Electrocardiographic Markers of Atrial Cardiomyopathy: Strengths and Limits of P‐Wave–Based Assessment

The association of electrocardiographic (ECG) markers of atrial cardiomyopathy with heart failure (HF) and its subtypes is unclear. This analysis included 6,754 participants free of clinical cardiovascular disease (CVD), including atrial fibrillation (AF), from the Multi-Ethnic Study of Atherosclerosis. Five ECG markers of atrial cardiomyopathy (P-wave terminal force in V1 [PTFV1], deep-terminal negativity in V1 [DTNV1], P-wave duration [PWD], P-wave axis [PWA], advanced intra-atrial block [aIAB]) were derived from digitally recorded electrocardiograms. Incident HF events through 2018 were centrally adjudicated. An ejection fraction (EF) of 50% at the time of HF was used to classify HF as HF with reduced EF (HFrEF), HF with preserved EF (HFpEF), or unclassified HF. Cox proportional hazard models were used to examine the associations of markers of atrial cardiomyopathy with HF. The Lunn-McNeil method was used to compare the associations in HFrEF vs. HFpEF. 413 HF events occurred over a median follow-up of 16 years. In adjusted models, abnormal PTFV1 (HR (95%CI): 1.56(1.15-2.13), abnormal PWA (HR (95%CI):1.60(1.16-2.22), aIAB (HR (95%CI):2.62(1.47-4.69), DTNPV1 (HR (95%CI): 2.99(1.63-7.33), and abnormal PWD (HR (95%CI): 1.33(1.02-1.73), were associated with increased HF risk. These associations persisted after further adjustments for intercurrent AF events. No significant differences in the strength of association of each ECG predictor with HFrEF and HFpEF were noted. Atrial cardiomyopathy defined by ECG markers is associated with HF, with no differences in the strength of association between HFrEF and HFpEF. Markers of atrial Cardiomyopathy may help identify individuals at risk of developing HF.

Atrial cardiomyopathy is associated with an increased risk of ischemic stroke. P-wave terminal force in lead V1, P-wave duration, and maximum P-wave area are electrocardiographic parameters that have been used to assess left atrial abnormalities related to developing atrial fibrillation. The aim of this systematic review and meta-analysis was to examine their values for predicting ischemic stroke risk. PubMed and EMBASE databases were searched until December 2016 for studies that evaluated the association between P-wave indices and stroke risk. Both fixed- and random-effects models were used to calculate the overall effect estimates. Ten studies examining P-wave terminal force in lead V1, P-wave duration, and maximum P-wave area were included. P-wave terminal force in lead V1 was found to be an independent predictor of stroke as both a continuous variable (odds ratio [OR] per 1 SD change, 1.18; 95% confidence interval [CI], 1.12-1.25; P<0.0001) and categorical variable (OR, 1.59; 95% CI, 1.10-2.28; P=0.01). P-wave duration was a significant predictor of incident ischemic stroke when analyzed as a categorical variable (OR, 1.86; 95% CI, 1.37-2.52; P<0.0001) but not when analyzed as a continuous variable (OR, 1.05; 95% CI, 0.98-1.13; P=0.15). Maximum P-wave area also predicted the risk of incident ischemic stroke (OR per 1 SD change, 1.10; 95% CI, 1.04-1.17). P-wave terminal force in lead V1, P-wave duration, and maximum P-wave area are useful electrocardiographic markers that can be used to stratify the risk of incident ischemic stroke.

