1
|
Fumagalli C, Zocchi C, Ciabatti M, Milazzo A, Cappelli F, Fumagalli S, Pieroni M, Olivotto I. From Atrial Fibrillation Management to Atrial Myopathy Assessment: The Evolving Concept of Left Atrium Disease in Hypertrophic Cardiomyopathy. Can J Cardiol 2024; 40:876-886. [PMID: 38286174 DOI: 10.1016/j.cjca.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 01/31/2024] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is the most prevalent genetically inherited cardiovascular disorder in adults and a significant cause of heart failure and sudden cardiac death. Historically, atrial fibrillation (AF) has been considered as a critical aspect in HCM patients as it is considered to be a marker of disease progression, escalates the frequency of heart failure hospitalisations, increases the risk of thromboembolic events, and worsens quality of life and outcome. Increasing evidence suggests that AF is the result of a subtle long-standing process that starts early in the history of HCM. The process of left atrial dilation accompanied by morphologic and functional remodelling is the quintessential prerequisite for the onset of AF. This review aims to describe the current understanding of AF pathophysiology in HCM, emphasising the role of left atrial myopathy in its development. In addition, we discuss risk factors and management strategies specific to AF in the context of HCM, providing insights into the complexities and challenges of treating this specific patient population.
Collapse
Affiliation(s)
- Carlo Fumagalli
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy.
| | - Chiara Zocchi
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Cardiovascular Department, San Donato Hospital, Arezzo, Italy
| | | | - Alessandra Milazzo
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesco Cappelli
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Stefano Fumagalli
- Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, Department of Experimental and Clinical Medicine, University of Florence and AOU Careggi, Florence, Italy
| | | | - Iacopo Olivotto
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Meyer Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Florence, Italy
| |
Collapse
|
2
|
Bernardini A, Crotti L, Olivotto I, Cecchi F. Diagnostic and prognostic electrocardiographic features in patients with hypertrophic cardiomyopathy. Eur Heart J Suppl 2023; 25:C173-C178. [PMID: 37125268 PMCID: PMC10132576 DOI: 10.1093/eurheartjsupp/suad074] [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] [Indexed: 05/02/2023]
Abstract
The standard 12-lead electrocardiogram (ECG) represents a cornerstone for the diagnosis and evaluation of hypertrophic cardiomyopathy (HCM), the most common genetically determined heart muscle disease, due to its cost-effectiveness and wide availability. The ECG may surprisingly look normal in 4-6% of adult patients, and in less than 3% of paediatric patients, but it is abnormal in the vast majority of the remaining patients. 'Specific' features comprise pathological Q-waves, deep S-waves in V1-V3, or high R-waves in V4-V6 due to left ventricular hypertrophy with T-wave (TW) depression or negative TWs. Negative giant TWs are often found in apical HCM. However, in many patients, the ECG may only show non-specific ST-T changes with diphasic or flat TWs. An isolated inverted TW in lateral leads (usually aVL) may be the only marker for HCM in some patients. Electrocardiogram helps to diagnose sarcomeric HCM and distinguish it from different phenocopies, such as cardiac amyloidosis, glycogen storage, or Fabry disease. Electrocardiogram may also have a prognostic role, identifying high-risk features that could impact the clinical outcome.
Collapse
Affiliation(s)
- Andrea Bernardini
- Cardiology and Electrophysiology Unit, Santa Maria Nuova Hospital, Piazza di Santa Maria Nuova 1, 50122 Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Largo Giovanni Alessandro Brambilla 3, 50134 Florence, Italy
| | - Lia Crotti
- Department of Medicine and Surgery, University Milano Bicocca, Piazza dell’Ateneo Nuovo 1, 20126 Milan, Italy
- IRCCS Istituto Auxologico Italiano, Department of Cardiology, San Luca Hospital, Piazzale Brescia 20, 20149 Milan, Italy
| | - Iacopo Olivotto
- Department of Experimental and Clinical Medicine, University of Florence, Largo Giovanni Alessandro Brambilla 3, 50134 Florence, Italy
- Meyer Children’s Hospital IRCCS, Viale Gaetano Pieraccini 24, 50139 Florence, Italy
| | - Franco Cecchi
- IRCCS Istituto Auxologico Italiano, Department of Cardiology, San Luca Hospital, Piazzale Brescia 20, 20149 Milan, Italy
| |
Collapse
|
3
|
Gossios T, Savvatis K, Zegkos T, Ntelios D, Rouskas P, Parcharidou D, Karvounis H, Efthimiadis GK. Deciphering hypertrophic cardiomyopathy with electrocardiography. Heart Fail Rev 2021; 27:1313-1323. [PMID: 34286451 DOI: 10.1007/s10741-021-10147-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2021] [Indexed: 11/30/2022]
Abstract
The comprehensive assessment of patients with hypertrophic cardiomyopathy is a complex process, with each step concurrently focusing on confirmation of the diagnosis, differentiation between sarcomeric and non-sarcomeric disease (phenocopy), and prognostication. Novel modalities such as genetic testing and advanced imaging have allowed for substantial advancements in the understanding of this condition and facilitate patient management. However, their availability is at present not universal, and interpretation requires a high level of expertise. In this setting, electrocardiography, a fast and widely available method, still retains a significant role in everyday clinical assessment of this population. In our review, we follow a stepwise approach for the interpretation of each electrocardiographic segment, discussing clinical implications of electrocardiographic patterns in sarcomeric disease, their value in the differential diagnosis from phenocopies, and impact on patient management. Outlining the substantial amount of information to be obtained from a simple tracing, we exhibit how electrocardiography is likely to remain an integral diagnostic tool in the future as well.
Collapse
Affiliation(s)
- Thomas Gossios
- Cardiology Department, NHS Foundation Trust, Guy's and St Thomas Westminster Bridge Road, London, SE1 7EH, UK. .,Inherited Cardiac Conditions Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK. .,Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece.
| | - Konstantinos Savvatis
- Inherited Cardiac Conditions Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Thomas Zegkos
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Dimitrios Ntelios
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Pavlos Rouskas
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Despoina Parcharidou
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Haralambos Karvounis
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Georgios K Efthimiadis
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| |
Collapse
|
4
|
Keane S, Fabre A, Keane D. Characterization of atrial histology in a patient with hypertrophic cardiomyopathy: Possible evidence of a primary atrial myopathy. HeartRhythm Case Rep 2021; 7:413-417. [PMID: 34194992 PMCID: PMC8226312 DOI: 10.1016/j.hrcr.2021.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Stephen Keane
- Department of Cardiology, St. Vincent’s University Hospital, Dublin, Ireland
| | - Aurelie Fabre
- Department of Pathology, St. Vincent’s University Hospital, Dublin, Ireland
| | - David Keane
- Department of Cardiology, St. Vincent’s University Hospital, Dublin, Ireland
| |
Collapse
|
5
|
Hourqueig M, Bouzille G, Mirabel M, Huttin O, Damy T, Labombarda F, Eicher JC, Charron P, Habib G, Réant P, Hagège A, Donal E. Hypertrophic cardiomyopathies requiring more monitoring for less atrial fibrillation-related complications: a clustering analysis based on the French registry on hypertrophic cardiomyopathy (REMY). Clin Res Cardiol 2021; 111:163-174. [PMID: 34043053 DOI: 10.1007/s00392-020-01797-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 12/16/2020] [Indexed: 11/25/2022]
Abstract
AIMS Defining the risk of atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) patients is an important clinical and prognostic challenge. The aim of this study is to determine HCM phenogroups with different risk of AF occurrence at 5 years. METHODS AND RESULTS We applied retrospectively the Bayesian method, which can analyze a large number of variables, to differentiate phenogroups of patients with different risks of AF and prognoses across a French prospective on-going hospital-based registry of adult HCM patients (REMY). Clinical and imaging data were prospectively recorded, and patients were followed for 5 years. A total of 1431 HCM patients were recruited, including 1275 analyzed in the present study after exclusion criteria. The population included 412 women, 369 patients with obstructive HCM, and 252 implanted with an ICD. AF occurred in 167 (11.6%) patients during the 5 year follow-up. Three phenogroups were defined according to their common clinical and echocardiographic characteristics. Patients at the highest risk were oldest, more often female, with more frequent comorbidities, anteroposterior diameter of the left atrium was significantly greater, with diastolic dysfunction, outflow-tract obstruction, and mitral valve abnormality, and presented higher pulmonary artery pressure and/or right-ventricular dysfunction. These also had a higher risk of all-cause hospitalizations and death. CONCLUSION Based on a clustering analysis, three phenogroups of HCM according to the risk of AF occurrence can be identified. It can indicate which patients should be more monitored and/or treated, particular to prevent the risk of stroke.
