Risk Of Paroxysmal Atrial Fibrillation Research Articles

The Effects of Blood Pressure Lowering on P-Wave Dispersion in Patients with Hypertensive Crisis in Emergency Setting

Hypertensive emergency refers to a severe hypertension (HT) that is associated with new or progressive end-organ damage. In these clinical situations, blood pressure (BP) should be reduced immediately to prevent or minimize organ dysfunction. The present study evaluated the diagnostic value of two electrocardiographic indices in detecting patients, who are at risk for paroxysmal atrial fibrillation (PAF), in the setting hypertensive crisis. The study population consisted of 30 consecutive patients aged ≥40 years, who were admitted to the emergency room with hypertensive crisis. Electrocardiographic (ECG) recordings of the patients were performed before and after the treatment. The minimum (Pmin) and maximum (Pmax) P wave duration on ECG, and P-wave dispersion (Pd), which was defined as the difference between Pmin and Pmax, were measured. The mean Pd was 118.0 ± 32.1 and 94.0 ± 44.3 before and after the treatment, respectively. The decrease observed in the mean Pd was statistically significant (p = 0.005). The mean Pmax was 214.7 ± 37.1 before the treatment, while it was 194.0 ± 47.3 after the treatment, and the difference was significant (p = 0.021). The mean Pmin was 96.7 ± 26.3 and 100.0 ± 41.0 before and after the treatment, respectively; however, the difference was not significant (p = 0.624). Pmax and Pd display significant changes with acute treatment of HT. There is a need for larger prospective studies to clearly elucidate the diagnostic value of ECG indices, Pmax and Pd as indicators of future PAF.

