P-wave Terminal Force In Lead V1 Research Articles

Embolic stroke of undetermined source: Focusing on atrial cardiopathy and patent foramen ovale

BackgroundAtrial cardiopathy(AC) and patent foramen ovale (PFO) are two etiologies of embolic strokes of undetermined source (ESUS). We aimed to explore the relationship between them in ESUS. MethodsA total of 1146 participants were included from January 2019 to June 2022, which included the ESUS group and non-embolic stroke which includes LAA(large arterial atherosclerosis) + SAO(small artery occlusion) group. AC was defined as the presence of at least one of the following: PTFV1(P-wave terminal force in lead V1) > 4000 μV*ms in the electrocardiograms, NT-proBNP(N-terminal probrain natriuretic peptide) > 250 pg/mL in laboratory tests or LAD(left atrial diameter) > 3.8 cm for women and > 4.0 cm for men in cardiac ultrasound. The presence of PFO was assessed by transthoracic echocardiography, transcranial Doppler ultrasound, transesophageal echocardiography or cardiac MRI. PFO was considered pathogenic if the RoPE score was 7 to 10. ResultsThe prevalence of AC and PFO was higher in the ESUS group than the LAA + SAO group. The prevalence of AC was lower in ESUS patients with pathogenic PFO (37.9%) than those without PFO (68.4%) and with incidental PFO (64.0%) (p = 0.006). The prevalence of pathogenic PFO was lower in ESUS patients with AC than those without AC (6.0% vs. 17.8%, p = 0.006). The AUC(area under the curve) of PTFV1 for predicting ESUS was 0.724 [95%CI (0.686–0.762), p < 0.05)], indicating that PTFV1 the most valuable AC biomarker. ConclusionsThe prevalence of AC is inversely related to the prevalence of pathogenic PFO in ESUS patients. PTFV1 was the most valuable index to predict ESUS among the AC biomarkers.

Association between P-wave terminal force in lead V1 and extent of left atrial low-voltage substrate in older patients with paroxysmal atrial fibrillation.

The P-wave terminal force in lead V1 (PTFV1) is a marker of cardiomyopathy and risk of atrial fibrillation (AF). Low-voltage area (LVA) in the left atrium (LA), which indicates underlying atrial fibrosis, could predict AF recurrence. This study aimed to investigate the correlation between PTFV1 and LVA in older patients with paroxysmal AF. From May 1, 2020, to October 31, 2021, a total of 162 patients aged 65-80years with paroxysmal AF who underwent index ablation procedures were enrolled. PTFV1 was measured in sinus rhythm (SR) using 12-lead electrocardiograms prior to the ablation. Abnormal PTFV1 was defined as a ≥ 4 mVms depression. Additional LVA ablation beyond circumferential pulmonary vein isolation (CPVI) was performed if LVAs were found. Among the 162 patients, 88 had a normal PTFV1 and 74 had an abnormal PTFV1 prior to ablation. There was a significant difference in LVA in patients with and without an abnormal PTFV1 (LVA, 11.0 vs. 5.1 cm2, P < 0.001; LVA burden, 8.9% vs. 4.5%, P < 0.001). PTFV1 and PTAV1 were highest in the upper tertile with extensive LVAs (P < 0.001). Multivariate analysis revealed that abnormal PTFV1 was an independent predictor of LVAs (β = 4.961; 95% CI, 2.135-7.788; P < 0.001). After a median follow-up of 23months, the AF-free survival rate was similar between the normal PTFV1 group and the abnormal PTFV1 group (13/88 vs. 12/74, hazard ratio [HR], 0.933 [95% CI, 0.425-2.047]; P = 0.861). Abnormal PTFV1 at baseline was independently associated with the extent of LVA in older patients with paroxysmal AF.

Prevalence and Prognostic Value of Atrial Cardiopathy in Embolic Stroke of Undetermined Source

Introduction: We utilized data from the Third China National Stroke Registry to investigate the prevalence of atrial cardiopathy markers in patients with embolic stroke of undetermined source (ESUS) and to assess their association with death and stroke recurrence. Methods: In China, patients experiencing transient ischemic attack or ischemic stroke were recruited consecutively by the Third China National Stroke Registry. We compared atrial cardiopathy markers, such as left atrial (LA) enlargement, increased P-wave terminal force in lead V1 (PTFV1), premature atrial contractions, paroxysmal supraventricular tachycardia, advanced interatrial block, prolonged PR interval, prolonged P-wave dispersion, and prolonged P-wave duration between ESUS patients and those with small vessel disease and large artery atherosclerosis strokes. The association between these markers and the recurrence of stroke as well as mortality risk in ESUS patients was evaluated using Cox regression analysis. Results: Of 8,528 ischemic stroke patients who underwent a standard diagnostic workup, 2,415 were identified as having ESUS. Multivariable analysis revealed a significant association between elevated PTFV1 and an increased risk of stroke recurrence (HR: 2.50; 95% CI: 1.53–4.09; p p p = 0.09). Both LA diameter (HR: 1.03; 95% CI: 1.00–1.06; p = 0.03) and the top quartile of the LA diameter index (HR: 1.56; 95% CI: 1.03–2.40; p = 0.04) were associated with stroke recurrence in patients with ESUS. Conclusions: PTFV1 was independently associated with an elevated risk of stroke recurrence and mortality in ESUS patients. Additionally, a trend toward a correlation between LA enlargement and high stroke recurrence risk after ESUS was observed.

