (J.T.T., M
| | - Jani T. Tikkanen
- From the Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (A.E., T.K., O.A.); Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital (A.L.A.) and Department of Health, Functional Capacity and Welfare, National Institute of Health and Welfare (H.A.R., P.K.), Helsinki, Finland; and Department on Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital & University of Oulu, Oulu, Finland (J.T.T., M
| | - M. Juhani Junttila
- From the Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (A.E., T.K., O.A.); Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital (A.L.A.) and Department of Health, Functional Capacity and Welfare, National Institute of Health and Welfare (H.A.R., P.K.), Helsinki, Finland; and Department on Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital & University of Oulu, Oulu, Finland (J.T.T., M
| | - Tuomas V. Kenttä
- From the Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (A.E., T.K., O.A.); Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital (A.L.A.) and Department of Health, Functional Capacity and Welfare, National Institute of Health and Welfare (H.A.R., P.K.), Helsinki, Finland; and Department on Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital & University of Oulu, Oulu, Finland (J.T.T., M
| | - Paul Knekt
- From the Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (A.E., T.K., O.A.); Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital (A.L.A.) and Department of Health, Functional Capacity and Welfare, National Institute of Health and Welfare (H.A.R., P.K.), Helsinki, Finland; and Department on Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital & University of Oulu, Oulu, Finland (J.T.T., M
| | - Heikki V. Huikuri
- From the Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (A.E., T.K., O.A.); Division of Cardiology, Heart and Lung Center, Helsinki University Central Hospital (A.L.A.) and Department of Health, Functional Capacity and Welfare, National Institute of Health and Welfare (H.A.R., P.K.), Helsinki, Finland; and Department on Internal Medicine, Institute of Clinical Medicine, Medical Research Center Oulu, University Hospital & University of Oulu, Oulu, Finland (J.T.T., M
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Holmqvist F, Platonov PG, Solomon SD, Petersson R, McNitt S, Carlson J, Zareba W, Moss AJ. P-wave morphology is associated with echocardiographic response to cardiac resynchronization therapy in MADIT-CRT patients. Ann Noninvasive Electrocardiol 2014; 18:510-8. [PMID: 24303967 DOI: 10.1111/anec.12121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND In this study we hypothesized that signs of atypical atrial activation would be associated with cardiac resynchronization therapy (CRT) response in patients with mildly symptomatic heart failure (CHF), left ventricular dysfunction, and wide QRS complex. METHODS Patients included in the CRT-D arm in MADIT-CRT were studied (n = 892). Unfiltered signal-averaged P waves were analyzed to determine orthogonal P-wave morphology (typical morphologies were predefined as having positive signals in Leads X and Y and a negative or negative-positive signal in Lead Z. All other patterns were classified as atypical). The association between P-wave morphology and data on echocardiographic response at 1 year was analyzed. RESULTS Atypical P-wave morphology was found in 21% (n = 186) of the patients at baseline. Patients with atypical P-wave morphology were more often female (31% vs. 24%, P = 0.025), had lower BMI (28 ± 5 kg/m(2) vs. 29 ± 5 kg/m(2) , P = 0.008), had more ischemic CHF (60% vs. 52%, P = 0.026) and had smaller left atrial volumes (90 ± 20 mL vs. 94 ± 22 mL, P = 0.034). Atypical P-wave morphology at baseline was associated with superior response to CRT at 1 year with a larger reduction in left ventricular end-diastolic volume (-23 ± 12% vs. -20 ± 11%, P = 0.009), left ventricular end-systolic volume (-36 ± 16% vs. -31 ± 16%, P = 0.006), and left atrial volume (-31 ± 12% vs. -27 ± 12%, P = 0.005), with a slightly larger absolute increase in left ventricular ejection fraction (LVEF) (12 ± 5% vs. 11 ± 5%, P = 0.009). These associations were found to be independent of traditional predictors. CONCLUSION The presence of atypical P-wave morphology recorded is independently associated with a favorable echocardiographic cardiac remodeling response to CRT.