Response to Letter by Stahrenberg et al

HomeStrokeVol. 41, No. 3Response to Letter by Stahrenberg et al Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse to Letter by Stahrenberg et al Laurent Suissa David Bertora Sylvain Lachaud and Marie Hélène Mahagne Laurent SuissaLaurent Suissa Centre Hospitalier Universitaire de Nice, Hôpital Saint Roch, Unité Neurovasculaire, Nice, France Search for more papers by this author David BertoraDavid Bertora Centre Hospitalier Universitaire–Hôpital Pasteur, Service de Cardiologie, Nice, France Search for more papers by this author Sylvain LachaudSylvain Lachaud Centre Hospitalier Universitaire de Nice, Hôpital Saint Roch, Unité Neurovasculaire, Nice, France Search for more papers by this author and Marie Hélène MahagneMarie Hélène Mahagne Centre Hospitalier Universitaire de Nice, Hôpital Saint Roch, Unité Neurovasculaire, Nice, France Search for more papers by this author Originally published4 Feb 2010https://doi.org/10.1161/STROKEAHA.109.575092Stroke. 2010;41:e170Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 4, 2010: Previous Version 1 Response:We thank Stahrenberg et al for the interest shown in our research letter.1 Dr Stahrenberg et al have emphasized the necessity for a score making it possible to target patients at high risk for paroxysmal atrial fibrillation, the more difficult documentation of which is restricted to the availability of expensive equipment and patient compliance. Dr Stahrenberg et al support a multicentric validation study, an important step for proposing screening algorithms of atrial fibrillation with an optimized cost–benefit ratio in the checkup for secondary prevention of cerebral infarction.Dr Stahrenberg et al underline that the score is based on a sample of unselected patients and might be less successful in the documentation of episodes of paroxysmal arrhythmia. In this preliminary study, we did not make the distinction between permanent arrhythmia and paroxysmal arrhythmia for which the embolic risk and the thromboembolic risk factors are the same to obtain a profile consistent with routine activity. Note that in the absence of this distinction, the diagnosis of arrhythmia in the initial electrocardiogram did not assume permanence of the disorder. Our multivariate model is compatible with the literature of cerebral infarction associated with atrial fibrillation.2 Score for the Targeting of Atrial Fibrillation (STAF) expresses these data in score form. As Dr Stahrenberg et al emphasize, the dilatation of the left atrium is a criterion of remodeling depending on the duration of the atrial fibrillation. It also appears to be the result of echographic anomalies (left valvulopathy, left ventricular dysfunction, and left ventricular hypertrophy) associated with the documentation of atrial fibrillation in our univariate analysis. Thus, this echographic item retained in our score does not reflect only the prolonged nature of the arrhythmia. It is also correlated with the etiologies and the cardiological thromboembolic factors of the atrial fibrillation independently of its permanent or paroxysmal nature. The other 3 clinic radiological items forming the score do not have reasons to be influenced by the nature of the arrhythmia, permanent or not. The undocumented 30% rate of patients in atrial fibrillation on admission does not seem to us to be negligible when it is known that the approach for detection of arrhythmia is often limited to a 24-hour Holter electrocardiogram that may be put in the wrong by its low sensitivity.3 Because of this, we have tested the STAF reproducibility in this subgroup. The sensitivity and specificity observed in this sample according to the total of the score can be superimposed on the calculated values on all patients.STAF has not been proposed to replace the tools for documentation of atrial fibrillation. We support the necessity for validating the score on a multicentric population and optimizing its predictive capacity. In the absence of current recommendations, it indeed, by its negative predictive value, could help the clinician on screening atrial fibrillation with an optimized cost–benefit ratio. The STAF II perspective will perhaps use the implementation of biological markers as recent literature data suggest.4DisclosuresNone.1 Suissa L, Bertora D, Lachaud S, Mahagne MH. Score for the Targeting of Atrial Fibrillation (STAF): a new approach to the detection of atrial fibrillation in the secondary prevention of ischemic stroke. Stroke. 2009; 40: 2866–2868.LinkGoogle Scholar2 Kimura K, Minematsu K, Yamaguchi T. Atrial fibrillation as a predictive factor for severe stroke and early death in 15,831 patients with acute ischaemic stroke. J Neurol Neurosurg Psychiatry. 2005; 76: 679–683.CrossrefMedlineGoogle Scholar3 Liao J, Khalid Z, Scallan C, Morillo C, O'Donnell M. Noninvasive cardiac monitoring for detecting paroxysmal atrial fibrillation or flutter after acute ischemic stroke: a systematic review. Stroke. 2007; 38: 2935–2940.LinkGoogle Scholar4 Montaner J, Perea-Gainza M, Delgado P, Ribo M, Chacon P, Rosell A, Quintana M, Palacios ME, Molina CA, Alvarez-Sabin J. Etiologic diagnosis of ischemic stroke subtypes with plasma biomarkers. Stroke. 2008; 39: 2280–2287.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails March 2010Vol 41, Issue 3 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.109.575092 Originally publishedFebruary 4, 2010 PDF download Advertisement

Triggering of Nocturnal Arrhythmias by Sleep-Disordered Breathing Events

This study sought to evaluate respiratory disturbances as potential triggers for arrhythmia in patients with sleep-disordered breathing (SDB). SDB is associated with an increased risk of atrial fibrillation and nonsustained ventricular tachycardia (NSVT) as well as a predilection for sudden cardiac death during nocturnal sleeping hours. However, prior research has not established whether respiratory disturbances operate as triggers for nocturnal arrhythmias. Overnight polysomnograms from the Sleep Heart Health Study (n = 2,816) were screened for paroxysmal atrial fibrillation and NSVT. We used the case-crossover design to determine whether apneas and/or hypopneas are temporally associated with episodes of paroxysmal atrial fibrillation or NSVT. For each arrhythmia, 3 periods of sinus rhythm were identified as control intervals. Polysomnograms were examined for the presence of respiratory disturbances, oxygen desaturations, and cortical arousals within a 90-s hazard period preceding each arrhythmia or control period. Fifty-seven participants with a wide range of SDB contributed 62 arrhythmias (76% NSVT). The odds of an arrhythmia after a respiratory disturbance were nearly 18 times (odds ratio: 17.5; 95% confidence interval: 5.3 to 58.4) the odds of an arrhythmia occurring after normal breathing. The absolute rate of arrhythmia associated with respiratory disturbances was low (1 excess arrhythmia per 40,000 respiratory disturbances). Neither hypoxia nor electroencephalogram-defined arousals alone increased arrhythmia risk. Although the absolute arrhythmia rate is low, the relative risk of paroxysmal atrial fibrillation and NSVT during sleep is markedly increased shortly after a respiratory disturbance. These results support a direct temporal link between SDB events and the development of these arrhythmias.