Collapse
Affiliation(s)
- Marion Hourqueig
- Service de Cardiologie-Hôpital Pontchaillou, Univ Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, F-35000, Rennes, France
| | - Guillaume Bouzille
- Service de Cardiologie-Hôpital Pontchaillou, Univ Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, F-35000, Rennes, France
| | - Mariana Mirabel
- Cardio-Oncology, Assistance Publique-Hôpitaux de Paris-Centre Université de Paris, University of Paris, Paris, France
| | - Olivier Huttin
- Cardiology Department, CHU de Nancy, Hopitaux de Brabois, Nancy, France
| | - Thibaud Damy
- IMRB and Cardiology Department, Assistance Publique-Hopitaux de Paris, Hopital Henri-Mondor, GRC Amyloid Research Institute, 94000, Creteil, France
| | - Fabien Labombarda
- Cardiology Department, CHU de Caen, Hopital Cote de Nacre, Caen, France
| | | | - Philippe Charron
- Cardiology Department, Assistance Publique-Hôpitaux de Paris, APHP; Hôpital Pitié-Salpêtrière, Paris, France.,Sorbonne Université, INSERM, UMR_S 1166 and ICAN Institute for Cardiometabolism and Nutrition, Paris, France
| | - Gilbert Habib
- Cardiology Department, Assistance Publique-Hopitaux de Marseille, Hopital La Timone, Marseille, France
| | - Patricia Réant
- Cardiology Department, CHU de Bordeaux, Hopital du Haut Leveque, University de Bordeaux, INSERM 1045, IHU Lyric, CIC 1401, Pessac, France
| | - Albert Hagège
- Cardiology Department, CHU de Nancy, Hopitaux de Brabois, Nancy, France
| | - Erwan Donal
- Service de Cardiologie-Hôpital Pontchaillou, Univ Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, F-35000, Rennes, France.
| | | |
Collapse
|
6
|
Mahfouz Badran H, Soltan G, Eltahan E, Yacoub MH, Faheem N. Relation of atrial electromechanical delay to P-wave dispersion on surface ECG using vector velocity imaging in patients with hypertrophic cardiomyopathy. Ann Noninvasive Electrocardiol 2021; 26:e12801. [PMID: 32969115 PMCID: PMC7816806 DOI: 10.1111/anec.12801] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/17/2020] [Accepted: 08/19/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Heterogeneity of structural and electrophysiologic properties of atrial myocardium is common characteristic in hypertrophic cardiomyopathy (HCM). We assessed the dispersion of atrial refractoriness on surface ECG using P-wave dispersion (PWD) and its relation to atrial electromechanical functions using vector velocity imaging (VVI) in HCM population. METHODS Seventy-nine HCM patients (mean age: 43.7 ± 13 years, 67% male) were compared with 25 healthy individuals as control. P-wave durations, Pmax and Pmin , P-wave dispersion (PWD), and P terminal force (PTF) were measured from 12-lead ECG. LA segmental delay (TTP-d) and dispersion (TTP-SD) of electromechanical activation were derived from atrial strain rate curves. RESULTS HCM patients had longer PR interval, PW duration, higher PWD, PTF, QTc compared to control (p < .001). HCM patients were classified according to presence of PWD into two groups, group I with PWD > 46 ms (n = 25) and group II PWD ≤ 46 ms (n = 54). Group I showed higher prevalence of female gender, higher PTF, QTc interval, left ventricular outflow tract (LVOT) obstruction, p < .01, LVOT gradient (p < .001), LV mass index (p < .01), E/E' (p < .01), and severe mitral regurgitation (p < .001). Moreover, PWD was associated with increased atrial electromechanical delay (TTP-d) and LA mechanical dyssynchrony (TTP-SD), p < .001. LA segmental delay and dispersion of electromechanical activation were distinctly higher among HCM patient. CONCLUSION PWD is simple ECG criterion, and it is associated with more severe HCM phenotype and LA electromechanical delay while PTF is linked only to atrial remodeling.
Collapse
Affiliation(s)
- Hala Mahfouz Badran
- Cardiology Department Menofia UniversityShebin ElkomEgypt
- The BAHCM National ProgramAswanEgypt
| | - Ghada Soltan
- Cardiology Department Menofia UniversityShebin ElkomEgypt
| | - Eslam Eltahan
- Cardiology Department Menofia UniversityShebin ElkomEgypt
| | - Magdi H. Yacoub
- The BAHCM National ProgramAswanEgypt
- Imperial CollegeLondonUK
| | - Naglaa Faheem
- Cardiology Department Menofia UniversityShebin ElkomEgypt
- The BAHCM National ProgramAswanEgypt
| |
Collapse
|
7
|
Palano F, Adduci C, Cosentino P, Silvetti G, Boldini F, Francia P. Assessing Atrial Fibrillation Substrates by P Wave Analysis: A Comprehensive Review. High Blood Press Cardiovasc Prev 2020; 27:341-347. [PMID: 32451990 DOI: 10.1007/s40292-020-00390-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/13/2020] [Indexed: 12/20/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia. Pharmacologic and non-pharmacologic rhythm control strategies impact on AF-related symptoms, while leaving largely unaffected the risk of stroke. Moreover, up to 20% of AF patients are asymptomatic during paroxysmal relapses of arrhythmia, thus underlying the need for early markers to identify at-risk patients and prevent cerebrovascular accidents. Indeed, non-invasive assessment of pre-clinical substrate changes that predispose to AF could provide early identification of at-risk patients and allow for tailored care paths. ECG-derived P wave analysis is a simple-to-use and inexpensive tool that has been successfully employed to detect AF-associated structural and functional atrial changes. Beyond standard electrocardiographic techniques, high resolution signal averaged electrocardiography (SAECG), by recording microvolt amplitude atrial signals, allows more accurate analysis of the P wave and possibly AF risk stratification. This review focuses on the evidence that support P wave analysis to assess AF substrates, predict arrhythmia relapses and guide rhythm-control interventions.
Collapse
Affiliation(s)
- Francesca Palano
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy.
| | - Carmen Adduci
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Pietro Cosentino
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Giacomo Silvetti
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Francesca Boldini
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Pietro Francia
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| |
Collapse
|
8
|
Garg L, Gupta M, Sabzwari SRA, Agrawal S, Agarwal M, Nazir T, Gordon J, Bozorgnia B, Martinez MW. Atrial fibrillation in hypertrophic cardiomyopathy: prevalence, clinical impact, and management. Heart Fail Rev 2018; 24:189-197. [DOI: 10.1007/s10741-018-9752-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
9
|
Shin SY, Shantsilla A, Lip GY. Does ECG have additive benefit for predicting atrial fibrillation in patients with or without hypertension? J Hypertens 2018; 36:1793-1794. [DOI: 10.1097/hjh.0000000000001788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
10
|
Vaidya K, Semsarian C, Chan KH. Atrial Fibrillation in Hypertrophic Cardiomyopathy. Heart Lung Circ 2017; 26:975-982. [PMID: 28602671 DOI: 10.1016/j.hlc.2017.05.116] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/09/2017] [Accepted: 05/10/2017] [Indexed: 12/27/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) is an inherited cardiac disorder with a spectrum of clinical manifestations. Patients with HCM are predisposed to developing atrial fibrillation (AF) due primarily to advanced diastolic dysfunction and left atrial (LA) dilatation and remodelling. Atrial fibrillation causes a progressive symptomatic and functional decline, as well as increased thromboembolic risk and mortality, particularly in the setting of rapid ventricular rates and left ventricular outflow tract (LVOT) obstruction. The mainstay of management of AF in HCM is a combination of non-pharmacological lifestyle and risk factor modification, long-term anticoagulation, and rhythm control with antiarrhythmic medications. There is a growing body of evidence indicating that an early and aggressive rhythm control strategy may result in more favourable outcomes.