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Affiliation(s)
- Fredrik Holmqvist
- Department of Cardiology, Lund University, Lund, Sweden; Center for Integrative Electrocardiology, Lund University, Lund, Sweden
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Murthy S, Rizzi P, Mewton N, Strauss DG, Liu CY, Volpe GJ, Marchlinski FE, Spooner P, Berger RD, Kellman P, Lima JAC, Tereshchenko LG. Number of P-wave fragmentations on P-SAECG correlates with infiltrated atrial fat. Ann Noninvasive Electrocardiol 2014; 19:114-21. [PMID: 24620844 DOI: 10.1111/anec.12084] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Although atrial fibrillation (AF) triggers are known, the underlying AF substrate is less well understood. The goal of our study was to explore correlations between electrophysiological and structural characteristics of atria in patients with paroxysmal AF and individuals at AF risk. METHODS Patients in sinus rhythm (N = 90; age 57 ± 10 year; 55 men [63.2%]) with structural heart disease and paroxysmal AF (n = 12 [13%]), or with AF risk factors and LVEF > 35% (n = 78), underwent SAECG and cardiac magnetic resonance study. Interatrial and epicardial fat was analyzed with a Dark-blood DIR-prepared Fat-Water-separated sequence in the horizontal longitudinal axis. All local P-wave extrema were identified on SAECG leads during sinus rhythm. A P-wave fragmentation (Pf) was defined as an absolute difference between adjacent extrema which was above three standard deviations of noise, and was normalized by the duration of the P wave in the corresponding lead. RESULTS The Pf was greater on the filtered than on the unfiltered P-SAECG signal (13.1 ± 3.8 vs. 3.4 ± 1.2; P < 0.0001). Pf was the greatest on the Y lead (13.0 ± 3.5 on Y lead vs. 12.1 ± 3.4 on Z lead; P = 0.003. Pf on Z lead correlated with interatrial fat index (r = 0.544; P = 0.001). Epicardial fat significantly correlated with body mass index (BMI; r = 0.302; P = 0.015). After adjustment for BMI, left atrium (LA) size, epicardial fat, and interatrial septum width, interatrial fat independently associated with the Pf on Z lead (β-coefficient 0.009 [95%CI 0.0003-0.019]; P = 0.043). CONCLUSIONS Infiltrated atrial fat correlates with discontinuous conduction on posterior LA wall and represents AF early substrate.
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Affiliation(s)
- Sindhoora Murthy
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD
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Petersson R, Berge HM, Gjerdalen GF, Carlson J, Holmqvist F, Steine K, Platonov PG. P-wave morphology is unaffected by atrial size: a study in healthy athletes. Ann Noninvasive Electrocardiol 2014; 19:366-73. [PMID: 24517470 DOI: 10.1111/anec.12132] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Orthogonal P-wave morphology has previously been described in different populations, but its relation to atrial size has not been studied in detail. In this study, we investigated whether atrial size affects P-wave morphology in athletes, who are known to have different degrees of atrial enlargement. METHODS A total of 504 healthy, male, professional soccer players were included (median age 25 years). All underwent echocardiographic and 12-lead electrocardiographic (ECG) recordings. The ECG was transformed into orthogonal leads, using the inverse Dower transform. The association between echocardiographic parameters and standard P-wave measures (i.e., orthogonal morphology, left atrial abnormality assessed as negative P-wave terminal force [PTF] in lead V1 > 0.04 mm × s, and duration) was analyzed. RESULTS The vast majority had either type 1 P-wave morphology (75%) (positive leads X and Y and negative lead Z) or type 2 P-wave morphology (22%) (positive leads X and Y and biphasic lead Z [negative/positive]). Left atrial enlargement (≥29 mL/m(2) ) was found in 79% on echocardiography. There was no significant difference in left atrial end-systolic volume, left or right atrial diameters, or right atrial area between individuals with different P-wave morphologies. ECG signs of left atrial abnormality were found in eight subjects, who did not have significantly larger left atrial dimensions than the rest. CONCLUSIONS We demonstrated that P-wave morphology does not depend on the size of the atria in young, healthy athletes, and that PTF is not a reliable marker of left atrial enlargement in the current population.
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Affiliation(s)
- Richard Petersson
- Department of Cardiology, Lund University and Center for Integrative Electrocardiology at Lund University, Lund, Sweden
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Martínez A, Alcaraz R, Rieta JJ. Morphological variability of the P-wave for premature envision of paroxysmal atrial fibrillation events. Physiol Meas 2013; 35:1-14. [PMID: 24345763 DOI: 10.1088/0967-3334/35/1/1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Interatrial blocks. A separate entity from left atrial enlargement: a consensus report. J Electrocardiol 2013; 45:445-51. [PMID: 22920783 DOI: 10.1016/j.jelectrocard.2012.06.029] [Citation(s) in RCA: 249] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Indexed: 12/14/2022]
Abstract
Impaired interatrial conduction or interatrial block is well documented but is not described as an individual electrocardiographic (ECG) pattern in most of ECG books, although the term atrial abnormalities to encompass both concepts, left atrial enlargement (LAE) and interatrial block, has been coined. In fact, LAE and interatrial block are often associated, similarly to what happens with ventricular enlargement and ventricular block. The interatrial blocks, that is, the presence of delay of conduction between the right and left atria, are the most frequent atrial blocks. These may be of first degree (P-wave duration >120 milliseconds), third degree (longer P wave with biphasic [±] morphology in inferior leads), and second degree when these patterns appear transiently in the same ECG recording (atrial aberrancy). There are evidences that these electrocardiographic P-wave patterns are due to a block because they may (a) appear transiently, (b) be without associated atrial enlargement, and (c) may be reproduced experimentally. The presence of interatrial blocks may be seen in the absence of atrial enlargement but often are present in case of LAE. The most important clinical implications of interatrial block are the following: (a) the first degree interatrial blocks are very common, and their relation with atrial fibrillation and an increased risk for global and cardiovascular mortality has been demonstrated; (b) the third degree interatrial blocks are less frequent but are strong markers of LAE and paroxysmal supraventricular tachyarrhythmias. Their presence has been considered a true arrhythmological syndrome.
