Extended ECG Improves Classification of Paroxysmal and Persistent Atrial Fibrillation Based on P- and f-Waves.

Matthias Daniel Zink,Mindy Vroomen,Sander Verheule,Laurent Pison,Ben J M Hermans,Nikki Pluymaekers,Arne Van Hunnik,Ulrich Schotten,Stef Zeemering,Luca Mainardi,Kevin Vernooy,Rita Laureanti,Astrid Hermans,Suzanne Philippens,Harry J G M Crijns,Angelo Auricchio,Dominik Linz

doi:10.3389/fphys.2022.779826

Abstract

BackgroundThe standard 12-lead ECG has been shown to be of value in characterizing atrial conduction properties. The added value of extended ECG recordings (longer recordings from more sites) has not been systematically explored yet.ObjectiveThe aim of this study is to employ an extended ECG to identify characteristics of atrial electrical activity related to paroxysmal vs. persistent atrial fibrillation (AF).MethodsIn 247 participants scheduled for AF ablation, an extended ECG was recorded (12 standard plus 3 additional leads, 5 min recording, no filtering). For patients presenting in sinus rhythm (SR), the signal-averaged P-wave and the spatiotemporal P-wave variability was analyzed. For patients presenting in AF, f-wave properties in the QRST (the amplitude complex of the ventricular electrical activity: Q-, R-, S-, and T-wave)-canceled ECG were determined.ResultsSignificant differences between paroxysmal (N = 152) and persistent patients with AF (N = 95) were found in several P-wave and f-wave parameters, including parameters that can only be calculated from an extended ECG. Furthermore, a moderate, but significant correlation was found between echocardiographic parameters and P-wave and f-wave parameters. There was a moderate correlation of left atrial (LA) diameter with P-wave energy duration (r = 0.317, p < 0.001) and f-wave amplitude in lead A3 (r = −0.389, p = 0.002). The AF-type classification performance significantly improved when parameters calculated from the extended ECG were taken into account [area under the curve (AUC) = 0.58, interquartile range (IQR) 0.50–0.64 for standard ECG parameters only vs. AUC = 0.76, IQR 0.70–0.80 for extended ECG parameters, p < 0.001].ConclusionThe P- and f-wave analysis of extended ECG configurations identified specific ECG features allowing improved classification of paroxysmal vs. persistent AF. The extended ECG significantly improved AF-type classification in our analyzed data as compared to a standard 10-s 12-lead ECG. Whether this can result in a better clinical AF type classification warrants further prospective study.

Highlights

Atrial fibrillation (AF) and structural heart disease can lead to atrial structural remodeling, which is characterized by atrial dilatation (Osranek et al, 2005; Potpara et al, 2013), fibrosis (Marrouche et al, 2014), and fatty infiltrations (Haemers et al, 2017), all of which contribute to local conduction heterogeneities during sinus rhythm (SR) and AF
The study design was approved by the institutional review board (IRB: 16-4-208; NCT03075930) and conducted in accordance with the declaration of Helsinki and Abbreviations: AF, Atrial fibrillation; area under the curve (AUC), Area under the curve; ECG, Electrocardiogram; interquartile range (IQR), Interquartile range; LA, Left atrium; RA, Right atrium; RMSSD, Root Mean Square of Successive Difference; receiver-operating characteristics (ROC), Receiver-operating characteristics; SR, Sinus rhythm
The time since first AF diagnosis was longer in persistent AF, and echocardiography revealed lower left ventricular ejection fractions and larger right and left atria

Summary

Introduction

Atrial fibrillation (AF) and structural heart disease can lead to atrial structural remodeling, which is characterized by atrial dilatation (Osranek et al, 2005; Potpara et al, 2013), fibrosis (Marrouche et al, 2014), and fatty infiltrations (Haemers et al, 2017), all of which contribute to local conduction heterogeneities during sinus rhythm (SR) and AF. Shortening and increased heterogeneity of refractory periods (Frustaci, 1997; Nattel, 1999; Heijman et al, 2016; Opacic et al, 2016) occur as a consequence of ion channel remodeling. These structural and electrical changes enhance stability and progression of AF and reduce responsiveness to therapy (Schotten et al, 2001; Nguyen et al, 2009). The standard 12-lead ECG is the gold standard to diagnose AF at the time of recording (Kirchhof et al, 2016) and is increasingly used to characterize atrial conduction properties during SR and AF (Platonov, 2012; Lankveld et al, 2014, 2016; Potse et al, 2016). The standard 12-lead ECG has been shown to be of value in characterizing atrial conduction properties. The added value of extended ECG recordings (longer recordings from more sites) has not been systematically explored yet

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