Collapse
Affiliation(s)
- Kaivan Vaidya
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
| | - Christopher Semsarian
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, NSW, Australia
| | - Kim H Chan
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| |
Collapse
|
11
|
Tuluce K, Yakar Tuluce S, Kahya Eren N, Kocabas U, Akyildiz Akcay F, Gunduz R, Akyildiz ZI, Ergene O. Predictors of Future Atrial Fibrillation Development in Patients with Hypertrophic Cardiomyopathy: A Prospective Follow-Up Study. Echocardiography 2015; 33:379-85. [DOI: 10.1111/echo.13093] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Kamil Tuluce
- Department of Cardiology; Tepecik Training and Research Hospital; Izmir Turkey
| | - Selcen Yakar Tuluce
- Department of Cardiology; Katip Celebi University Ataturk Training and Research Hospital; Izmir Turkey
| | - Nihan Kahya Eren
- Department of Cardiology; Katip Celebi University Ataturk Training and Research Hospital; Izmir Turkey
| | - Ugur Kocabas
- Department of Cardiology; Katip Celebi University Ataturk Training and Research Hospital; Izmir Turkey
| | - Filiz Akyildiz Akcay
- Department of Cardiology; Katip Celebi University Ataturk Training and Research Hospital; Izmir Turkey
| | - Ramazan Gunduz
- Department of Cardiology; Merkez Efendi State Hospital; Manisa Turkey
| | - Zehra I. Akyildiz
- Department of Cardiology; Katip Celebi University Ataturk Training and Research Hospital; Izmir Turkey
| | - Oktay Ergene
- Department of Cardiology; Dokuz Eylul University Faculty of Medicine; Izmir Turkey
| |
Collapse
|
12
|
Iio C, Ogimoto A, Nagai T, Suzuki J, Inoue K, Nishimura K, Uetani T, Okayama H, Okura T, Shigematsu Y, Tabara Y, Kohara K, Miki T, Hamada M, Higaki J. Association Between Genetic Variation in the SCN10A Gene and Cardiac Conduction Abnormalities in Patients With Hypertrophic Cardiomyopathy. Int Heart J 2015; 56:421-7. [PMID: 26104176 DOI: 10.1536/ihj.14-411] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Arrhythmias are associated with reduced quality of life and poor prognosis in patients with hypertrophic cardiomyopathy (HCM). Recent genome-wide association studies revealed that a nonsynonymous single nucleotide polymorphism, rs6795970, in the SCN10A gene was associated with the PR interval. We examined whether the PR prolonging allele (A allele) in the SCN10A gene may be associated with cardiac conduction abnormalities in HCM patients.We genotyped the polymorphism in 149 HCM patients. Conduction abnormalities were defined as first-degree heart block, bundle-branch block, and bifascicular heart block. Patients were divided into two groups: group A consisted of 122 patients (82%) without a conduction abnormality; and group B consisted of 27 patients (18%) with one or more cardiac conduction abnormalities. The frequency distribution of the SCN10A genotypes (G/G, G/A, and A/A) among the patients with HCM was 71%, 26%, and 3%, respectively. A cardiac conduction abnormality was documented in 9% with G/G and 40% with G/A or A/A. There was a significant difference in the genotype distribution between the two groups (P = 0.0002). In the dominant A allele model, there was a significant difference in genotypes between the two groups (P < 0.0001). In addition, the A allele remained significant after adjusting for other covariates in a multivariate model (odds ratio = 6.30 [95% confidence interval: 2.24 to 19.09], P = 0.0005).The rs6795970 in the SCN10A gene, which is reported to carry a high risk of heart block, might be associated with cardiac conduction abnormalities in HCM patients.
Collapse
Affiliation(s)
- Chiharuko Iio
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Kumar KR, Mandleywala SN, Link MS. Atrial and ventricular arrhythmias in hypertrophic cardiomyopathy. Card Electrophysiol Clin 2015; 7:173-86. [PMID: 26002384 DOI: 10.1016/j.ccep.2015.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Hypertrophic cardiomyopathy (HCM) is an autosomal dominant disease caused by mutations in genes coding for cardiac sarcomeres. HCM is the most common inherited heart disease, with a prevalence of 0.2%. There are multiple genetic variants that cause pleomorphic clinical attributes and disease characterized by myocardial disarray and myocardial hypertrophy. Patients are at an increased risk of atrial and ventricular arrhythmias. Management of these arrhythmias is complex. Atrial fibrillation is associated with increased mortality and thromboembolism. Ventricular arrhythmias are life threatening and best treated with an implantable defibrillator.
Collapse
Affiliation(s)
- Kartik R Kumar
- Department of Cardiology, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Swati N Mandleywala
- Department of Cardiology, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Mark S Link
- Department of Cardiology, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA.
| |
Collapse
|
14
|
Tuluce K, Tuluce SY. Predictors of Atrial Fibrillation Risk in Hypertrophic Cardiomyopathy. J Atr Fibrillation 2015; 7:1200. [PMID: 27957152 DOI: 10.4022/jafib.1200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/09/2015] [Accepted: 03/20/2015] [Indexed: 11/10/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) is a genetic cardiovascular disease that predisposes individuals to the development of arrhythmias. The most common sustained arrhythmia is atrial fibrillation (AF). Compared with the general population, patients with HCM are more prone to the development of AF. To avoid embolic complications and the clinical deterioration caused by the development of AF in HCM, identifying patients with a tendency toward AF might affect the management of HCM. In this review, we evaluated the predictors of AF development in patients with HCM.
Collapse
Affiliation(s)
- Kamil Tuluce
- Department of Cardiology, Karsiyaka State Hospital, Izmir, Turkey
| | - Selcen Yakar Tuluce
- Department of Cardiology, Ataturk Training and Research Hospital, Izmir, Turkey
| |
Collapse
|
15
|
Azarbal F, Singh M, Finocchiaro G, Le VV, Schnittger I, Wang P, Myers J, Ashley E, Perez M. Exercise capacity and paroxysmal atrial fibrillation in patients with hypertrophic cardiomyopathy. Heart 2013; 100:624-30. [DOI: 10.1136/heartjnl-2013-304908] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BackgroundAtrial fibrillation (AF) is the most common arrhythmia among patients with hypertrophic cardiomyopathy (HCM). The relationship between paroxysmal AF and exercise capacity in this population is incompletely understood.MethodsPatients with HCM underwent symptom-limited cardiopulmonary testing with expired gas analysis at Stanford Hospital between October 2006 and October 2012. Baseline demographics, medical histories and resting echocardiograms were obtained for all subjects. Diagnosis of AF was established by review of medical records and baseline ECG. Those with paroxysmal AF were in sinus rhythm at the time of cardiopulmonary testing with expired gas analysis. Exercise intolerance was defined as peak VO2<20 mL/kg/min. We used multivariate logistic regression to evaluate the association between exercise intolerance and paroxysmal AF.ResultsAmong the 265 patients recruited, 55 had AF (28 paroxysmal and 27 permanent). Compared with those without AF, subjects with paroxysmal AF were older, more likely to use antiarrhythmic and anticoagulant medications, and had larger left atria. Patients with paroxysmal AF achieved lower peak VO2 (21.9±9.2 mL/kg/min vs 26.9±10.8 mL/kg/min, p=0.02) and were more likely to have exercise intolerance (61% vs 28%, p<0.001) compared with those without AF. After adjustment for age, sex and body mass index (BMI) exercise intolerance remained significantly associated with paroxysmal AF (OR 4.65, 95% CI 1.83 to 11.83, p=0.001).ConclusionsPatients with HCM and paroxysmal AF demonstrate exercise intolerance despite being in sinus rhythm at the time of exercise testing.