High-Sensitivity C-Reactive Protein Modifies P-Wave Terminal Force in Lead V1-Associated Prognosis in Acute Ischemic Stroke or TIA Patients

Little is known about the role of high-sensitivity C-reactive protein (hsCRP) in the relationship between P-wave terminal force in lead V1 (PTFV1) and stroke prognosis. We aimed to investigate how hsCRP influences the effect of PTFV1 on ischemic stroke recurrence and mortality. In this study, patients enrolled in the Third China National Stroke Registry, which enrolled consecutive patients who had suffered an ischemic stroke or transient ischemic attack in China, were analyzed. After excluding patients with atrial fibrillation, 8271 patients with PTFV1 and hsCRP measurements were included in this analysis. Cox regression analyses were used to assess the association between PTFV1 and stroke prognosis according to different inflammation statuses stratified by an hsCRP level of 3 mg/L. A total of 216 (2.6%) patients died, and 715 (8.6%) patients experienced ischemic stroke recurrence within 1 year. In patients with hsCRP levels ≥ 3 mg/L, elevated PTFV1 was significantly associated with mortality (HR, 1.75; 95% CI, 1.05-2.92; p = 0.03), while in those with hsCRP levels < 3 mg/L, such an association did not exist. In contrast, in patients with hsCRP levels < 3 mg/L and those with hsCRP levels ≥ 3 mg/L, elevated PTFV1 remained significantly associated with ischemic stroke recurrence. The predictive role of PTFV1 towards mortality but not ischemic stroke recurrence differed in terms of hsCRP levels.

The Association Between Standard Electrocardiography and Cerebral Small Vessel Disease in a Memory Clinic Study.

P-wave terminal force in lead V1 (PTFV1) on electrocardiography has been associated with atrial fibrillation and ischemic stroke. To investigate whether PTFV1 is associated with cerebral small vessel disease (CSVD) markers and etiological subtypes of cognitive impairment and dementia. Participants were recruited from ongoing memory clinic study between August 2010 to January 2019. All participants underwent physical and medical evaluation along with an electrocardiography and 3 T brain magnetic resonance imaging. Participants were classified as no cognitive impairment, cognitive impairment no dementia, vascular cognitive impairment no dementia, and dementia subtypes (Alzheimer's disease and vascular dementia). Elevated PTFV1 was defined as > 4,000μV×ms and measured manually on ECG. Of 408 participants, 78 (19.1%) had elevated PTFV1 (37 women [47%]; mean [SD] age, 73.8 [7.2] years). The participants with elevated PTFV1 had higher burden of lacunes, cerebral microbleeds (CMB), and cortical microinfarcts. As for the CMB location, persons with strictly deep CMB and mixed CMB had significantly higher PTFV1 than those with no CMB (p = 0.005, p = 0.007). Regardless of adjustment for cardiovascular risk factors and/or heart diseases, elevated PTFV1 was significantly associated with presence of CMB (odds ratio, 2.26; 95% CI,1.33-3.91). Elevated PTFV1 was associated with CSVD, especially deep CMB. PTFV1 in vascular dementia was also higher compared to Alzheimer's disease. Thus, PTFV1 might be a potential surrogate marker of brain-heart connection and vascular brain damage.

P-Wave Terminal Force V1 Is Associated with Left Ventricular Diastolic Function in Patients with No Significant Perfusion Abnormality.