P-wave dispersion in endogenous and exogenous subclinical hyperthyroidism

The aim of this study was to measure maximum P wave duration (Pmax) and P wave dispersion (PWD), which can be indicators for the risk of paroxysmal atrial fibrillation when increased, and to reveal their relationship with thyroid hormone levels in patients with endogenous and exogenous subclinical hyperthyroidism. Seventy-one patients with sublinical thyrotoxicosis (34 endogenous, 37 exogenous) and 69 healthy individuals were enrolled in the study. Pmax and minimum P wave duration (Pmin) on electrocardiogram recordings were measured and PWD was calculated as Pmax-Pmin. Pmax (p<0.001) and PWD (p<0.001) values were significantly higher in patients with endogenous subclinical hyperthyroidism compared with the control group. Pmax (p<0.001) and PWD (p<0.001) values were significantly higher in patients with exogenous subclinical thyrotoxicosis compared with the control group. Pmax (p=0.710) and PWD (p=0.127) were not significantly different in patients with endogenous subclinical hyperthyroidism compared with exogenous subclinical hyperthyroid patients. Pmax and PWD negatively associated with TSH in endogenous and exogenous subclinical hyperthyroidism. In the present study, we observed that Pmax and PWD were longer in patients with endogenous and exogenous subclinical hyperthyroidism. Lack of a difference in Pmax and PWD between patients with endogenous and exogenous subclinical hyperthyroidism seems to support the idea that hormone levels rather than the etiology of thyrotoxicosis affect the heart.

EFFECT OF ANAESTHETIC AGENTS ON P‐WAVE DISPERSION ON THE ELECTROCARDIOGRAM: COMPARISON OF PROPOFOL AND DESFLURANE

Anaesthetics influence cardiac electrical activity by various mechanisms; thus, they may have pro-arrhythmic or anti-arrhythmic actions. Increased P-wave dispersion is associated with a risk of paroxysmal atrial fibrillation. The aim of the present study was to analyse the impact of propofol and desflurane on changes in P wave dispersion, which may reflect the anti-arrhythmic effects of these drugs. Fifty patients undergoing scheduled surgery were included in the study. Patients were divided into two equal groups: a propofol group and a desflurane group. Patients in the propofol group were initially administered 2.5 mg/kg propofol, followed by infusion of 6 mg/kg per h propofol. Anaesthesia in the desflurane group was achieved using inhalation induction, with concentrations up to 8-12.5 vol%. When signs of adequate anaesthesia were observed, the concentration of desflurane was reduced to 6 vol%. An electrocardiogram (ECG) was obtained before induction and then again 1, 3 and 5 min after the initiation of propofol infusion or the induction of anaesthesia in the desflurane group; additional measurements were performed after tracheal intubation. P-wave dispersion was assessed by differences in maximal and minimal P-wave duration on a 12-lead ECG. P-wave dispersion did not change over time in the desflurane group. In the propofol group, there was a significant decrease in P-wave dispersion after 3 and 5 min of anaesthesia. Significant differences were observed between study groups after 1, 3 and 5 min of anaesthesia, and disappeared after tracheal intubation. Mean and maximal P-wave duration did not change in either group. In conclusion, propofol decreases P-wave dispersion and this seems to be connected with the anti-arrhythmic properties of the drug.

