Paced P-wave duration as a significant predictor for atrial high-rate episodes in patients with cardiac implantable electronic devices

Introduction: Atrial pacing can unmask or aggravate a preexisting interatrial block (IAB). Our study aimed to determine whether atrial pacing is associated with the development of atrial high-rate episodes (AHRE) during follow-up. Methods and Results: Patients with dual-chamber cardiac implantable electronic devices (CIED), no previous documented atrial fibrillation, and with a 6-month minimum follow-up were included. In all patients, sinus and paced P-wave duration was measured. AHRE was defined as an episode of atrial rate ≥ 225 bpm with a minimum duration of 5 min, excluding those documented during the first three months after implantation. Two hundred twenty patients were included (75 ± 10 years, 61% male). After a mean follow-up of 59±25 months, 46% of patients presented AHRE. Mean paced P-wave duration was significantly longer than the sinus P-wave duration (154±27 vs 115±18 ms; p < 0.001). Sinus and paced P-waves were significantly longer in those who developed AHRE (sinus: 119±20 vs 112±16; p = 0.006; paced: 161±29 vs 148±23; p < 0.001). A paced P-wave ≥160 ms was the best predictor of AHRE, especially those lasting >24 h (OR 4.2 (95% CI) [1.6-11.4]; p = 0.004). Conclusion: Atrial pacing significantly prolongs P-wave duration and is associated with further development of AHRE. A paced P-wave ≥160 ms is a strong predictor of AHRE and should be taken into consideration as a new definition of IAB in the presence of atrial pacing.

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Abstract 15360: Prolonged P Wave Duration is Not Associated With New Onset Atrial Fibrillation During 10-year Follow-up After First-ever Ischemic Stroke in Lund Stroke Register

Circulation ◽

10.1161/circ.130.suppl_2.15360 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Maria A Baturova ◽

Arne Lindgren ◽

Jonas Carlson ◽

Yuri V Shubik ◽

Bertil Olsson ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

P Wave ◽

Stroke Patients ◽

Wave Duration ◽

Control Subjects ◽

P Wave Duration ◽

Stroke Register ◽

New Onset

Introduction: Prolonged P-wave duration (PWD) is associated with paroxysmal atrial fibrillation (AF), which might be underdiagnosed in ischemic stroke patients, in whom it might be pivotal for initiation of secondary prevention oral anticoagulation therapy. We aimed to assess whether PWD predicts new-onset AF during 10-year follow-up in ischemic stroke patients compared to control subjects enrolled in the Lund Stroke Register (LSR). Methods: Study sample comprised of 227 first-ever ischemic stroke patients without AF (mean age 72±12 y, 92 female) and 1:1 age- and gender- matched control subjects without stroke and AF enrolled in LSR from Mar 2001 to Feb 2002. The date of new-onset AF during follow-up was assessed by the date of first AF ECG in the regional ECG database and by record linkage with the Swedish National Patient Register. The available standard snapshot 12-lead sinus rhythm ECGs at baseline were retrieved from electronic database and digitally processed. Results: Patients with ischemic stroke compared to controls more often had hypertension (57% vs 31%), diabetes (15% vs 7%) and vascular diseases (42% vs 13%, all p < 0.005). New-onset AF was detected in 39 (17%) stroke patients and in 30 (13%) controls, p=0.296. In the multivariate Cox regression analysis, new onset AF in the stroke group was associated with age>65 years (HR=3.78, 95%CI 1.32-10.85, p=0.013) and hypertension (HR=2.42, 95%CI 1.09-5.40, p=0.030), but not with PWD. On the contrary, PWD>120 ms was the only independent predictor of new onset AF in the control group after adjustment for age and cardiovascular risk factors (HR=3.36, 95%CI 1.41-8.01, p=0.006, Figure 1). Conclusions: Prolonged P-wave duration is the strongest predictor of AF incidence during 10-year follow-up in stroke-free population. However, in ischemic stroke patients the developing of AF is more likely associated with more advanced cardiovascular comorbidities than with electrical abnormalities in the heart.

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P5350Atrial fibrillation prediction using P wave signal-averaged ECG in patients with embolic stroke of undetermined source

European Heart Journal ◽

10.1093/eurheartj/ehz746.0317 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

S Shin ◽

M Jung ◽

J Song ◽

J Kim ◽

K Park ◽

...