P-wave terminal force in lead V1 (PTFV1) is a marker of increased left atrial (LA) overload. Whether PTFV1 is associated with left ventricular (LV) diastolic function remains undetermined. We tested the hypothesis that PTFV1 is associated with LV diastolic parameters derived from gated myocardial perfusion single-photon emission computed tomography (SPECT) in patients with no significant perfusion abnormalities.The study population included 158 patients with preserved ejection fraction and no significant perfusion abnormalities. The amplitude and duration of the P-wave negative phase in lead V1 were measured using an electrocardiogram, and PTFV1 was calculated. The peak filling rate (PFR) and one-third mean filling rate (1/3 MFR) were obtained as LV diastolic parameters using gated SPECT.PTFV1 showed a weak correlation with the LA volume index (r = 0.31; P < 0.001). Significant associations were observed between PTFV1 and PFR (r = -0.27; P < 0.001) and 1/3 MFR (r = -0.26; P = 0.001). A multivariate linear regression analysis showed that age (β = -0.26; P < 0.001), LV end-diastolic volume index (β = -0.27; P = 0.001), and PTFV1 (β = -0.15; P = 0.036) were significant factors associated with PFR. Moreover, male gender (β = -0.16; P = 0.041), LV mass index (β = -0.17; P = 0.046), and PTFV1 (β = -0.17; P = 0.022) were significant factors associated with the 1/3 MFR.PTFV1 is associated with LV diastolic function, as derived from gated SPECT in patients with no significant perfusion abnormalities.

Abstract TP217: Potential Utility Of Magnetocardiogram For Patients With Embolic Stroke Of Undetermined Source

Background: The magnetocardiogram (MCG) is a promising medical tool for detecting and visualizing abnormal cardiac electrical activation in cardiovascular disease patients. MCG has higher spatial resolution than the electrocardiogram (ECG) because the magnetic field is not distorted by flow through tissues. Taking advantage of these features, MCG has been applied for studying arrhythmia, such as atrial fibrillation (AF) and long-QT syndrome. Paroxysmal AF is the most common sources of thromboembolism for ESUS. Since factors that reflect left atrial overload (LAO) are independent predictors of paroxysmal AF, evaluation of these factors in ESUS patients is essential to improve their prognosis. We aimed to investigate the potential utility of MCG in ESUS patients for evaluation of the factors that reflect LAO. Methods: ESUS patients who underwent MCG (MC-6400 MCG system with 64 magnetic sensors) in our hospital were enrolled between September 2018 and July 2021. The peak P-wave magnitude of the right atrium segment and the left atrium segment on the MCG (MCG-RA, MCG-LA) were measured. Subsequently, the ratio of peak magnitude of the LA segment to that of the RA segment (MCG-LA/RA) was used to evaluate LAO. Other factors that reflect LAO, such as PAC frequency on Holter monitoring, LAD in transthoracic echocardiography (TTE), serum level of brain natriuretic peptide, left ventricular ejection fraction (LVEF) in TTE, and P-wave terminal force in lead V1 (PTFV1) on ECG were also evaluated. Results: Fifty-two ESUS patients with a mean age of 67.9±14.3 years (females, 42%) were included. The mean MCV-RA and MCG-LA were 7.70±12.82 and 4.50±7.74 pico-Tesla, respectively. The mean MCG-LA/RA was 0.66±0.31. The MCG-LA/RA was significantly correlated with the PAC frequency (r=0.293, p=0.039), although either MCG-RA or MCG-LA was not correlated. Also, the MCG-LA/RA ratio was significantly correlated with LAD (r=0.301, p=0.03) but not with brain natriuretic peptide (r= 0.25, p= 0.09), LVEF (r= -0.06, p= 0.654), or PTFV1 (r= 0.02, p=0.91). Conclusion: This is the first study that evaluated the relationship of the MCG-LA/RA ratio with factors that reflect LAO in ESUS patients. These results suggest that the MCG-LA/RA ratio is a novel biomarker for LAO in ESUS patients.

Atrial cardiopathy and non-stenotic intracranial complicated atherosclerotic plaque in patients with embolic stroke of undetermined source

ObjectiveTo assess (1) the association between atrial cardiopathy (AC) and non-stenotic intracranial complicated atherosclerotic plaque (NICAP) in patients with embolic stroke of undetermined source (ESUS) or small-vessel disease (SVD), and...