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Abstract
Increasing awareness of atrial fibrillation (AF) and its impact on public health revives interest in identification of noninvasive markers of predisposition to AF and ECG-based risk stratification. P-wave duration is generally accepted as the most reliable noninvasive marker of atrial conduction, and its prolongation has been associated with history of AF. However, patients with paroxysmal AF without structural heart disease may not have any impressive P-wave prolongation, thus suggesting that global conduction slowing is not an obligatory requirement for development of AF. P-wave morphology is therefore drawing increasing attention as it reflects the three-dimensional course of atrial depolarization propagation and detects local conduction disturbances. The factors that determine P-wave appearance include (1) the origin of the sinus rhythm that defines right atrial depolarization vector, (2) localization of left atrial breakthrough that defines left atrial depolarization vector, and (3) the shape and size of atrial chambers. However, it is often difficult to distinguish whether P-wave abnormalities are caused by atrial enlargement or interatrial conduction delay. Recent advances in endocardial mapping technologies have linked certain P-wave morphologies with interatrial conduction patterns and the function of major interatrial conduction routes. The value of P-wave morphology extends beyond cardiac arrhythmias associated with atrial conduction delay and can be used for prediction of clinical outcome of a wide range of cardiovascular disorders, including ischemic heart disease and congestive heart failure.
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Affiliation(s)
- Pyotr G Platonov
- Center for Integrative Electrocardiology at Lund University (CIEL) and Arrhythmia Clinic, Skåne University Hospital, Lund, Sweden.
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Blanche C, Tran N, Rigamonti F, Burri H, Zimmermann M. Value of P-wave signal averaging to predict atrial fibrillation recurrences after pulmonary vein isolation. ACTA ACUST UNITED AC 2012; 15:198-204. [DOI: 10.1093/europace/eus251] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Kabutoya T, Ishikawa S, Ishikawa J, Hoshide S, Kario K. P-wave morphologic characteristics predict cardiovascular events in a community-dwelling population. Ann Noninvasive Electrocardiol 2012; 17:252-9. [PMID: 22816544 DOI: 10.1111/j.1542-474x.2012.00529.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND There have been few reports on the relationship between P-wave characteristics and long-term cardiovascular events. METHODS A nested case-control study was conducted as part of the Jichi Medical School cohort study, which enrolled 12,490 subjects in a community-dwelling population. The mean follow-up period was 10.7 years. The P-wave characteristics of 526 patients who suffered cardiovascular events (fatal/nonfatal stroke, fatal/nonfatal myocardial infarction, and sudden death) within the follow-up period (case group) were compared with those of 1578 matched controls (control group). The P-wave morphology was classified as normal, deflected, and notched type in precordial leads. A broad P wave was defined as a maximum P-wave duration of more than 120 ms in any of the 12 leads. RESULTS The mean age was 64 ± 8 years and the percentage of males was 54% in both groups. A notched P wave at baseline was observed in 10.1% of the case group and 6.0% of the control group (P = 0.001). A notched P wave was a significant predictor of cardiovascular events after adjustment for covariates (odds ratio = 1.59; 95% confidence interval = 1.08-2.33). Among the patients with left ventricular hypertrophy as evaluated by the Sokolow-Lyon criteria or Cornell product criteria, there was no significant difference in cardiovascular events between those with and those without a notched P wave, but in the absence of left ventricular hypertrophy, patients with a notched P wave suffered more cardiovascular events than those without a notched P wave by each criteria. CONCLUSION P-wave morphologic characteristics were effective for predicting cardiovascular events.
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Affiliation(s)
- Tomoyuki Kabutoya
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.