Keyword(s):

Atrial Fibrillation ◽

Odds Ratio ◽

Unknown Origin ◽

Embolic Stroke ◽

P Wave ◽

Stroke Recurrence ◽

Wave Duration ◽

P Wave Duration ◽

Potential Association

Abstract Background Approximately 10–25% of ischemic strokes are of unknown origin. Determining their potential association with subclinical atrial fibrillation (SCAF) is important for proper secondary prevention. We investigated whether SCAF can be predicted by assessing the atrial substrate with signal-averaged electrocardiography (SAECG). Methods Between April 2015 and February 2018, we recruited 125 consecutive patients with embolic stroke of undetermined source (ESUS) and 125 patients with paroxysmal atrial fibrillation (AF) patients as control. All participants underwent P wave SAECG at baseline and ESUS patients were followed up with ECG and Holter ECG, at baseline, 3, 6, and 12 months after discharge, and every 12 months thereafter. Results In the ESUS group (69 males, 68.4±12.1 years), 32 (25.6%) patients were diagnosed with SCAF during follow-up. There were no significant differences between both groups in terms of P wave duration [PWD] (ESUS vs. AF, P=0.321). PWD demonstrated a significant predictive efficacy for SCAF detection during follow-up (C-index of standard PWD=0.657, 95% confidence interval (CI) 0.552–0.761, P=0.008). Stroke recurrence occurred in 22 patients (17.6%) and was significantly associated with PWD but not SCAF (odds ratio 2.756, 95% CI 1.061–7.161, P=0.037). Conclusion PWD, an ECG biomarker associated with atrial substrate directly contributes to AF and ESUS, is useful for predicting SCAF. The potential for using this simple ECG biomarker for screening for SCAF amongst ESUS patients merits further exploration.

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Predictors of recurrence of atrial fibrillation within the first 3 months after ablation

EP Europace ◽

10.1093/europace/euaa132 ◽

2020 ◽

Vol 22 (9) ◽

pp. 1337-1344

Author(s):

Matthias Daniel Zink ◽

Winnie Chua ◽

Stef Zeemering ◽

Luigi di Biase ◽

Bayes de Luna Antoni ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Vitamin K Antagonists ◽

P Wave ◽

Interventional Treatment ◽

Wave Duration ◽

P Wave Duration ◽

History Of ◽

Artery Disease

Abstract Aims Freedom from atrial fibrillation (AF) at 1 year can be achieved in 50–70% of patients undergoing catheter ablation. Recurrent AF early after ablation most commonly terminates spontaneously without further interventional treatment but is associated with later recurrent AF. The aim of this investigation is to identify clinical and procedural factors associated with recurrence of AF early after ablation. Methods and results We retrospectively analysed data for recurrence of AF within the first 3 months after catheter ablation from the randomized controlled AXAFA–AFNET 5 trial, which demonstrated that continuous anticoagulation with apixaban is as safe and as effective compared to vitamin K antagonists in 678 patients undergoing first AF ablation. The primary outcome of first recurrent AF within 90 days was observed in 163 (28%) patients, in which 78 (48%) patients experienced an event within the first 14 days post-ablation. After multivariable adjustment, a history of stroke/transient ischaemic attack [hazard ratio (HR) 1.54, 95% confidence interval (CI) 0.93–2.6; P = 0.11], coronary artery disease (HR 1.85, 95% CI 1.20–2.86; P = 0.005), cardioversion during ablation (HR 1.78, 95% CI 1.26–2.49; P = 0.001), and an age:sex interaction for older women (HR 1.01, 95% CI 1.00–1.01; P = 0.04) were associated with recurrent AF. The P-wave duration at follow-up was significantly longer for patients with AF recurrence (129 ± 31 ms vs. 122 ± 22 ms in patients without AF, P = 0.03). Conclusion Half of all early AF recurrences within the first 3 months post-ablation occurred within the first 14 days post-ablation. Vascular disease and cardioversion during the procedure are strong predictors of recurrent AF. P-wave duration at follow-up was longer in patients with recurrent AF. Trial registration Clinicaltrials.gov identifier NCT02227550

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P wave dispersion – fading light of a popular parameter

European Heart Journal ◽

10.1093/ehjci/ehaa946.3449 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J Zawadzki ◽

J Mercik ◽

A Marecka ◽

G Zawadzki ◽

J Adamowicz ◽

...