Background and purposeGrowing evidence suggests that atrial cardiomyopathy may play an essential role in thrombosis and ischemic stroke. The aim of this systematic review and meta-analysis was to quantify the values of cardiomyopathy markers for predicting ischemic stroke risk.MethodsPubMed, Embase, and the Cochrane Library were searched for longitudinal cohort studies evaluating the association between cardiomyopathy markers and incident ischemic stroke risk.ResultsWe included 25 cohort studies examining electrocardiographic, structural, functional, and serum biomarkers of atrial cardiomyopathy involving 262,504 individuals. P-terminal force in the precordial lead V1 (PTFV1) was found to be an independent predictor of ischemic stroke as both a categorical variable (HR 1.29, CI 1.06–1.57) and a continuous variable (HR 1.14, CI 1.00–1.30). Increased maximum P-wave area (HR 1.14, CI 1.06–1.21) and mean P-wave area (HR 1.12, CI 1.04–1.21) were also associated with an increased risk of ischemic stroke. Left atrial (LA) diameter was independently associated with ischemic stroke as both a categorical variable (HR 1.39, CI 1.06–1.82) and a continuous variable (HR 1.20, CI 1.06–1.35). LA reservoir strain independently predicted the risk of incident ischemic stroke (HR 0.88, CI 0.84–0.93). N-terminal pro-brain natriuretic peptide (NT-proBNP) was also associated with incident ischemic stroke risk, both as a categorical variable (HR 2.37, CI 1.61–3.50) and continuous variable (HR 1.42, CI 1.19–1.70).ConclusionAtrial cardiomyopathy markers, including electrocardiographic markers, serum markers, LA structural and functional markers, can be used to stratify the risk of incident ischemic stroke.

Prevalence of markers of atrial cardiomyopathy in embolic stroke of undetermined source: A systematic review

Association of P-Wave Abnormalities With Sudden Cardiac and Cardiovascular Death: The ARIC Study.

Predictive value of P wave parameters, indices, and a novel electrocardiographic marker for silent cerebral infarction and future cerebrovascular events

Background Atrial cardiomyopathy is associated with increased risk for future atrial fibrillation (AF) and ischemic stroke. Several ECG-derived parameters have been reported to assess the risk for future ischemic stroke. Purpose To predict risk of future ischemic stroke by comparison of the novel parameter duration of the amplified digital sinus-p-wave (APWD; 80mm/mV; 175mm/sec) vs previously described p-wave indices and clinical risk factors (cerebrovascular disease (CVD), CHADS-VASc-score). Methods P-wave-derived parameters were measured on digital 12-lead-sinus-ECGs (recorded +/- 6 months from the clinical stroke event) using the software "ECG-Precision-Analysis V-1-2023". and clinical CHA2DS2-VASc Score was assessed in 80 patients with ischemic stroke (no history of AF, no oral anticoagulation (OAC)) and compared to 80 control patients (without OAC, AF or ischemic stroke within the next five years). Results Patients with ischemic stroke vs control patients presented a higher CHA2DS2-VASc Score (3.7 vs 3.2, p=0.04), had more frequently heart failure (25% vs 13%, p=0.04) and cerebrovascular atherosclerotic disease with stenosis &amp;gt;40% ((22.5% vs 10%, p=0.032). P-wave indices were as follows in patients who developed ischemic stroke within the next 12 months versus patients without stroke within a follow-up period of five years, respectively: APWD (144 vs 128ms, p&amp;lt;0.0001), non-amplified SPWD (118 vs 116ms, p=0.081), A-PTF-V1 (-4660 vs -3860µV*ms, p=0.005), durations and amplitudes of terminal-p-wave in V1 (A-Duration-V1 (83 vs 79ms, p=0.119), A-Amplitude-V1 (-50µV vs -50µV, p=0.028), and advanced interatrial block (aIAB in 25% vs 3.8% of patients; p&amp;lt;0.0001. The novel ECG-derived parameter (duration of the amplified sinus-P-wave &amp;gt;140ms) was the best predictor for future ischemic stroke (accuracy: 74%, sensitivity and specificity: 61% and 86%, respectively; PPV: 82%; area under ROC: 0.776). Sensitivity and specificity of the SPWD, aPTFV1 and aIAB were significantly lower (SPWD&amp;gt;120ms: sensitivity 35% and specificity 78%, PPV: 61%; aPTFV1 ≤-5000µV*ms, accuracy: 61%, sensitivity 46%% and specificity 75%, PPV: 65%; aIAB: accuracy: 61%, sensitivity 25% and specificity 96%, PPV: 87%). Conclusions Among the currently identified ECG markers of atrial cardiomyopathy, the novel APWD and advanced interatrial block have the best predictive performances for diagnosis of persons at risk for ischemic stroke.Comparison between ECG ParametersPredictive Accuracy of Parameters

