Abstract
Introduction: Mitral stenosis is associated with an atrial cardiomyopathic process, leading to abnormal atrial electrophysiology, manifesting as prolonged P-wave duration (PWD), larger P-wave area, increased P-wave dispersion (PWDmax—PWDmin), and/or higher P-wave terminal force on lead V1 (PTFV1) on the electrocardiogram.Methods: This was a single-center retrospective study of Chinese patients, diagnosed with mitral stenosis in sinus rhythm at baseline, between November 2009 and October 2016. Automated ECG measurements from raw data were determined. The primary outcome was incident atrial fibrillation (AF).Results: A total 59 mitral stenosis patients were included (age 59 [54–65] years, 13 (22%) males). New onset AF was observed in 27 patients. Age (odds ratio [OR]: 1.08 [1.01–1.16], P = 0.017), systolic blood pressure (OR: 1.03 [1.00–1.07]; P = 0.046), mean P-wave area in V3 (odds ratio: 3.97 [1.32–11.96], P = 0.014) were significant predictors of incident AF. On multivariate analysis, age (OR: 1.08 [1.00–1.16], P = 0.037) and P-wave area in V3 (OR: 3.64 [1.10–12.00], P = 0.034) remained significant predictors of AF. Receiver-operating characteristic (ROC) analysis showed that the optimum cut-off for P-wave area in V3 was 1.45 Ashman units (area under the curve: 0.65) for classification of new onset AF. A decision tree learning model with individual and non-linear interaction variables with age achieved the best performance for outcome prediction (accuracy = 0.84, precision = 0.84, recall = 0.83, F-measure = 0.84).Conclusion: Atrial electrophysiological alterations in mitral stenosis can detected on the electrocardiogram. Age, systolic blood pressure, and P-wave area in V3 predicted new onset AF. A decision tree learning model significantly improved outcome prediction.
Highlights
Mitral stenosis is associated with an atrial cardiomyopathic process, leading to abnormal atrial electrophysiology, manifesting as prolonged P-wave duration (PWD), larger P-wave area, increased P-wave dispersion (PWDmax—PWDmin), and/or higher P-wave terminal force on lead V1 (PTFV1) on the electrocardiogram
P-wave terminal force in V1 (PTFV1) was defined as the area subtended by the terminal negative component of a biphasic P-wave in lead V1, with the area calculated by multiplication of the duration and depth of the waveform (He et al, 2017)
The major findings of this study are that (i) a high proportion of patients with mitral stenosis had Inter-atrial block (IAB), (ii) age and P-wave area in V3 predicted new onset atrial fibrillation (AF), and (iii) a stepwise improvement in the predictive performance after incorporation of interaction variables and machine learning using a decision tree approach
Summary
Mitral stenosis is associated with an atrial cardiomyopathic process, leading to abnormal atrial electrophysiology, manifesting as prolonged P-wave duration (PWD), larger P-wave area, increased P-wave dispersion (PWDmax—PWDmin), and/or higher P-wave terminal force on lead V1 (PTFV1) on the electrocardiogram. Inter-atrial block (IAB) results from impaired conduction of action potentials along Bachmann’s bundle that connects the right and left atria (Tse et al, 2016). It is characterized electrocardiographically by a prolonged P-wave duration of >120 ms. IAB has been associated with higher incidence of stroke as well as cardiovascular and allcause mortality (Ariyarajah et al, 2007; Magnani et al, 2011) It is unclear any benefit derived from early initiation of anti-coagulation in IAB before the development of atrial fibrillation (AF), and the risk may differ depending on the severity of IAB and the presence of other cardio-metabolic co-morbidities. AF complexity parameters derived from the ECG predicted long-term outcomes following catheter ablation (Lankveld et al, 2016)
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