Collapse
|
16
|
Guttmann OP, Rahman MS, O'Mahony C, Anastasakis A, Elliott PM. Atrial fibrillation and thromboembolism in patients with hypertrophic cardiomyopathy: systematic review. Heart 2013; 100:465-72. [DOI: 10.1136/heartjnl-2013-304276] [Citation(s) in RCA: 189] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
|
17
|
Girasis C, Vassilikos V, Efthimiadis GK, Papadopoulou SL, Dakos G, Dalamaga EG, Chouvarda I, Giannakoulas G, Kamperidis V, Paraskevaidis S, Maglaveras N, Karvounis HI, Parcharidis GE, Styliadis IH. Patients with hypertrophic cardiomyopathy at risk for paroxysmal atrial fibrillation: advanced echocardiographic evaluation of the left atrium combined with non-invasive P-wave analysis. Eur Heart J Cardiovasc Imaging 2012; 14:425-34. [DOI: 10.1093/ehjci/jes172] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
18
|
Abstract
Hypertrophic cardiomyopathy is a fascinating disease of marked heterogeneity. Hypertrophic cardiomyopathy was originally characterized by massive myocardial hypertrophy in the absence of known etiology, a dynamic left ventricular outflow obstruction, and increased risk of sudden death. It is now well accepted that multiple mutations in genes encoding for the cardiac sarcomere are responsible for the disease. Complex morphologic and pathophysiologic differences, disparate natural history studies, and novel treatment strategies underscore the challenge to the practicing cardiologist when faced with the management of the hypertrophic cardiomyopathy patient.
Collapse
|
19
|
Kimura M, Ogawa H, Wakeyama T, Takaki A, Iwami T, Hadano Y, Mochizuki M, Hiratsuka A, Shimizu A, Matsuzaki M. Effects of mineralocorticoid receptor antagonist spironolactone on atrial conduction and remodeling in patients with heart failure. J Cardiol 2010; 57:208-14. [PMID: 21185153 DOI: 10.1016/j.jjcc.2010.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Revised: 10/13/2010] [Accepted: 11/10/2010] [Indexed: 11/17/2022]
Abstract
BACKGROUND Spironolactone was shown to reduce mortality in patients with heart failure (HF). However, the effect of spironolactone on the incidence of atrial fibrillation remains unknown. Therefore, we examined the effects of spironolactone on atrial conduction and remodeling in patients with HF. METHODS AND RESULTS A total of 21 patients with HF were divided into either spironolactone group (n=11) or control group (n=10). The patients were followed up for 12 months. Blood examination, echocardiogram, and signal-averaged electrocardiogram were performed at study enrollment and after 3 and 12 months of treatment. In the spironolactone group, atrial natriuretic peptide tended to reduce, left atrium dimension was significantly smaller, the ratio of E wave to A wave tended to improve, and P-duration was significantly shortened. CONCLUSIONS Spironolactone improves atrial conduction and remodeling in patients with HF.
Collapse
Affiliation(s)
- Masayasu Kimura
- Division of Cardiology, Tokuyama Central Hospital, Kouda-cho 1-1, Shunan, Yamaguchi 745-8522, Japan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Perez MV, Dewey FE, Marcus R, Ashley EA, Al-Ahmad AA, Wang PJ, Froelicher VF. Electrocardiographic predictors of atrial fibrillation. Am Heart J 2009; 158:622-8. [PMID: 19781423 DOI: 10.1016/j.ahj.2009.08.002] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Accepted: 08/06/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most prevalent arrhythmia in the United States and accounts for more than 750,000 strokes per year. Noninvasive predictors of AF may help identify patients at risk of developing AF. Our objective was to identify the electrocardiographic characteristics associated with onset of AF. METHODS This was a retrospective cohort analysis of 42,751 patients with electrocardiograms (ECGs) ordered by physician's discretion and analyzed using a computerized system. The population was followed for detection of AF on subsequent ECGs. Cox proportional hazard regression analysis was performed to test the association between these ECG characteristics and development of AF. RESULTS For a mean follow-up of 5.3 years, 1,050 (2.4%) patients were found to have AF on subsequent ECG recordings. Several ECG characteristics, such as P-wave dispersion (the difference between the widest and narrowest P waves), premature atrial contractions, and an abnormal P axis, were predictive of AF with hazard ratio of approximately 2 after correcting for age and sex. P-wave index, the SD of P-wave duration across all leads, was one of the strongest predictors of AF with a concordance index of 0.62 and a hazard ratio of 2.7 (95% CI 2.1-3.3) for a P-wave index >35. These were among the several independently predictive markers identified on multivariate analysis. CONCLUSIONS Several ECG markers are independently predictive of future onset of AF. The P index, a measurement of disorganized atrial depolarization, is one of the strongest predictors of AF. The ECG contains valuable prognostic information that can identify patients at risk of AF.
Collapse
Affiliation(s)
- Marco V Perez
- Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | | | | | | | | | | | | |
Collapse
|
21
|
Papavassiliu T, Germans T, Flüchter S, Doesch C, Suriyakamar A, Haghi D, Süselbeck T, Wolpert C, Dinter D, Schoenberg SO, van Rossum AC, Borggrefe M. CMR findings in patients with hypertrophic cardiomyopathy and atrial fibrillation. J Cardiovasc Magn Reson 2009; 11:34. [PMID: 19740409 PMCID: PMC2749835 DOI: 10.1186/1532-429x-11-34] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Accepted: 09/09/2009] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We sought to evaluate the relation between atrial fibrillation (AF) and the extent of myocardial scarring together with left ventricular (LV) and atrial parameters assessed by late gadolinium-enhancement (LGE) cardiovascular magnetic resonance (CMR) in patients with hypertrophic cardiomyopathy (HCM). BACKGROUND AF is the most common arrhythmia in HCM. Myocardial scarring is also identified frequently in HCM. However, the impact of myocardial scarring assessed by LGE CMR on the presence of AF has not been evaluated yet. METHODS 87 HCM patients underwent LGE CMR, echocardiography and regular ECG recordings. LV function, volumes, myocardial thickness, left atrial (LA) volume and the extent of LGE, were assessed using CMR and correlated to AF. Additionally, the presence of diastolic dysfunction and mitral regurgitation were obtained by echocardiography and also correlated to AF. RESULTS Episodes of AF were documented in 37 patients (42%). Indexed LV volumes and mass were comparable between HCM patients with and without AF. However, indexed LA volume was significantly higher in HCM patients with AF than in HCM patients without AF (68 +/- 24 ml.m-2 versus 46 +/- 18 ml.m-2, p = 0.0002, respectively). The mean extent of LGE was higher in HCM patients with AF than those without AF (12.4 +/- 14.5% versus 6.0 +/- 8.6%, p = 0.02). When adjusting for age, gender and LV mass, LGE and indexed LA volume significantly correlated to AF (r = 0.34, p = 0.02 and r = 0.42, p < 0.001 respectively). By echocardiographic examination, LV diastolic dysfunction was evident in 35 (40%) patients. Mitral regurgitation greater than II was observed in 12 patients (14%). Multivariate analysis demonstrated that LA volume and presence of diastolic dysfunction were the only independent determinant of AF in HCM patients (p = 0.006, p = 0.01 respectively). Receiver operating characteristic curve analysis indicated good predictive performance of LA volume and LGE (AUC = 0.74 and 0.64 respectively) with respect to AF. CONCLUSION HCM patients with AF display significantly more LGE than HCM patients without AF. However, the extent of LGE is inferior to the LA size for predicting AF prevalence. LA dilation is the strongest determinant of AF in HCM patients, and is related to the extent of LGE in the LV, irrespective of LV mass.