Gender Differences of P Wave Signal Averaged Electrocardiograms: Based on the Risk of Atrial Fibrillation

Background and Objectives: Certain types of arrhythmias have gender differences. Women have a higher incidence of drug-induced QT prolongation than in men. However, there are no reports regarding gender-related differences of the P wave signal averaged electrocardiogram (PWSAE), based on the risk of atrial fibrillation (AF). PWSAE has been recognized as a diagnostic tool for identifying the risk of paroxysmal atrial fibrillation (PAF). We therefore investigated the influence of gender in the parameters of PWSAE and in the risk of AF. Subjects and Methods: We recorded 100 PWSAEs in apparently healthy Korean subjects (53 men and 47 women), aged 20 to 79 years. Results: The mean age of the male subjects was 38.2 years and the mean age of the female subjects was 43.2 years (p=0.19). The body surface area (BSA) were larger in men (1.83 m 2 vs. 1.53 m 2 , p<0.05). In men, the filtered P wave duration (fPD) was longer than in women (136.8 msec vs. 125.2 msec, p<0.05). The root mean square voltage in the terminal 20 ms of the filtered P wave (RMS20) was 5.9 μV in women and 4.5 μV in men (p<0.05). Conclusion: Men have a longer fPD and lower RMS20 than women. The BSA showed a positive correlation with fPD and a negative correlation with RMS20. This study suggests that BSA is an important factor for fPD and RMS20. In addition, as men have a larger BSA as compared with women, we suspect that men have a higher risk of AF as compared with women. (Korean Circ J 2007;37:656-662)

High Prevalence of Paroxysmal Atrial Fibrillation and/or Atrial Flutter in Metabolic Syndrome

Because metabolic syndrome is associated with cardiovascular diseases, its association with the risk of paroxysmal atrial fibrillation (PAF) and/or atrial flutter (PAFL) was examined in the present study. A prospective analysis was performed in 592 consecutive hospitalized patients without obvious structural heart diseases. Sinus rhythm was confirmed by electrocardiography in all patients. PAF/PAFL occurred in 32 (5%) and metabolic syndrome was present in 127 (21%) of the patients enrolled. PAF/PAFL occurred in 12 (9%) of the patients with metabolic syndrome, but only 20 (4%) of patients without metabolic syndrome (p=0.02). Multivariate logistic regression analysis showed that metabolic syndrome was a significant risk factor for PAF/PAFL that was independent of left atrial diameter (> 44 mm) or age (> 70 years) (odds ratio (OR) 2.8, 95% confidence interval (CI) 1.3-6.2, p<0.01). Among the 5 components of the metabolic syndrome, body mass index > or = 25 kg/m2 was the most strongly associated with PAF/PAFL (OR; 3.0, 95% CI 1.2-7.4, p=0.02). Metabolic syndrome is highly associated with PAF/PAFL in patients without structural heart diseases and obesity may be an underlying mechanism for the higher prevalence.

Seasonal variation in paroxysmal atrial fibrillation documented by 24-hour Holter electrocardiogram

The incidence of various cardiovascular diseases is known to exhibit seasonal variations, but seasonal patterns of paroxysmal atrial fibrillation (AF) have not been well characterized. The objective of this study was to determine whether seasonal variation affects the incidence of paroxysmal AF and whether this pattern is affected by patient age. We identified 258 paroxysmal AF episodes in 237 patients (age 65 +/- 14 years, mean +/- standard deviation; age range 16-95 years) among 12,390 consecutive 24-hour Holter electrocardiogram recordings obtained from 2001 to 2005 at our institute. Seasonal variations were analyzed by both month and by season. The relative risk (RR) of AF for each period was determined as being high or low in relation to the overall mean incidence. The association among clinical covariates and risk of paroxysmal AF was tested by logistic regression analysis. The incidence of paroxysmal AF was highest in September (RR = 1.40, 95% confidence interval [CI] 1.36-1.44) and lowest in June (RR = 0.52, 95% CI 0.50-0.54), with an RR difference of 63% (P < .001) among all patients. Patients aged > or =65 years demonstrated a peak incidence in September (RR = 1.46, 95% CI 1.41-1.51) and a minimum in June (RR = 0.55, 95% CI 0.52-0.58), while those aged <65 years showed a peak incidence in December (RR = 1.33, 95% CI 1.27-1.39) and a minimum in June (RR = 0.49, 95% CI 0.45-0.53). The incidence of paroxysmal AF also showed an autumn peak (RR = 1.21, 95% CI 1.16-1.27) and a summer minimum (RR = 0.66, 95% CI 0.62-0.70), with an RR difference of 53% (P < .001) among all patients. This seasonal variation in paroxysmal AF did not differ between patients of different age ranges. Clinical covariates including underlying disease or medications did not influence the monthly or seasonal variation in paroxysmal AF. There was a significant inverse relationship between the incidence of paroxysmal AF and the length of daylight in patients aged <65 years (r = -0.57, P < .05). There was a significant seasonal variation in paroxysmal AF, with maximum and minimum incidences in autumn and summer, respectively, and this pattern was not age dependent.