Reduced left atrial strain in magnetic resonance imaging is associated with abnormal P-waves in patients after acute myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): ReForM-B-Program Background Abnormal P-wave terminal force in lead V1 (PTFV1) is associated with atrial remodeling. The relationship between PTFV1 and atrial function after acute myocardial injury is insufficiently understood and may be elucidated by detailed feature tracking (FT) strain analysis of cardiac magnetic resonance images (CMR). Purpose We investigated the relationship between PTFV1 and left atrial (LA) strain (measured by CMR) in a patient cohort presenting with acute myocardial infarction (MI). Methods 56 patients with acute MI underwent CMR within 3-5 days after MI. PTFV1 was measured as the product of negative P-wave amplitude and duration in lead V1 (Fig. A). A PTFV1 &amp;gt;4000 ms*µV was defined as abnormal. CMR cine data were retrospectively analyzed using a dedicated FT software. LA strain (ε) and strain rate (SR) for atrial reservoir ([εs]; [SRs]), conduit ([εe]; [SRe]) and booster function ([εa]; [SRa]) were measured in two long-axis views (Fig. A). Results Patients with abnormal PTFV1 had significantly reduced LA conduit function εe and SRe (Fig. B + D). There was a significant negative correlation between the extent of PTFV1 and both εe and SRe (Fig. C + E). In univariate and multivariate regression models, both PTFV1 and age predicted atrial conduit function. In contrast, multiple clinical co-factors had no significant influence on εe (Table). Interestingly, linear regression models revealed only mild dependency of PTFV1 on conventional parameters of cardiac function such as left ventricular ejection fraction (p = 0.059; R²(adj.)=0.047), and no dependency on structural parameters such as LA area (p = 0.639; R²(adj.)=0.016), or LA fractional area change (p = 0.825; R²(adj.)=0.020). Conclusion Abnormal PTFV1 was associated with reduced LA function independent from numerous clinical co-factors in patients presenting with acute myocardial infarction. Table N = 56 Linear Regression Analysis Multiple Linear Regression Analysis (R2 (adj.)=0.376, p = 0.016) Variable B 95% CI P value R2 (adj.) B 95% CI P value PTFV1 [µV*ms] -1.628 17085.298 to 27210.854 0.013 0.092 -1.315 -2.614 to -0.016 0.047 Age [y] -425.775 24985.168 to 54634.995 0.002 0.145 -610.815 -982.78 to -238.849 0.001 Body mass indes [kg/m2] -185.653 -3259.187 to 47020.775 0.671 -0.015 -506.096 -1327.357 to 315.165 0.219 Creatinine kinase [U/l] -1.571 14806.991 to 24842.272 0.121 0.027 -1.791 -3.72 to 0.138 0.067 Male sex -893.28 10701.206 to 23504.066 0.802 -0.017 4275.631 -3842.517 to 12393.78 0.292 Estimated glomerular filtration rate [ml/min/1.73m2] 88.617 -4564.177 to 21395.361 0.202 0.012 -163.981 -331.343 to 3.381 0.054 Systolic blood pressure [mmHg] -2.001 14045.786 to 22037.253 0.095 0.038 29.331 -108.243 to 166.906 0.668 nt-pro brain natriuretic peptide [pg/ml] 24.629 -4060.804 to 30920.828 0.716 -0.016 1.015 -1.778 to 3.809 0.466 Univariate and multivariate linear regression models for left atrial conduit strain Abstract Figure

Decoding electrocardiographic predictors of left ventricular mechanical remodeling in patients with left bundle branch block

Introduction – Left bundle branch block (LBBB) occurrence is uncommon in the general population (~1-3%), but is more prevalent among patients with congestive heart failure (~30%), and portends worse prognosis1-3. The impact of LBBB on left ventricular (LV) systolic function can range from minimal to dramatic reduction of ejection fraction. The delay in electrical activation subsequently triggers dyssynchronous contraction of the LV opposing walls, leading to ventricular remodeling and elevated LV filling pressures. This is turn results in electrical and mechanical left atrium (LA) remodeling. The left ventricular activation time (LVAT) and P-wave terminal force in lead V1 (PTFV1) have been correlated with cardiac resynchronization response. However, the relationship between these electrocardiographic markers and LV mechanical remodeling has not been evaluated. Aims – The aim of this study is to investigate the relationship between LVAT and PTFV1 recorded on ECG and the LV mechanical remodeling evaluated by the left ventricular end-diastolic diameter (LVEDd) in patients with LBBB. Methods – We have conducted a retrospective, observational study on 155 consecutive patients diagnosed with LBBB admitted in our clinic between January 2017 and December 2019 with NYHA class I-IV, regardless of the left ventricle ejection fraction (LVEF). Biventricular electrical activation in LBBB was performed by measuring the right and left ventricular activation times (RVAT, LVAT) and electrical activation of the LA was analyzed by measuring P-wave terminal force in lead V1 (PTFV1). Results – In our cohort, LVEDd is statistically significantly correlated with LVAT and PTFV1, with a higher Pearson correlation coefficient for LVAT compared to PTFV1. In multivariate analysis LVAT and PTFV1 are independent predictors of LVEDd. Conclusion – This study suggests that LV mechanical remodeling in patients with LBBB can be predicted by the delayed electrical activation of the LV and the magnitude of P-wave negative terminal forces in V1.