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Kirchhof P, Lip GYH, Van Gelder IC, Bax J, Hylek E, Kaab S, Schotten U, Wegscheider K, Boriani G, Brandes A, Ezekowitz M, Diener H, Haegeli L, Heidbuchel H, Lane D, Mont L, Willems S, Dorian P, Aunes-Jansson M, Blomstrom-Lundqvist C, Borentain M, Breitenstein S, Brueckmann M, Cater N, Clemens A, Dobrev D, Dubner S, Edvardsson NG, Friberg L, Goette A, Gulizia M, Hatala R, Horwood J, Szumowski L, Kappenberger L, Kautzner J, Leute A, Lobban T, Meyer R, Millerhagen J, Morgan J, Muenzel F, Nabauer M, Baertels C, Oeff M, Paar D, Polifka J, Ravens U, Rosin L, Stegink W, Steinbeck G, Vardas P, Vincent A, Walter M, Breithardt G, Camm AJ. Comprehensive risk reduction in patients with atrial fibrillation: emerging diagnostic and therapeutic options--a report from the 3rd Atrial Fibrillation Competence NETwork/European Heart Rhythm Association consensus conference. Europace 2012; 14:8-27. [PMID: 21791573 PMCID: PMC3236658 DOI: 10.1093/europace/eur241] [Citation(s) in RCA: 159] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 06/17/2011] [Indexed: 02/07/2023] Open
Abstract
While management of atrial fibrillation (AF) patients is improved by guideline-conform application of anticoagulant therapy, rate control, rhythm control, and therapy of accompanying heart disease, the morbidity and mortality associated with AF remain unacceptably high. This paper describes the proceedings of the 3rd Atrial Fibrillation NETwork (AFNET)/European Heart Rhythm Association (EHRA) consensus conference that convened over 60 scientists and representatives from industry to jointly discuss emerging therapeutic and diagnostic improvements to achieve better management of AF patients. The paper covers four chapters: (i) risk factors and risk markers for AF; (ii) pathophysiological classification of AF; (iii) relevance of monitored AF duration for AF-related outcomes; and (iv) perspectives and needs for implementing better antithrombotic therapy. Relevant published literature for each section is covered, and suggestions for the improvement of management in each area are put forward. Combined, the propositions formulate a perspective to implement comprehensive management in AF.
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Nielsen JB, Olesen MS, Tangø M, Haunsø S, Holst AG, Svendsen JH. Incomplete right bundle branch block: a novel electrocardiographic marker for lone atrial fibrillation. Europace 2010; 13:182-7. [PMID: 21138928 DOI: 10.1093/europace/euq436] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
AIMS P-wave morphology and PR interval have both been previously associated with atrial fibrillation (AF). We hypothesized that incomplete right bundle branch block (IRBBB) would be associated with early-onset lone AF. METHODS AND RESULTS We conducted a case-control study comparing electrocardiographic (ECG) markers from patients with early-onset lone AF and from a healthy control population. We included 187 patients with early-onset lone AF and 383 healthy controls. Sixty-two lone AF patients were excluded from the study because of AF at the time of enrolment or because of the use of antiarrhythmic drugs. For the remaining 125 patients with paroxysmal or persistent lone AF (84% males, mean age 37), controls were matched on a 1:1 basis on the parameters gender and age. A significantly higher proportion of the lone AF population had an IRBBB compared with the subjects in the control group (33.6 vs. 10.4%; P<0.001). In multivariable analysis adjusted for conventional risk factors, IRBBB was strongly associated with lone AF [odds ratio (OR) 5.43; 95% confidence interval (CI) 2.30-13.02; P<0.001]. Lone AF patients had a significantly longer PR interval than the control group (175.1 vs. 160.9 ms; P<0.001), but in multivariable analysis, every 10 ms increase in the PR interval was only borderline significantly associated with an OR of 1.15 (95% CI 0.99-1.32; P=0.060) for lone AF. CONCLUSION We are the first to report that IRBBB is strongly and independently associated with early-onset lone AF.
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Affiliation(s)
- Jonas Bille Nielsen
- Danish National Research Foundation Centre for Cardiac Arrhythmia (DARC), Copenhagen, Denmark.
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Holmqvist F, Olesen MS, Tveit A, Enger S, Tapanainen J, Jurkko R, Havmoller R, Haunso S, Carlson J, Svendsen JH, Platonov PG. Abnormal atrial activation in young patients with lone atrial fibrillation. Europace 2010; 13:188-92. [DOI: 10.1093/europace/euq352] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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van Diepen S, Siha H, Fu Y, Westerhout CM, Lopes RD, Granger CB, Armstrong PW. Do baseline atrial electrocardiographic and infarction patterns predict new-onset atrial fibrillation after ST-elevation myocardial infarction? Insights from the Assessment of Pexelizumab in Acute Myocardial Infarction Trial. J Electrocardiol 2010; 43:351-8. [DOI: 10.1016/j.jelectrocard.2010.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Indexed: 10/19/2022]
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