Collapse
Affiliation(s)
- Theano Papavassiliu
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Tjeerd Germans
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Stephan Flüchter
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Christina Doesch
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Anton Suriyakamar
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Dariusch Haghi
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Tim Süselbeck
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Christian Wolpert
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| | - Dietmar Dinter
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Albert C van Rossum
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Martin Borggrefe
- 1st Department of Medicine-Cardiology, University Hospital of Mannheim, Mannheim, Germany
| |
Collapse
|
22
|
Matsuura H, Murakami T, Hina K, Yamamoto K, Kawamura H, Sogo T, Shinohata R, Usui S, Ninomiya Y, Kusachi S. Association of elevated plasma B-type natriuretic peptide levels with paroxysmal atrial fibrillation in patients with nonobstructive hypertrophic cardiomyopathy. Clin Biochem 2008; 41:134-9. [DOI: 10.1016/j.clinbiochem.2007.10.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2007] [Revised: 10/02/2007] [Accepted: 10/30/2007] [Indexed: 10/22/2022]
|
23
|
Filtered signal-averaged P-wave duration during pneumoperitoneum in patients undergoing laparoscopic cholecystectomy: A reflection of pathophysiological cardiac changes. Surg Endosc 2007; 22:221-7. [DOI: 10.1007/s00464-007-9676-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2006] [Revised: 01/29/2007] [Accepted: 02/24/2007] [Indexed: 10/22/2022]
|
24
|
Budeus M, Hennersdorf M, Reinsch N, Wieneke H, Sack S, Erbel R. Prediction of Atrial Fibrillation with Atrial Late Potentials and Pathological Chemoreflexsensitivity. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:1254-61. [PMID: 17897128 DOI: 10.1111/j.1540-8159.2007.00847.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a very common arrhythmia that often causes the serious complication of a stroke. OBJECT The aim was to evaluate the utility of pathological chemoreflexsensitivity (PCHRS) and atrial late potentials (ALP) to predict AF in follow-up. METHODS We investigated a prospective study on the basis of our observation about a PCHRS and ALP in paroxysmal AF. The PCHRS was predefined as a chemoreflexsensitivity below 3.0 ms/mmHg and ALP were predefined as a filtered P-wave duration > or =120 ms and a root mean square voltage of the last 20 ms of the P-wave < or =3.5 microV. A P-wave triggered P-wave signal averaged electrocardiograph (ECG) and chemoreflexsensitivity was performed on 250 consecutive patients who were divided into four groups. Group I consisted of patients with ALP and PCHRS, patients of group II had only ALP, a PCHRS was only present in group III, and patients of group IV had neither ALP nor PCHRS. RESULTS During the mean follow-up of 37.8 months AF was observed in 10 patients (4%). The patients of the four groups were similar according to clinical baseline characteristics. The incidence of AF was higher in group I (18% of patients) than in group II (6% of patients, P = 0.229) and significantly higher than in group III (3% of patients, P = 0.034) or group IV (1% of patients, P < 0.0001). Patients with ALP and PCHRS showed a 33-fold risk (P < 0.001) for the onset AF. CONCLUSIONS The results of our study suggest that the probability of AF could be predicted with a P-wave signal averaged ECG and an analysis of chemoreflexsensitivity. The predictive power of the combination of ALP and PCHRS seemed not high enough for risk stratification.
Collapse
Affiliation(s)
- Marco Budeus
- Department of Cardiology, West-German Heart Centre, University of Duisburg-Essen, Germany.
| | | | | | | | | | | |
Collapse
|
25
|
De Bacquer D, Willekens J, De Backer G. Long-term prognostic value of p-wave characteristics for the development of atrial fibrillation in subjects aged 55 to 74 years at baseline. Am J Cardiol 2007; 100:850-4. [PMID: 17719332 DOI: 10.1016/j.amjcard.2007.04.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Revised: 04/13/2007] [Accepted: 04/13/2007] [Indexed: 11/25/2022]
Abstract
Atrial fibrillation (AF) is the most prevalent arrhythmia in the elderly, associated with high mortality and morbidity rates. Changes in electrocardiographic P waves were associated with AF in patient series, but the long-term prognostic value of P-wave characteristics in the development of AF was not shown. The aim was to evaluate P-wave duration and morphologic characteristics as potential independent risk markers for the long-term development of AF in the general population. A nested case-control design was adopted in subjects aged 55 to 74 years and apparently healthy at baseline. Baseline P-wave items of 40 patients who developed AF within the 10-year period were compared retrospectively with those of 120 matched controls. Broad maximum P waves (>/=120 ms) at baseline were observed in 70% of patients with AF and 41% of controls (p = 0.002). Maximum P-wave duration proved to be a significant risk marker independent of blood pressure, body mass index, and other electrocardiographic findings. However, this association seems overruled by the predictive value of morphologic changes defined as notched or deflected P waves (p = 0.0002). The joint occurrence of longer duration in combination with morphologic changes in the P wave proved a very important risk indicator for the development of AF over 10 years, with an adjusted odds ratio of 13.4 (95% confidence interval 3.3 to 46.6). In conclusion, enhanced clinical appreciation of P-wave items on the standard electrocardiogram at rest, preferably evaluated in all 12 leads, may help identify a group at high risk of the development of AF at an early stage.
Collapse
Affiliation(s)
- Dirk De Bacquer
- Department of Public Health, Ghent University, Ghent, Belgium.
| | | | | |
Collapse
|
26
|
Holmqvist F, Platonov PG, Carlson J, Havmöller R, Waktare JEP, McKenna WJ, Olsson SB, Meurling CJ. Variable interatrial conduction illustrated in a hypertrophic cardiomyopathy population. Ann Noninvasive Electrocardiol 2007; 12:227-36. [PMID: 17617068 PMCID: PMC6932290 DOI: 10.1111/j.1542-474x.2007.00166.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Patients with hypertrophic cardiomyopathy (HCM) have a high incidence of atrial fibrillation. They also have a longer P-wave duration than healthy controls, indicating conduction alterations. Previous studies have demonstrated orthogonal P-wave morphology alterations in patients with paroxysmal atrial fibrillation. In the present study, the P-wave morphology of patients with HCM was compared with that of matched controls in order to explore the nature of the atrial conduction alterations. METHODS AND RESULTS A total of 65 patients (45 men, mean age 49 +/- 15) with HCM were included. The control population (n = 65) was age and gender matched (45 men, mean age 49 +/- 15). Five minutes of 12-lead ECG was recorded. The data were subsequently transformed to orthogonal lead data, and unfiltered signal-averaged P-wave analysis was performed. The P-wave duration was longer in the HCM patients compared to the controls (149 +/- 22 vs 130 +/- 16 ms, P < 0.0001). Examination of the P-wave morphology demonstrated changes in conduction patterns compatible with interatrial conduction block of varying severity in both groups, but a higher degree of interatrial block seen in the HCM population. These changes were most prominent in the Leads Y and Z. CONCLUSION The present study suggests that the longer P-wave duration observed in HCM patients may be explained by a higher prevalence of block in one or more of the interatrial conduction routes.
Collapse
|
27
|
Chalfoun N, Harnick D, Pe E, Undavia M, Mehta D, Gomes JA. Reverse Electrical Remodeling of the Atria Post Cardioversion in Patients Who Remain in Sinus Rhythm Assessed by Signal Averaging of the P-Wave. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:502-9. [PMID: 17437574 DOI: 10.1111/j.1540-8159.2007.00700.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study was designed to determine whether the signal-averaged electrocardiogram of the P-wave (SAPW) is an independent predictor of recurrence of atrial fibrillation (AF) post cardioversion (CV), and to assess atrial remodeling using SAPW. BACKGROUND There are limited electrophysiologic data to predict the recurrence of AF post-CV. The electrical remodeling that occurs post-CV is poorly understood. METHODS Sixty-four patients with persistent AF undergoing CV were prospectively enrolled. SAPW parameters were measured the day of CV and repeated at 1 month. These SAPW parameters were compared to other baseline indices for the recurrence of AF. RESULTS Sixty patients (94%) had successful CV. At 1 month, 22 (37%) maintained sinus rhythm (SR). The SAPW total duration decreased significantly in those who remained in SR (159 ms +/- 19 to 146 ms +/- 17; P < 0.0001). Only the duration of AF (46 +/- 50 days vs 147 +/- 227 days, P = 0.03) and the presence of left ventricular hypertrophy (LVH, 12% vs 65%, P = 0.0006) were significantly associated with recurrence of AF. Atrial size strongly correlated with the SAPW duration in patients who remained in SR (R(2)= 0.67, P = 0.003) but not in those who returned to AF (R(2)= 0.11, P = 0.65). CONCLUSIONS Atrial electrical reverse remodeling occurs in patients with AF who maintain SR post-CV. This remodeling is likely inversely related to the duration of AF and LVH. SAPW duration does not predict recurrence of AF post-CV.