Background Rhythm control using electrical cardioversion (CV) is a common treatment strategy for patients with symptomatic atrial fibrillation (AF). However, little is known about electrocardiographic (ECG) markers predicting CV failure and AF recurrence. Methods This study included 726 patients who underwent a CV for AF lasting &amp;gt;48h in a referral hospital. We analysed markers of atrial cardiomyopathy in post-CV sinus rhythm ECGs and compared them with CV failure and AF recurrence rates within 30 days after CV as well as their combination (ineffective CV). Of those with failed CV the most recent sinus rhythm ECG was used. Results CV was unsuccessful in 66 out of 726 patients (9.09%). Advanced interatrial block (IAB) defined as P-wave duration ≥120ms and biphasic morphology in inferior (II, III and aVF) leads (OR 3.96, 95%-CI 2.09–7.52, p&amp;lt;0.001) was an independent predictor for CV failure. Within 30 days after CV, AF recurred in 214 (32.4%) patients. Advanced IAB (OR 2.10, 95%-CI 1.19–3.72, p=0.011) was an independent predictor for AF recurrence. In total CV was ineffective (CV failure or AF recurrence) 280 of 726 times (38.6%). Advanced IAB (OR 2.72, 95%-CI 1.64–4.51, p&amp;lt;0.001) was an independent predictor for ineffective CV. Partial IAB categorized as P-wave duration ≥120ms with no biphasic morphology did not predict any end points. Conclusions Advanced IAB predicts CV inefficacy. This study identified ECG markers of atrial cardiomyopathy for clinical use in CV patient selection. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): This study research was funded by grants from the Finnish Medical Foundation, the Finnish Foundation for Cardiovascular Research, State Clinical Research Fund of Turku University Hospital, Turku, Finland, Finnish Cardiac Society, the Emil Aaltonen Foundation, and the Maud Kuistila Foundation.

Introduction: Abnormally negative P-wave terminal force in lead V1 (aPTFV1 &lt;-5000μV*ms) is an electrocardiographic marker of left atrial (LA) myopathy and is associated with an increased risk of stroke, independent of atrial fibrillation. Whether the LA myopathy associated with aPTFV1 is associated with LA structural/mechanical dysfunction is unknown. Hypothesis: aPTFV1 is positively correlated with markers of LA mechanical dysfunction including LA end diastolic volume (LAEDV), systolic volume (LAESV), and ejection fraction (LA EF). Methods: Dallas Heart Study participants free of atrial fibrillation with concomitant cardiac MRI (CMR) and ECG were included. Participants were categorized as aPTFV1, defined as &lt;-5000μV*ms, or normal PTFV1 (nPTFV1). Demographics, established cardiovascular risk factors, and CMR markers of LA and LV structure/function were compared. Multivariable forward step-wise logistic regression models tested the association of aPTFV1 with the univariate variables (p&lt;0.1 for entry/exit). Results: Among 1,880 participants, 214 had an aPTFV1. Participants with aPTFV1 were more likely to be older, black, and have traditional atherosclerotic risk factors including hypertension, diabetes, smoking, and prior stroke (Table 1). aPTFV1 was associated with larger LAEDV and LAESV, and lower LA EF. Multivariable regression models demonstrated increased LV mass, but no markers of LA structural or mechanical dysfunction were associated with an aPTFV1. Modeling explained little of the variability in PTFV1 (cumulative R 2 = 0.03). Conclusions: In a large, multi-ethnic cohort, important differences in traditional cardiovascular risk exist between aPTFV1 and nPTFV1; however, cardiac MRI-derived LA structure/function explain very little of the variability in PTFV1. These data suggest the LA cardiomyopathy associated with aPTFV1 may be a manifestation of electrical rather than structural/mechanical dysfunction.