Effect of haemodialysis on signal-averaged electrocardiogram P-wave parameters

The P-wave signal-averaged electrocardiogram (SAECG) is a non-invasive technique considered to indicate an increased risk for paroxysmal atrial fibrillation. The study was designed to evaluate the effect of the haemodialysis (HD) process on SAECG parameters in the group of selected HD patients. Forty-seven HD patients (without relevant cardiac diseases) were included. SAECGs were performed pre- and post-dialysis together with evaluating extracellular body water (ECW) by using bioimpedance and biochemical measurements. For each SAECG, filtered P-wave duration (FPD) and root mean square voltage of the final 20 ms of filtered P-wave (RMS20) were established. The duration of either pre- or post-dialysis FDP was higher in HD patients than in the control group (P<0.001 and P = 0.005, respectively). The voltage of either pre- or post-dialysis RMS20 was reduced in HD patients compared with controls (P<0.001 in both cases). HD induced a decrease in the duration of the FDP and a significant increase in the voltage of RMS20 (P<0.001 in both cases). Stepwise multiple regression identified independent predictors of pre- and post-dialysis FDP as: (1) age; (2) pre- and post-dialysis ECW/kg body weight, respectively and; (3) pre- and post-dialysis haemoglobin levels, respectively. In the case of RMS20, we did not find any independent predictors either pre- or post-dialysis. Our study revealed that P-wave SAECG parameters are abnormal in a significant portion of HD patients and improved with HD process. We have also demonstrated that patients' age, volume status as well as the presence of anaemia are important factors influencing P-wave SAECG parameters in HD patients.

757 Raised NT-pro ANP plasma levels is independently associated with an increased risk for paroxysmal atrial fibrillation in hypertensive patients

757 Raised NT-pro ANP plasma levels is independently associated with an increased risk for paroxysmal atrial fibrillation in hypertensive patients

757 Raised NT-pro ANP plasma levels is independently associated with an increased risk for paroxysmal atrial fibrillation in hypertensive patients

757 Raised NT-pro ANP plasma levels is independently associated with an increased risk for paroxysmal atrial fibrillation in hypertensive patients

High levels of brain natriuretic peptide and prolonged P-wave dispersion are associated with an increased risk of paroxysmal atrial fibrillation in hypertensive patients

High levels of brain natriuretic peptide and prolonged P-wave dispersion are associated with an increased risk of paroxysmal atrial fibrillation in hypertensive patients

Raised BNP is indepently associated with an increased risk for paroxysmal atrial fibrillation in hypertensive patients

Raised BNP is indepently associated with an increased risk for paroxysmal atrial fibrillation in hypertensive patients

P wave signal averaged ECG and chemoreflexsensitivity in paroxysmal atrial fibrillation