Collapse
Affiliation(s)
- Nagib Chalfoun
- Department of Electrophysiology, Mount Sinai Medical Center, New York, New York, USA.
| | | | | | | | | | | |
Collapse
|
28
|
|
29
|
Dilaveris PE, Färbom P, Batchvarov V, Ghuran A, Malik M. Circadian behavior of P-wave duration, P-wave area, and PR interval in healthy subjects. Ann Noninvasive Electrocardiol 2006; 6:92-7. [PMID: 11333165 PMCID: PMC7027634 DOI: 10.1111/j.1542-474x.2001.tb00092.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The prolongation of P-wave duration has long been shown to indicate the presence of high risk for atrial fibrillation. The circadian variation of P-wave characteristics and their dynamic adaptation to heart rate changes was not tested before. METHODS To evaluate the diurnal pattern of P-wave duration, P area, and PR interval and of their linearly fitted relation with RR interval, 50 healthy volunteers (25 men, mean age 34 +/- 10 years) underwent 24-hour ambulatory electrocardiographic (ECG) recording with digital 12-lead Holter recorders. The median P-wave duration, P area, and PR interval were calculated from the average 12-lead ECG constructed from each 10-second ECG recording. Single harmonic regression analysis was performed to reveal the presence of circadian variation in the aforementioned ECG parameters. RESULTS The P area (P < 0.0001, R(2) = 0.78), the PR interval (P < 0.0001, R(2) = 0.92), the P area / RR slope (P < 0.0001, R(2) = 0.55), and the PR/RR slope (P < 0.0001, R(2) = 0.42) showed a highly significant circadian variation while the periodic nature of P-wave duration (P = 0.016, R(2) = 0.32) and of the P duration / RR slope (P = 0.011, R(2) = 0.18) was only indicated by harmonic regression analysis. CONCLUSIONS P-wave duration, P area, and PR interval show a significant circadian variation in healthy subjects. The relations between P area/RR,PR/ RR, and P duration/RR also demonstrate a significant diurnal pattern.
Collapse
Affiliation(s)
- P E Dilaveris
- Department of Cardiological Sciences, St George's Hospital Medical School, London, England.
| | | | | | | | | |
Collapse
|
30
|
Maddukuri PV, Vieira MLC, DeCastro S, Maron MS, Kuvin JT, Patel AR, Pandian NG. What Is the Best Approach for the Assessment of Left Atrial Size? Comparison of Various Unidimensional and Two-dimensional Parameters with Three-dimensional Echocardiographically Determined Left Atrial Volume. J Am Soc Echocardiogr 2006; 19:1026-32. [PMID: 16880098 DOI: 10.1016/j.echo.2006.03.011] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND Left atrial (LA) size has prognostic importance in a variety of cardiac conditions. Diameters, area, or volume derived from 2-dimensional (2D) echocardiography (2DE) are commonly used to measure LA size, but involve numerous assumptions. This study examined the accuracy of these 2DE parameters compared to 3-dimensional echocardiographic LA volume (3DV). METHODS LA diameters, area, and volume measured from 2DE were correlated with 3DV in 118 patients with dilated cardiomyopathy, hypertrophic cardiomyopathy, or without structural heart disease. RESULTS Diameter (anterior-posterior, superior-inferior, and medial-lateral) and 2DE area measurements had statistically significant, but modest, correlations with 3DV, and exhibited a large degree of scatter in comparison with 3DV. The 2DE-derived volume had an excellent correlation with 3DV, but consistently underestimated LA volume. CONCLUSION The 2DE LA volume correlates better than other parameters with 3DV, but often results in underestimation. Thus, caution should be exercised when using unidimensional and 2D measurements of LA size.
Collapse
Affiliation(s)
- Prasad V Maddukuri
- Cardiovascular Imaging and Hemodynamic Laboratory, Division of Cardiology, Tufts-New England Medical Center, Boston, Massachusetts 02111, USA
| | | | | | | | | | | | | |
Collapse
|
31
|
Aytemir K, Amasyali B, Abali G, Kose S, Kilic A, Onalan O, Tokgozoglu L, Kabakci G, Ozkutlu H, Nazli N, Isik E, Oto A. The signal-averaged P-wave duration is longer in hypertensive patients with history of paroxysmal atrial fibrillation as compared to those without. Int J Cardiol 2004; 103:37-40. [PMID: 16061121 DOI: 10.1016/j.ijcard.2004.08.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2003] [Revised: 07/26/2004] [Accepted: 08/07/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Onset of atrial fibrillation in hypertensive patients is usually associated with a high occurrence of cardiovascular complications. Therefore, it is important to assess non-invasively the risk of developing paroxysmal atrial fibrillation (PAF) in hypertensive patients during sinus rhythm. This study was undertaken to determine if hypertensive patients with history of PAF could be identified while in sinus rhythm by measurement of signal-averaged ECG P-wave duration. METHODS Signal-averaged electrocardiography (SAECG) P-wave recording was performed in 44 hypertensive patients (30 men and 14 women; mean age 60+/-11 years, group A) who had a history of paroxysmal AF and in 50 hypertensive patients without history of AF (33 men and 17 women; mean age 57+/-12, group B). All patients were also evaluated by using echocardiography to measure left ventricular ejection fraction (LVEF) and left atrial diameter (LAD). RESULTS SAECG P-wave duration was found to be significantly higher in group A than in group B (146+/-14 ms vs. 128+/-11 ms, p<0.001). Left atrial diameter was not significantly different (40.1+/-3.4 mm vs. 39.3+/-3.0 mm, p>0.05), whereas LVEF was significantly lower in group A than group B (63+/-5% vs. 67+/-4%, p=0.03). There was a correlation between SAECG P-wave duration and age (r=0.32, p<0.05). In univariate analysis, SAECG P-wave duration and LVEF were significant predictors of PAF, but only SAECG P-wave duration remained a significant independent predictor of PAF in multivariate analysis. CONCLUSION The results of this study indicate that hypertensive patients with history of PAF can be detected while in sinus rhythm by signal-averaged ECG P-wave duration.
Collapse
Affiliation(s)
- Kudret Aytemir
- Hacettepe University Faculty of Medicine, Department of Cardiology, Ankara, Turkey
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Losi MA, Betocchi S, Aversa M, Lombardi R, Miranda M, D'Alessandro G, Cacace A, Tocchetti CG, Barbati G, Chiariello M. Determinants of atrial fibrillation development in patients with hypertrophic cardiomyopathy. Am J Cardiol 2004; 94:895-900. [PMID: 15464672 DOI: 10.1016/j.amjcard.2004.06.024] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2004] [Revised: 06/14/2004] [Accepted: 06/14/2004] [Indexed: 11/27/2022]
Abstract
Predictors of the development of atrial fibrillation (AF) in patients who have hypertrophic cardiomyopathy (HC) have not been extensively studied, although, in these patients, AF contributes to the exacerbation of symptoms and the development of heart failure. The present study determined the role of left atrial (LA) function in the development of AF in patients who have HC. One hundred fifty consecutive patients who had HC, had no history of AF, and who were followed for 5.2 +/- 2.9 years constituted the study population. Using M-mode echocardiography, we measured LA function as global LA fractional shortening and LA diameter. LA volume was measured from 2-dimensional 4-chamber views by the method of disks. During follow-up, 20 patients developed AF. LA function was an independent predictor of AF (odds ratio 0.716, p = <0.001), whereas LA diameter and volume were predictors in addition to age. Kaplan-Meier analysis showed that LA dysfunction carried a high risk of AF. Thus, in patients who have HC, LA function is a strong predictor of AF development and is independent of age.