Evaluation of left ventricular diastolic function of patients with coronary heart disease by ultrasound images on bilateral filtering image noise reduction algorithm combined with electrocardiogram

Objective:To explore the evaluation of left ventricular diastolic function (LVDF) in patients with coronary heart disease (CHD) using ultrasound images (UI) combined with electrocardiogram (ECG) on bilateral filtering image noise reduction algorithm (BFINRA).Methods:A BFINRA was constructed, and 60 subjects who were investigated were divided into a control group (CG) from June 2019 to November 2019 in Taizhou People’s Hospital, a myocardial infarction group (MIG), and an angina pectoris group (APG). The patient’s LVDF was examined by two-dimensional electrophoresis (2DE) and real-time three-dimensional echocardiography (RT-3DE) combined with ECG. The results showed BFINRA could improve UI quality.Results:Clinical data indicated there were no substantial differences in age, gender, and fasting blood glucose of all subjects. 2DE examination results showed the left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), and early diastolic mitral blood flow velocity / early diastolic mitral annulus velocity (E/E’) of MIG were much higher than CG (P<0.05), while the left ventricular ejection fraction (LVEF), E / late diastolic mitral blood flow velocity (E/A) and E’ peak value were sharply decreased (P<0.05);LVESV and E/E’ of APG were increased dramatically (P<0.05), while E peak, E/A and E’ peak were decreased greatly. RT-3DE examination results indicated LVEDV and LVESV of MIG were considerably higher than CG (P<0.05), while LVEF and macrophage resistance factor (MRF) were enormously decreased (P<0.05);LVEDV and LVESV of APG were greatly increased (P<0.05). However, LVEF and MRF were not changed significantly (P>0.05). LVEDV had a remarkable difference (P<0.05), but LVESV and LVEF had no obvious differences (P>0.05). The electrocardiogram results illustrated the increase in QT dispersion (QTd) of MIG and APG was statistically significant (P<0.05) compared with CG, while the negative increase of P-wave terminal force in lead V1 (PTFV1) also had a statistical significance (P<0.05). Correlation analysis revealed that MRF and PTFV1 had positive correlation, while MRF and QTd showed a negative correlation.Conclusion:The combination of UI and ECG could better assess LVDF in CHD patients.

Abnormal P-waves found in patients with sleep-disordered breathing are associated with triggered pro-arrhythmic activity

Abstract Background Sleep-disordered breathing (SDB) is frequently associated with atrial arrhythmias, but diagnostic markers that predict the propensity for atrial arrhythmias are missing. Abnormal P-wave terminal force in lead V1 (PTFV1) has been associated with atrial structural/electrical remodeling and arrhythmias. Purpose Here we investigate the association of triggered pro-arrhythmic activity with abnormal PTFV1 in human right atrial appendage biopsies of patients without and with SDB. Methods 30 patients undergoing elective coronary artery bypass grafting were screened for SDB by polygraphy. An apnoea-hypopnea index (AHI) of ≥15/h defined SDB. PTFV1 was measured as product of negative P-wave amplitude and duration in lead V1 and was defined as abnormal if &amp;gt;4000 ms*μV. Ca/Calmodulin-dependent protein kinase II (CaMKII) activity was measured in human right atrial appendage biopsies by a specific HDAC4 pull-down assay. Premature atrial contractions (PACs) were triggered by exposure to 100 nM isoproterenol (at 3.5 mM [Ca]o) in human atrial trabeculae. PACs severity was classified by a score from 0 points (no arrhythmias) to 5 points (salve). In addition, atrial fibrosis was quantified by Masson's trichrome stain in cryo-sectioned atrial tissue. Multivariate linear regression analyses were performed accounting for age, sex, BMI, existing AF, heart failure, diabetes, and creatinine. Results Interestingly, the AHI was independently associated with the magnitude of PTFV1 (fig. A+B, B=57.47±21.03, R2=0.48, P=0.01). Importantly, patients with an abnormal PTFV1 had a significantly increased CaMKII activity (fig. C, P=0.04) and showed significantly more severe triggered PACs (fig. D, P=0.02). Moreover, the magnitude of PTFV1 correlated significantly and independently with PAC severity (fig. D, B=0.0005±0.0002, R2=0.50, P=0.03). Consistently, these arrhythmias could be significantly reduced by acute CaMKII inhibition (5 μM KN93, P&amp;lt;0.01), which abolished the correlation between PTFV1 and PAC severity (P=N.S.). Surprisingly, atrial fibrosis was significantly decreased in patients with an abnormal PTFV1 (fig. E, P=0.02), suggesting that abnormal PTFV1 is a marker of proarrhythmic atrial electrical remodeling of functional cardiomyocytes but not of fibrotic tissue. Conclusion The severity of sleep-disordered breathing (AHI) is independently associated with an abnormal PTFV1. Intriguingly, this abnormality is associated with an increased CaMKII activity and with CaMKII-dependent arrhythmias, suggesting PTFV1 to be a potential tool to evaluate the pro-arrhythmic risk of patients with SDB. Figure 1 Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Part of this study was funded by Philips Respironics.