Detailed analysis of the QRS-complex and autonomic dysfunction can identify patients at risk to suffer from ventricular arrhythmias. To determine whether patients at risk for paroxysmal atrial fibrillation (PAF) could be identified while in sinus rhythm, a P wave triggered signal averaged ECG and an analysis of the autonomic function by chemoreflexsensitivity (CHRS) were examined. The ratio between the difference of RR intervals in the ECG and the venous partial pressure of oxygen before and after 5-min oxygen inhalation was measured for the determination of CHRS. We examined 224 patients (group A) who suffered from PAF, 250 patients (group B) without arrhythmic history and 30 young volunteers (group C). The filtered P wave duration (FPD) was significantly longer in group A than in group B (140.9±21.0 vs. 118.2±9.4 ms, p<0.0001) or C (105.2±14.1 ms, p<0.0001) while the root mean square voltage of the last 20 ms of the P wave (RMS 20) was significantly lower in group A than in group B (2.68±1.12 vs. 4.06±1.57 μV, p<0.0001) or C (3.97±1.36 μV, p<0.0001). Atrial late potentials (ALP) were defined as a FPD>120 ms and a RMS 20≤3.5 μV. ALP could identify patients of group A with a specificity of 78% and a sensitivity of 83%. Patients with PAF (2.32±1.15 ms/mm Hg) showed a significantly lower CHRS than group B (4.14±1.58 ms/mm Hg, p<0.0001) or group C (4.98±1.51 ms/mm Hg, p<0.0001). The sensitivity for the presence of atrial fibrillation was 71% for a CHRS below 3.0 ms/mm Hg with a specificity of 70%. A combination of both methods showed a specificity of 85% and a sensitivity of 65% when ALP and pathological CHRS were present. The results of our study suggest that risk of atrial fibrillation could be detected by P wave signal averaged ECG and CHRS. An analysis of CHRS seems to be an appropriate method to demonstrate a neurovegetative imbalance, which might be one possible trigger mechanism.

Left atrial volume and the risk of paroxysmal atrial fibrillation in patients with hypertrophic cardiomyopathy

Paroxysmal atrial fibrillation (PAF) is a common complication of patients with hypertrophic cardiomyopathy, often leading to acute or progressive heart failure and cerebral infarction. We assessed the echocardiographic data of 141 consecutive patients with hypertrophic cardiomyopathy, with and without PAF. In all, 31 patients (22%) had a history of PAF with spontaneous conversion to in sinus rhythm. Left atrial volume and left atrial volume indexed to body surface area were significantly increased for patients with PAF compared with those without PAF. Maximum left atrial volume was the most sensitive and specific parameter for the occurrence of PAF in patients with hypertrophic cardiomyopathy.

Association between P-wave dispersion and left atrial dimension in hypertensive patients at risk for paroxysmal atrial fibrillation

P-317 Key Words: P Wave Dispersion, LA Dimensions, Hypertension

1037-144 Left atrial volume and the risk of paroxysmal atrial fibrillation in patients with hypertrophic cardiomyopathy

1037-144 Left atrial volume and the risk of paroxysmal atrial fibrillation in patients with hypertrophic cardiomyopathy

P-053 detection of hypertensive patient at risk for paroxysmal atrial fibrillation by manual measurements of P-wave dispersion dyring sinus rhythm

P-053 detection of hypertensive patient at risk for paroxysmal atrial fibrillation by manual measurements of P-wave dispersion dyring sinus rhythm

P-053 detection of hypertensive patient at risk for paroxysmal atrial fibrillation by manual measurements of P-wave dispersion dyring sinus rhythm

P-053 detection of hypertensive patient at risk for paroxysmal atrial fibrillation by manual measurements of P-wave dispersion dyring sinus rhythm

Duration of the P Wave and P Wave Dispersion in Subclinical Hyperthyroidism

To determine whether the values for P wave dispersion (Pdis) and adjusted Pdis, which are simple noninvasive electrocardiographic markers to detect paroxysmal atrial fibrillation, differ in patients with endogenous subclinical hyperthyroidism in comparison with those in healthy control subjects. We measured the maximal P wave duration and the difference between the maximal and the minimal P wave duration (Pdis) from the 12-lead surface electrocardiogram of 36 patients with endogenous subclinical hyperthyroidism and of 22 age- and sex-matched healthy control subjects. Adjusted Pdis (Pdis/square root of the number of measured electrocardiographic leads) was also calculated from each electrocardiogram. The minimal P wave duration was significantly shorter in patients with subclinical hyperthyroidism than in healthy control subjects (P<0.001). Pdis and adjusted Pdis were also significantly higher in the patient group than in the control subjects (P<0.05). By univariate analysis, only thyrotropin levels were found to be associated with adjusted Pdis (r = -0.28; P = 0.03). Pdis and adjusted Pdis differed in patients with endogenous subclinical hyperthyroidism in comparison with those values in healthy control subjects. Thus, these simple electrocardiographic markers may be useful for identifying patients with endogenous subclinical hyperthyroidism who are at risk for paroxysmal atrial fibrillation.