Collapse
Affiliation(s)
- Maria-Angela Losi
- Department of Clinical Medicine, Cardiovascular and Immunological Sciences, Federico II University School of Medicine, Naples, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Bauer F, Shiota T, White RD, Lever HM, Qin JX, Drinko J, Martin M, Tsujino H, Sitges M, Kim YJ, Thomas JD. Determinant of left atrial dilation in patients with hypertrophic cardiomyopathy: A real-time 3-dimensional echocardiographic study. J Am Soc Echocardiogr 2004; 17:968-75. [PMID: 15337962 DOI: 10.1016/j.echo.2004.05.018] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To identify the determinants of left atrial (LA) dilation for patients with hypertrophic obstructive cardiomyopathy (HOCM), first we validated LA volume determination by real-time 3-dimensional echocardiography using magnetic resonance imaging in patients. Subsequently, real-time 3-dimensional echocardiography and 2-dimensional Doppler echocardiography were performed in 60 patients with HOCM and in 17 age-matched control subjects. LA volumes and left ventricular (LV) filling pressures were higher for patients with HOCM than in control subjects. By stepwise multilinear regression analysis, LV end-diastolic pressure, resting LV outflow tract pressure gradient, and LV wall thickness were significant determinants of LA dilation. However, tau, -dP/dt, LV stiffness, provokable pressure gradient, and mitral regurgitation did not have any independent relationship with LA volumes. Therefore, it is concluded that LA volume can be accurately determined by real-time 3-dimensional echocardiography; and LA dilation in patients with HOCM is related to LV filling pressure, LV outflow tract pressure gradient, and LV wall thickness.
Collapse
|
34
|
Ozdemir O, Soylu M, Demir AD, Topaloglu S, Alyan O, Turhan H, Bicer A, Kutuk E. P-wave durations as a predictor for atrial fibrillation development in patients with hypertrophic cardiomyopathy. Int J Cardiol 2004; 94:163-6. [PMID: 15093974 DOI: 10.1016/j.ijcard.2003.01.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2002] [Revised: 11/08/2002] [Accepted: 01/29/2003] [Indexed: 11/23/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia observed in hypertropic cardiomyopathy (HCM) and is associated with an acute deterioration. Recently, P wave dispersion (PWD) reflecting inhomogeneous atrial conduction has been proposed as being useful for the estimation of paroxysmal AF. In this study, we aimed to define the clinical, echocardiographic and electrocardiographic predictors for AF occurrence in patients with HCM. Twenty-seven patients diagnosed with HCM and having a history of documented AF attack were compared with 53 age- and gender-matched patients who had no such history. LA diameter was significantly greater and gradient in the left ventricle outflow tract was lower in patients with AF than those without AF. Maximum P-wave duration (Pmax), PWD and PTF1 values were significantly higher in patients with AF. A Pmax>134.5 ms separated the patients with AF from controls with a sensitivity of 92%, specificity of 89% and a positive predictive value of 80%. APWD value>52.5 ms separated patients from controls with a sensitivity of 96%, a specificity of 91% and a positive predictive accuracy of 84%. An LA diameter>4.2 cm separated patients from controls with a sensitivity of 96% and a specificity of 81%. We concluded that LA diameter and PWD values are the most significant predictors for AF occurrence in patients with HCM, and simply by measuring Pmax and PWD values, we could easily identify the patients with high risk, and prescribe the necessary treatment and follow-up protocols for such patients.
Collapse
Affiliation(s)
- Ozcan Ozdemir
- Cardiology Department, Turkey Yuksek Yhtisas Hospital, 06200 Ankara, Turkey.
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Köse S, Aytemir K, Sade E, Can I, Özer N, Amasyali B, Aksöyek S, Övünç K, Özmen F, Atalar E, Işik E, Kes S, Demirtaş E, Oto A. Detection of patients with hypertrophic cardiomyopathy at risk for paroxysmal atrial fibrillation during sinus rhythm by P-wave dispersion. Clin Cardiol 2004; 26:431-4. [PMID: 14524601 PMCID: PMC6654222 DOI: 10.1002/clc.4960260910] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Paroxysmal atrial fibrillation (PAF) in hypertrophic cardiomyopathy (HCM) is associated with poor prognosis. Previous studies have shown good correlation between P-wave dispersion (Pd) and occurrence of PAF. However, Pd in patients with HCM for predicting PAF has not been studied. HYPOTHESIS The aim of the study was to determine whether Pd could identify patients with HCM who are likely to suffer from PAF. METHODS Twenty-two patients with HCM with a history of PAF (Group 1) and 26 patients with HCM without a history of PAF (Group 2) were studied. Maximum (Pmax) and minimum (Pmin) P-wave durations, as well as P-wave dispersion (Pd = Pmax - Pmin) were calculated from 12-lead surface electrocardiograms (ECG). RESULTS P-wave dispersion was significantly different between the groups (Group 1: 55 +/- 6 ms vs. Group 2: 37 +/- 8 ms; p<0.001), while Pmax (Group 1: 134 +/- 11 ms vs. Group 2: 128 +/- 13 ms; p = 0.06) and Pmin (Group 1: 78 +/- 9 ms vs. Group 2: 81 +/- 7 ms; p = 0.07) was not significantly different. Patients with a history of PAF had higher left atrial diameter than the patients without PAF (Group 1: 52 +/- 8 mm vs. Group 2: 48 +/- 10 mm; p = 0.02). A cut-off value of 46 ms for Pd had a sensitivity of 76% and a specificity of 82% in discriminating between patients with and without PAF. CONCLUSION This study suggests that P-wave dispersion could identify patients with HCM who are likely to develop PAF.
Collapse
Affiliation(s)
- Sedat Köse
- Gülhane Military Medical Academy, Department of Cardiology, Ankara, Turkey
| | - Kudret Aytemir
- Hacettepe University School of Medicine, Department of Cardiology, Ankara, Turkey
| | - Elif Sade
- Hacettepe University School of Medicine, Department of Cardiology, Ankara, Turkey
| | - Ilknur Can
- Hacettepe University School of Medicine, Department of Cardiology, Ankara, Turkey
| | - Necla Özer
- Hacettepe University School of Medicine, Department of Cardiology, Ankara, Turkey
| | - Basri Amasyali
- Gülhane Military Medical Academy, Department of Cardiology, Ankara, Turkey
| | - Serdar Aksöyek
- Hacettepe University School of Medicine, Department of Cardiology, Ankara, Turkey
| | - Kenan Övünç
- Hacettepe University School of Medicine, Department of Cardiology, Ankara, Turkey
| | - Ferhan Özmen
- Hacettepe University School of Medicine, Department of Cardiology, Ankara, Turkey
| | - Enver Atalar
- Hacettepe University School of Medicine, Department of Cardiology, Ankara, Turkey
| | - Ersoy Işik
- Gülhane Military Medical Academy, Department of Cardiology, Ankara, Turkey
| | - Sirri Kes
- Hacettepe University School of Medicine, Department of Cardiology, Ankara, Turkey
| | - Ertan Demirtaş
- Gülhane Military Medical Academy, Department of Cardiology, Ankara, Turkey
| | - Ali Oto
- Hacettepe University School of Medicine, Department of Cardiology, Ankara, Turkey
| |
Collapse
|
36
|
Abstract
Cardiac hypertrophy is well recognized as a cardiac manifestation of systemic disorders such as hypertension or intrinsic myocardial disease, but it can also reflect an underlying genetic defect. Molecular studies of inherited forms of cardiac hypertrophy have defined 2 novel pathways that lead to cardiac remodeling in adults, discoveries that increasingly provide insights relevant for both diagnosis and management. This article reviews the genetic studies that led to the current molecular understanding of hypertrophic cardiomyopathy and discusses more recently discovered causes of inherited cardiac hypertrophy.