Interatrial Block Predicts Atrial Fibrillation and Total Mortality in Patients with Cardiac Resynchronization Therapy

Abstract Background Interatrial block (IAB) and abnormal P-wave terminal force in lead V1 (PTFV1) are electrocardiographic (ECG) abnormalities associated with new-onset atrial fibrillation (AF) and death. However, their prognostic importance has not been proven in CRT recipients with advanced heart failure (HF). Purpose To assess if IAB and abnormal PTFV1 are associated with new-onset AF or death in CRT recipients. Methods CRT recipients without AF history before CRT implantation were included (n=210, median age 67 years, 80% male, 55% ischemic heart disease, 70% NYHA Class III/IV, median LVEF 25%, 51% CRT-P). Automated analysis of P-wave duration (PWD) and morphology classified patients as having either No IAB (PWD &amp;lt;120ms), Partial IAB (pIAB: PWD ≥120 ms, positive P waves in leads II and aVF) or Advanced IAB (aIAB: PWD ≥120 ms and biphasic or negative P wave in leads II or aVF). PTFV1 &amp;gt;0.04 mm·s was considered abnormal. Cox regression analyses adjusted for age, NYHA Class, ischemic etiology of HF, LBBB, LVEF and CRT-P vs. CRT-D were performed to assess the impact of IAB and abnormal PTFV1 on the primary endpoint new-onset AF, death or heart transplant (HTx) and the secondary endpoint death or HTx at 5 years of follow up. Results IAB was found in 45% (34% pIAB and 11% aIAB) and was associated with both the primary (HR 1.9, 95% CI 1.2–2.9, p=0.004) and the secondary (HR 2.1, 95% CI 1.2–3.4, p=0.006) endpoints. Abnormal PTFV1 was not associated with outcome. See Forest plot for adjusted HRs for individual P-wave indices. Conclusions IAB is associated with new-onset AF and death in CRT recipients and may be helpful in risk stratification in the context of HF management. Abnormal PTFV1 did not demonstrate any prognostic value in the setting of CRT-treated patients with advanced HF. Forest plot Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swedish Heart and Lung Foundation

Roles of Morris Index on Poor Outcomes in Patients with Non-ST Segment Elevation Acute Coronary Syndrome

BackgroundThis study aimed to assess the roles of the Morris index in predicting poor outcomes in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS).Material/MethodsThis study included 905 patients with newly diagnosed NSTE-ACS. The Morris index, also known as P wave terminal force in lead V1 (PTFV1), was recorded at admission and discharge. PTVF1 (+) was defined as an absolute value >0.04 mm·s, while PTFV1 (−) was defined as an absolute value <0.04 mm·s. Based on their PTFV1 values at admission/discharge, patients were divided into 4 groups: PTFV1 (−)/(−), PTFV1 (+)/(−), PTFV1 (−)/(+), and PTFV1 (+)/(+). Univariate and multivariate regression analyses were utilized to identify the variables that could contribute to NSTE-ACS risk.ResultsCompared with the PTFV1 (−)/(−) group, the incidence of poor outcomes was significantly higher in the PTFV1 (−)/(+) (hazard ratio [HR], 3.548; 95% confidence interval [95% CI], 2.024–6.219) and PTFV1 (+)/(+) (HR, 2.133; 95% CI, 1.141–3.986) groups, but not statistically different in the PTFV1 (+)/(−) group (risk ratio, 0.983; 95% CI, 0.424–2.277).ConclusionsPrimary PTFV1 (+) at discharge and PTFV1 (+) during hospitalization were independent risk factors for poor outcomes, which may provide useful prognostic information for patients with NSTE-ACS.

Electrocardiographic Left Atrial Abnormality and B-Type Natriuretic Peptide in a General Japanese Population: NIPPON DATA2010.