Keyword(s):

Wave Dispersion ◽

P Wave ◽

P Wave Dispersion ◽

P Waves ◽

Wave Duration ◽

P Wave Duration ◽

Basic Measurement ◽

Atrial Activation ◽

Electrophysiological System ◽

Ecg Leads

Abstract Background The P wave dispersion concept was created to describe the non-uniform atrial conduction as a separate AF factor. However the major assumptions of the theory are inconsistent with the main principle of electrocardiography, which assumes that 12 leads of ECG, recorded simultaneously, register the same events at the same time. The presence of dispersion suggests the presence of a P wave in one lead, while in the other one it has ended and no longer exists. This observation per se could be considered as a methodological artifact. Objective The major objective is to present that the P wave dispersion descends from imprecise measurements in various ECG leads. We intend to demonstrate that more accurate measurements make this parameter disappear. Methods Our study included 150 patients (89F, 61M) assessed using the electrophysiological system, which allowed to assess the sinus P waves. The P wave duration was measured by 3 independent researchers in all leads twice: 1. paper speed=50 mm/s, enhancement 16x (basic measurement) 2. paper speed=200 mm/s, enhancement 128–256x, simultaneously measuring the P wave dispersion. All measurements were repeated 3 times. Results The results are presented in Table 1 Conclusion 1. The P wave dispersion is the artifact of measurement. It is clear that after using much more accurate tools, the parameter disappears. 2. The P-wave dispersion is connected with Pmax, therefore may be apparently clinically useful but as a matter of fact, doesn't carry any meaning itself. 3.The significant P wave duration parameter should be a total atrial activation time, from the beginning of the earliest recorded P wave, till the end of the last Pwave recorded in any lead. Funding Acknowledgement Type of funding source: None

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Abstract 207: Signal Averaged Electrocardiogram can Indicate the Arrhythmogenic Potential of Right Insular Stroke

Stroke ◽

10.1161/str.47.suppl_1.207 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Hee-Kwon Park ◽

Cindy W Yoon ◽

Ji-Won Kwon ◽

Soo-Jeong Kim ◽

Eung-Seok Lee ◽

...

Keyword(s):

Acute Stroke ◽

Insular Cortex ◽

Wave Dispersion ◽

P Wave ◽

Stroke Patients ◽

P Wave Dispersion ◽

Wave Duration ◽

P Wave Duration ◽

The Right

Backgrounds: The right insular cortical stroke is believed to have arrhythmogenic potential such as secondary atrial fibrillation (AF). The P wave-triggered signal-averaged electrocardiogram (SA-ECG) can reveal the P wave dispersion which is associated with the risk of AF in the future. However, there has been no relevant clinical study and we investigated the P wave dispersion after stroke involving right insula. Methods: We recruited acute stroke patients consecutively, who admitted from February 2012 to October 2013 and took routine work-up with SA-ECG. Patients who had AF on admission were excluded. SA-ECG was followed up two years after stroke onset. Significant P-wave dispersion was defined as ‘P-wave duration (PWD) >125ms for the predictor of future AF risk. We analyzed the difference of SA-ECG between the right insular cortex lesion and other stroke. Results: A total of 252 subjects were enrolled and 49 among them had right insular involvement. Follow up SA-ECG were available in 69 patients. In acute stroke period, the patients with right insular lesion had longer P wave duration than the other stroke patients (154.0+29.6 vs. 133.5+26.5 ms, p<0.001). In the patients with right insular involvement, prolonged P wave duration in acute period was shortened in follow up SA-ECG after two years (n=17, 164.5+35.2 vs. 131.7+22.3 ms, p=0.003). However, patients with other stroke lesion did not show such interval change. During observation period, AF occurred more frequently in the subjects with right insular lesion than other stroke patients (33% vs 17%, p=0.01). Conclusion: Our data suggest that the right insular lesion is associated with increased P wave dispersion transiently in acute stroke period and this might explain the development of secondary AF shortly after right insular cortex stroke.

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P-wave and interatrial block: New predictor for atrial high rate episodes in patients with cardiac implantable electronic devices

Pacing and Clinical Electrophysiology ◽

10.1111/pace.13268 ◽

2018 ◽

Vol 41 (3) ◽

pp. 223-228 ◽

Cited By ~ 6

Author(s):

José M. Rubio Campal ◽

Juan Benezet-Mazuecos ◽

José Antonio Iglesias Bravo ◽

Pepa Sánchez Borque ◽

Ángel Miracle Blanco ◽

...