Collapse
Affiliation(s)
- Christine Seidman
- Howard Hughes Medical Institute and Cardiovascular Division, Brigham & Women's Hospital, Boston, Mass, USA.
| |
Collapse
|
37
|
Olivotto I, Cecchi F, Casey SA, Dolara A, Traverse JH, Maron BJ. Impact of atrial fibrillation on the clinical course of hypertrophic cardiomyopathy. Circulation 2001; 104:2517-24. [PMID: 11714644 DOI: 10.1161/hc4601.097997] [Citation(s) in RCA: 533] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clinical impact of atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) is largely unresolved. Thus, we analyzed the prognostic implications of AF in a large, community-based HCM population assembled from Italian and US cohorts. METHODS AND RESULTS Occurrence of AF and outcome were assessed in 480 consecutive HCM patients (age at diagnosis, 45+/-20 years; 61% male) who were followed up for 9.1+/-6.4 years. AF occurred in 107 patients (22%; incidence, 2%/y) and was independently predicted by advancing age, congestive symptoms, and increased LA size at diagnosis. Patients with AF had increased risk for HCM-related death (OR, 3.7; P<0.002) because of excess heart failure-related mortality but not sudden, unexpected death. This risk associated with AF was substantially greater in patients with outflow obstruction or with earlier development of AF (</=50 years of age). AF patients were also at increased risk for stroke (OR, 17.7; P=0.0001) and severe functional limitation (OR for NYHA class III or IV, 2.8; P<0.0001). Compared with those with exclusively paroxysmal AF, patients developing chronic AF showed higher combined probability of HCM-related death, functional impairment, and stroke (P<0.0001). In a subgroup of 37 patients with AF (35%), the clinical course was largely benign in the absence of stroke and severe symptoms. CONCLUSIONS In a community-based HCM population, AF (1) was common, with 22% prevalence over 9 years; (2) was associated with substantial risk for heart failure-related mortality, stroke, and severe functional disability, particularly in patients with outflow obstruction, those </=50 years of age, or those developing chronic AF; and (3) was nevertheless compatible with benign outcome in 35% of patients.
Collapse
Affiliation(s)
- I Olivotto
- Cardiologia S. Luca, Azienda Ospedaliera Careggi, Florence, Italy.
| | | | | | | | | | | |
Collapse
|
38
|
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia in patients with hypertrophic cardiomyopathy (HCM), and it bears numerous pathophysiologic consequences that potentially affect patient outcome and symptoms. However, studies regarding the impact of AF on the long-term prognosis of HCM patients have been limited in number, with sometimes conflicting results. Recently, studies on community-based patient populations showed that AF is associated with long-term clinical deterioration, embolic complications, and increased cardiovascular mortality due to heart failure and stroke. The consequences of AF on the long-term prognosis of HCM patients are not uniformly unfavorable, however, and in about one third of patients the arrhythmia is compatible with an uneventful course.
Collapse
Affiliation(s)
- I Olivotto
- Cardiologia S. Luca, Azienda Ospedaliera Careggi, Via Jacopo Nardi 30, Florence, 50132, Italy.
| | | | | |
Collapse
|
39
|
Dilaveris P, Batchvarov V, Gialafos J, Malik M. Comparison of different methods for manual P wave duration measurement in 12-lead electrocardiograms. Pacing Clin Electrophysiol 1999; 22:1532-8. [PMID: 10588156 DOI: 10.1111/j.1540-8159.1999.tb00358.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To determine whether different methods for the manual measurement of P wave duration are mutually consistent, we evaluated the intraobserver and interobserver errors of P wave measurements obtained in three different ways: (1) by cursor on a high resolution computer screen (on screen), (2) by calipers and a magnifying glass (on paper), and (3) by a high resolution digitizing board (on board). The agreement between the methods was assessed in 30 normal subjects and 30 patients with a history of atrial fibrillation. The maximum P wave duration (P maximum), the minimum P wave duration (P minimum), mean P wave duration (P mean), P wave dispersion (P dispersion = P maximum - P minimum), and the standard deviation of the P wave duration in all measured leads (P SD) were calculated from a 12-lead electrocardiogram in each subject. Only P maximum, P mean, and P dispersion were significantly higher in patients than in controls with all three methods. Intraobserver and interobserver relative errors were significantly different among the three methods; the lowest errors were associated with the on-screen measurement. The agreement between the three different methods was acceptable for P maximum, P mean, and P SD and rather poor for P minimum and P dispersion in both groups. The differences of the measurement by different methods did not consistently differ between the two groups. Hence, the on-screen measurements are consistent with other manual methods and provide more stable results. Manual measurement of ECG patterns should be preferably performed with digital ECG recordings displayed on a high resolution computer screen.
Collapse
Affiliation(s)
- P Dilaveris
- Department of Cardiological Sciences, St. George's Hospital Medical School, London, England
| | | | | | | |
Collapse
|
40
|
|
41
|
Aytemir K, Aksoyek S, Yildirir A, Ozer N, Oto A. Prediction of atrial fibrillation recurrence after cardioversion by P wave signal-averaged electrocardiography. Int J Cardiol 1999; 70:15-21. [PMID: 10402041 DOI: 10.1016/s0167-5273(99)00038-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The purpose of this report was to determine prospectively whether P wave signal-averaged electrocardiography (ECG) is useful for the prediction of recurrences of atrial fibrillation after cardioversion. The P wave signal-averaged ECG was recorded in 73 patients after successful cardioversion. Duration of the filtered P wave and the root mean square voltages for the last 20 ms of the P wave were calculated. In addition to signal-averaged ECG P wave analysis, all patients were evaluated by echocardiography. During 6 months follow-up period recurrence of atrial fibrillation was observed in 31 (42.5%) patients and in 42 (57.5%) patients sinus rhythm was maintained. There was no difference in gender, age, presence of organic heart disease, left atrial diameter, left ventricular ejection fraction, use of antiarrhythmic drug, and duration of atrial fibrillation (P>0.05). The filtered P-wave duration was longer and the root mean square voltages for the last 20 ms of the P wave was lower in patients with recurrence of atrial fibrillation than in patients who maintained sinus rhythm (138.3+/-12.5 ms vs. 112.4+/-11.8 ms, P = 0.001; 1.9+/-0.7 microV vs. 2.5+/-0.6 microV, P = 0.001). A filtered P-wave duration > or =128 ms associated with a root mean square voltage for the last 20 ms of the P wave < or =2.1 microV had a sensitivity of 70% and specificity of 76% for the detection of patients with recurrence of atrial fibrillation after successful cardioversion of atrial fibrillation. We found that the likelihood of recurrence of atrial fibrillation after cardioversion was increased 4.31-fold (95% confidence interval 2.08-9.83) if these parameters were used. These results suggest that P wave signal-averaged ECG could be useful to identify patients at risk for recurrence of atrial fibrillation after cardioversion.
Collapse
Affiliation(s)
- K Aytemir
- Hacettepe University, Faculty of Medicine, Department of Cardiology, Ankara, Turkey.
| | | | | | | | | |
Collapse
|
42
|
Gruver EJ, Fatkin D, Dodds GA, Kisslo J, Maron BJ, Seidman JG, Seidman CE. Familial hypertrophic cardiomyopathy and atrial fibrillation caused by Arg663His beta-cardiac myosin heavy chain mutation. Am J Cardiol 1999; 83:13H-18H. [PMID: 10750581 DOI: 10.1016/s0002-9149(99)00251-9] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
More than 40 different beta-cardiac myosin heavy chain (beta-MHC) missense mutations have been identified that cause familial hypertrophic cardiomyopathy (FHC). Some of these are recognized to have important clinical manifestations, such as an increased incidence of sudden death. We report that the beta-MHC missense mutation Arg663His causes predominant cardiac morphology and atrial fibrillation. Longitudinal clinical evaluations were performed in a kindred with FHC. The nucleotide sequence of the beta-MHC gene was analyzed to define the causal mutation. A missense mutation in the beta-MHC gene, Arg663His, was identified in 24 individuals. Clinical studies demonstrated modest left ventricular hypertrophy in affected individuals, predominantly localized in the proximal segment of the interventricular septum, which increased (average = 40 +/- 8%) during 7 years of follow-up. Results showed that 47% of Arg663His adults (age > 16 years) with ventricular hypertrophy developed atrial fibrillation, significantly more (p <0.001) than observed in ungenotyped FHC populations. Survival of affected individuals remained near normal. The beta-MHC missense mutation Arg663His causes a characteristic pattern of ventricular hypertrophy. Arg663His individuals have a markedly higher prevalence of atrial fibrillation, compared with a population with ungenotyped hypertrophic cardiomyopathy. The demonstration of phenotype as a direct consequence of genotype further extends the utility of molecular data in clinical medicine. Early identification of Arg663His individuals has the potential to minimize the serious sequelae of this arrhythmia in this FHC group.
Collapse
Affiliation(s)
- E J Gruver
- Department of Cardiology, Children's Hospital, Boston, Massachusetts, USA
| | | | | | | | | | | | | |
Collapse
|