Aims: P-wave terminal force in lead V1 (PTFV1) is an electrocardiogram marker of increased left atrial pressure and may be a noninvasive and early detectable marker for future cardiovascular events in the general population compared to serum B-type natriuretic peptide (BNP) concentration. The clinical significance of PTFV1 in the contemporary general population is an area of unmet need. We aimed to demonstrate the correlation between PTFV1 and BNP concentrations in a contemporary representative Japanese population.Methods: Among 2,898 adult men and women from 300 randomly selected districts throughout Japan (NIPPON DATA2010), we analyzed 2,556 participants without cardiovascular disease (stroke, myocardial infarction, and atrial fibrillation). Elevated BNP was defined as a value of ≥ 20 pg/mL based on the definition from the Japanese Circulation Society guidelines.Results: In total, 125 (4.9%) participants had PTFV1. Participants with PTFV1 were older with a higher prevalence of hypertension, major electrocardiographic findings, and elevated BNP concentrations (13.5 [6.9, 22.8] versus 7.8 [4.4, 14.5] pg/mL; P < 0.001). After adjustment for confounders, PTFV1 was correlated with elevated BNP (odds ratio, 1.66; 95% confidence interval, 1.05–2.62; P = 0.030). This correlation was consistent among various subgroups and was particularly evident in those aged < 65 years or those without a history of hypertension.Conclusions: In the contemporary general population cohort, PTFV1 was independently related to high BNP concentration. PTFV1 may be an alternative marker to BNP in identifying individuals at a higher risk of future cardiovascular events in the East Asian population.

Predictive value of P wave terminal force in lead V1 for atrial fibrillation: A meta-analysis.

BackgroundSeveral studies have explored the association between P wave terminal force in lead V1 (PTFV1) and risk of atrial fibrillation (AF) occurrence, but the results were controversial. This meta‐analysis aimed to examine whether abnormal PTFV1 could predict AF occurrence.MethodsWe searched PubMed, Embase, and Cochrane Library databases for articles published before August 25, 2018. Pooled odds ratios (ORs) of AF occurrence were calculated using random‐effects models to explore the significance of PTFV1.ResultsA total of 12 studies examining 51,372 participants were included, with 9 studies analyzing PTFV1 as a categorical variable and 4 studies analyzing PTFV1 as a continuous variable. As a categorical variable, abnormal PTFV1 (>0.04 mm s) was significantly associated with AF occurrence with a pooled OR of 1.39 (95% confidence interval [CI] 1.08–1.79, p = .01). Subgroup analysis found that ORs of studies in hemodialysis patients (OR = 4.89, 95% CI 2.54–9.90, p < .001) and acute ischemic stroke patients (OR = 1.60, 95% CI 1.14–2.25, p = .007) were higher than general population (OR = 1.15, 95% CI 1.03–1.29, p = .01). Studies from Europe (OR = 1.05, 95% CI 0.91–1.20, p = .51) yielded lower OR of endpoints compared with Asia (OR = 1.89, 95% CI 1.38–2.60, p < .001) and United States (OR = 1.43, 95% CI 1.19–1.72, p < .001). As a continuous variable, PTFV1 was also significantly associated with AF occurrence with a polled OR per 1 standard deviation (SD) change of 1.27 (95% CI 1.02–1.59, p = .03).ConclusionsPTFV1 was significantly associated with the risk of AF and was considered to be a good predictor of AF occurrence in population with or without cardiovascular diseases.

Poor reliability of P-wave terminal force V1 in ischemic stroke

IntroductionSeveral ECG markers are postulated to represent underlying atrial remodelling and have been associated with ischemic stroke. P-wave terminal force in lead V1 (PTFV1) is one such marker. We examined the factors that contribute to the reliability of PTFV1 and its association with ischemic stroke. Material and methodsFour hundred and thirty-five patients that presented with an ischemic stroke or transient ischemic attack (TIA) were identified through a prospectively maintained multi-site institutional stroke database. Control group consisted of age matched patients without prior history of an ischemic stroke or TIA. All patients underwent a 12-lead ECG and 24-hour Holter monitoring during the study period to exclude atrial fibrillation. ResultsMorphology consistent with PTFV1 occurred commonly in both the stroke/TIA and control groups. There was no significant difference in the median PTFV1 value between the stroke 3.96 mV ms [Interquartile range (IQR) 2.78–5.58] and control 4.23 mV ms [IQR 2.91–5.57] groups. Measurements of PTFV1 demonstrated excellent intra-observer reliability on assessment of the same P-wave (Intra class correlation (ICC) 0.91, p < 0.001) with narrow limits of agreement 2.21 to −2.95 mV ms. A change in the P wave assessed led to a significant reduction in reliability (ICC 0.79, p < 0.001). Inter-observer, inter P-wave assessment demonstrated further reduction in reliability (ICC 0.68, p < 0.002) with wide limits of agreement 6.17 to −5.78 mV ms, indicating significant under and overestimation of PTFV1. ConclusionThe utility of PTFV1 as a clinical marker for ischemic stroke is limited by the reduction in reliability associated with inter-observer and inter P-wave measurements.

Influence of left atrial size on P-wave morphology: differential effects of dilation and hypertrophy.