Keyword(s):

Electronic Devices ◽

P Wave ◽

High Rate ◽

Cardiac Implantable Electronic Devices ◽

Interatrial Block

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Filtered P-wave Duration (FPD) on atrial pacing as a predictor of atrial fibrillation occurrence in Sick Sinus Syndrome (SSS) patients with pacemaker implantation

Heart Rhythm ◽

10.1016/j.hrthm.2005.02.451 ◽

2005 ◽

Vol 2 (5) ◽

pp. S144-S145

Author(s):

Norihiro Komiya ◽

Shinji Seto ◽

Yoshiyuki Doi ◽

Manabu Moriya ◽

Satoki Fukae ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sick Sinus Syndrome ◽

Pacemaker Implantation ◽

P Wave ◽

Atrial Pacing ◽

Wave Duration ◽

P Wave Duration

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Characterization of “Super-Responders” to Cryoballoon Ablation

Austin Journal of Clinical Cardiology ◽

10.26420/austinjclincardiolog.2021.1082 ◽

2021 ◽

Vol 7 (3) ◽

Author(s):

Martí-Almor J ◽

◽

Casteigt B ◽

Jiménez-López J ◽

Conejos J ◽

...

Keyword(s):

Statistical Significance ◽

Pulmonary Veins ◽

P Wave ◽

Cryoballoon Ablation ◽

Wave Duration ◽

P Wave Duration ◽

Ablation Index ◽

Group 2

Background: Pulmonary Veins Isolation (PVI) is the cornerstone in the treatment of atrial fibrillation. Recurrence rate is common in the long-term followup (FU); nevertheless, some patients maintain Sinus Rhythm (SR) for more than 5 years after the index ablation. The aim of this study is characterize this kind of patients so called “super-responders”. Methods: This is a retrospective single-center study including all patients summited for cryo-balloon ablation in our hospital from January 2011 to September 2020. We investigated clinical, electrocardiographic, echocardiographic variables and those linked to the ablation procedure. A univariate and multivariate logistic regression was performed. Results: During this period, 422 patients underwent PVI; however, 193 were excluded: 21 lost in the FU, 30 got radiofrequency ablation and 142 did not reach a minimum 5 years FU. Of the 229 finally included, 85 (group 1) did not have any recurrence during the follow-up, in front of 144 (group 2) with AF recurrences. In the multivariate analysis the p wave duration: OR: 0.92; 95% CI (0.89-0.94); p <0.001, BMI kg/m²: OR: 0.74; 95% CI (0.65-0.85); p <0.001, a temperature <-40°C in all the targeted veins: OR: 3.52; 95% CI (1.45-8.54); p=0.005 and SR on the ablation index day OR: 7.29; 95% CI (1.53-34.71); p=0.012, maintained statistical significance. Conclusions: In our series the p wave duration, BMI, the presence of SR the ablation index day and achieving a temperature <-40°C in all the targeted veins, resulted as protective factors to maintain SR in the long term follow-up. An adequate selection of patients probably could improve results and optimize resources.

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Usefulness of P Wave Duration in Embolic Stroke of Undetermined Source

Journal of Clinical Medicine ◽

10.3390/jcm9041134 ◽

2020 ◽

Vol 9 (4) ◽

pp. 1134

Author(s):

Moonki Jung ◽

Jin-Seok Kim ◽

Ju Hyeon Song ◽

Jeong-Min Kim ◽

Kwang-Yeol Park ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Holter Monitoring ◽

Embolic Stroke ◽

P Wave ◽

Stroke Recurrence ◽

Wave Duration ◽

P Wave Duration ◽

Potential Association

The investigation of the potential association between ischemic stroke and subclinical atrial fibrillation (SCAF) is important for secondary prevention. We aimed to determine whether SCAF can be predicted by atrial substrate measurement with P wave signal-averaged electrocardiography (SAECG). We recruited 125 consecutive patients with embolic stroke of undetermined source (ESUS) and 125 patients with paroxysmal atrial fibrillation as controls. All participants underwent P wave SAECG at baseline, and patients with ESUS were followed up with Holter monitoring and electrocardiography at baseline, 3, 6, and 12 months after discharge and every 6 months thereafter. In the ESUS group, 32 (25.6%) patients were diagnosed with SCAF during follow-up. There were no significant differences between the groups regarding atrial substrate. P wave duration (PWD) was a significant predictor of SCAF. Stroke recurrence occurred in 22 patients (17.6%), and prolonged PWD (≥ 135 ms) predicted stroke recurrence more robustly than SCAF detection. In ESUS patients, PWD can be a useful biomarker to predict SCAF and to identify patients who are more likely to have a recurrent embolic stroke associated with an atrial cardiopathy. Further research is needed for supporting the utility and applicability of PWD.

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