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Novel electrocardiographic classification for stroke prediction in atrial fibrillation patients undergoing
Arto Relander1, Ilkka Ruohonen1, Samuli Jaakkola1
1Heart Center, Turku University Hospital and University of Turku, Turku, Finland.
Insights
Electrocardiographic P-wave abnormalities effectively predict stroke or systemic embolism (SSE) in atrial fibrillation (AF) patients after cardioversion. This novel P-wave classification offers valuable prognostic insights for AF management.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Diagnostics
Background:
- Atrial fibrillation (AF) and stroke are linked to abnormal atrial myocardium conduction, structure, and function.
- The predictive value of electrocardiographic (ECG) indices for stroke or systemic embolism (SSE) post-cardioversion (CV) in AF patients, particularly low-risk individuals, is not well-established.
Purpose of the Study:
- To systematically evaluate P-wave abnormalities (PWAs) for predicting SSE risk 30 days and long-term after CV in AF patients.
- To develop and validate a novel ECG-based classification for PWA.
Main Methods:
- Manual review of 1773 ECGs from AF patients undergoing acute CV.
- Derivation of a composite PWA variable using 30-day post-CV data.
- Long-term validation of ECG findings in non-anticoagulated patients and histopathologic analysis of atrial appendage biopsies.
Main Results:
- A composite PWA variable combining prolonged P-wave, deflected P-wave morphology in lead II, biphasic P-waves in inferior leads, and increased P-terminal force demonstrated optimal performance.
- In the validation cohort, extensive PWA predicted SSE (adjusted hazard ratio, 2.1 per category; P < .001) over a median follow-up of 4.9 years.
- The combination of PWA and CHA₂DS₂-VASc score showed superior predictive ability for SSE (AUC 0.86 at 3 years). Extensive PWA correlated with interstitial fibrosis.
Conclusions:
- A novel electrocardiographic PWA classification provides significant additional prognostic information for AF patients.
- This classification can aid in risk stratification and management decisions for AF patients undergoing cardioversion.
Background:
Abnormal conduction, structure, and function of the atrial myocardium predispose to atrial fibrillation (AF) and stroke. The usefulness of electrocardiographic indices in predicting stroke or systemic embolism (SSE) in patients undergoing cardioversion (CV) for AF remains unknown, especially in those at low estimated risk.
Objective:
We systematically evaluated the performance of various P-wave abnormalities (PWAs) in predicting SSE 30 days after CV (derivation cohort) and in the long term (validation cohort).
Methods:
Electrocardiograms (n = 1773) of AF patients undergoing an acute CV were manually reviewed. The 30-day post-CV data were used to derive a composite PWA variable. The electrocardiographic findings were validated by the long-term follow-up of patients with no anticoagulation. Electrocardiograms of 27 CAREBANK study patients with right atrial appendage biopsies were further analyzed for histopathologic validation.
Results:
During data derivation, the best performance was found with a combination of prolonged P-wave (≥180 ms), deflected P-wave morphology in lead II, biphasic P-waves in inferior leads, or increased P-terminal force (≥80 mm·ms) as markers for extensive PWA. In the validation cohort, 219 of 874 (25.1%) had extensive PWA. During a median follow-up of 4.9 years, there were 51 patients (5.8%) with SSE in total. In a competing risk model, PWA predicted SSE (adjusted hazard ratio, 2.1 per category; 95% CI, 1.4-3.1; P < .001). Areas under the curve for SSE at 3 years were 0.77, 0.79, and 0.86 for PWA, CHA2DS2-VASc, score, and their combination, respectively. On histologic evaluation, extensive PWA was associated with interstitial fibrosis (P = .033).
Conclusion:
Novel electrocardiographic PWA classification provided additional prognostic insight in AF patients.
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