Chronic left atrial enlargement (LAE) increases the risk of atrial fibrillation. Electrocardiogram (ECG) criteria might provide a means to diagnose LAE and identify patients at risk; however, current criteria perform poorly. We seek to characterize the potentially differential effects of atrial dilation vs. hypertrophy on the ECG P-wave. We predict effects on the P-wave of (i) left atrial dilation (LAD), i.e. an increase of LA cavity volume without an increase in myocardial volume, (ii) left atrial concentric hypertrophy (LACH), i.e. a thickened myocardial wall, and (iii) a combination of the two. We performed a computational study in a cohort of 72 anatomical variants, derived from four human atrial anatomies. To model LAD, pressure was applied to the LA endocardium increasing cavity volume by up to 100%. For LACH, the LA wall was thickened by up to 3.3 mm. P-waves were derived by simulating atrial excitation propagation and computing the body surface ECG. The sensitivity regarding changes beyond purely anatomical effects was analysed by altering conduction velocity by 25% in 96 additional model variants. Left atrial dilation prolonged P-wave duration (PWd) in two of four subjects; in one subject a shortening, and in the other a variable change were seen. Left atrial concentric hypertrophy, in contrast, consistently increased P-wave terminal force in lead V1 (PTF-V1) in all subjects through an enlarged amplitude while PWd was unaffected. Combined hypertrophy and dilation generally enhanced the effect of hypertrophy on PTF-V1. Isolated LAD has moderate effects on the currently used P-wave criteria, explaining the limited utility of PWd and PTF-V1 in detecting LAE in clinical practice. In contrast, PTF-V1 may be a more sensitive indicator of LA myocardial hypertrophy.

P-wave terminal force in lead V1 is a predictive indicator for the diagnosis of tuberculous constrictive pericarditis

ObjectivesThe purpose of this study is to explore the value of P-wave terminal force in lead V1 (PTFV1) in the clinical diagnosis of tuberculous constrictive pericarditis (TCP). MethodsA total of 53 patients with TCP and 64 patients with tuberculous exudative pericarditis were enrolled in this retrospective study. The demographic and clinical characteristics were collected, including gender, age, the course of disease and New York Heart Association (NYHA) classification. Besides, echocardiography data also were obtained, including left atrial diameter, left ventricular end-diastolic diameter and left ventricular ejection fraction. In addition, the parameters of electrocardiogram (ECG) were obtained, such as heart rate, the time from the corrected ORS wave origin to T-wave terminal, atrial fibrillation, right bundle branch block, atrial premature beat, and PTFV1 value. ResultsNo significant differences were found in age, gender, the course of disease, echocardiography results, ECG parameters (in addition to PTFV1) between patients with TCP and patients with tuberculous exudative pericarditis. The percentage of patients located in NYHA class IV in the patients with TCP was significantly higher than those of patients with tuberculous exudative pericarditis (p = 0.041). Moreover, the incidence rate of abnormal PTFV1 (≤ -0.04 mm·s) was obviously higher in patients with TCP than those of patients with tuberculous exudative pericarditis (64.2% vs 9.4%, p < 0.001). ConclusionsAbnormal PTFV1 (≤ -0.04 mm·s) is associated with TCP, and PTFV1 may be a potential novel diagnostic indicator for TCP diagnosis.

Relation of Electrocardiographic Left Atrial Abnormalities to Risk of Stroke in Patients with Atrial Fibrillation

The P-wave terminal force in lead V1 (PTFV1) on the 12-lead electrocardiogram (ECG) quantifies left atrial (LA) structural and electrophysiologic abnormalities. We aimed to evaluate the association between PTFV1 and cerebrovascular accident (CVA) as well as LA structure and function in patients with atrial fibrillation (AF). We conducted a cross-sectional study of 229 patients with AF (60 ± 10years, 72% men) with (n = 21) and without (n = 208) a history of CVA, who underwent preablation ECG and cardiac magnetic resonance in sinus rhythm. PTFV1 was defined as the duration (in milliseconds) of the downward deflection of the P wave in lead V1 multiplied by the absolute value of its amplitude (in microvolts) on ECG. PTFV1 is associated with LA minimum volume (Vmin) and left ventricular ejection fraction but not associated with the extent of LA fibrosis quantified by cardiac magnetic resonance late gadolinium enhancement. In addition, PTFV1 is associated with CVA independent of the CHA2DS2-VASc score and LA Vmin (odds ratio 1.23; 95% confidence interval 1.08 to 1.40; p = 0.002). Furthermore, PTFV1 has an incremental value over the CHA2DS2-VASc score as a marker of CVA (p <0.001). In conclusion, ECG-defined PTFV1 is independent marker of stroke in patients with AF and reflects the underlying LA remodeling. Our findings suggest that evaluation of PTFV1 can improve the current risk stratification of stroke.