Signal-averaged P wave: predictor of atrial fibrillation

Abnormalities of the P wave seen during sinus rhythm are associated with atrial fibrillation and other supraventricular arrhythmias. Intra-atrial conduction delays can be seen on the surface ECG as P wave prolongation, which is more visible with averaging techniques used in advanced recording devices. Averaging followed by amplification after proper filtering of the electrical signal should allow more precise measurements of duration and amplitude of the P wave. Data on reproducibility, filter settings, required number of beats, and precise definitions of onset and offset are dependent largely on the system used, which can be QRS or, preferably, P wave triggered. This explains conflicting data in the literature. It is clear that P wave duration is one of the best predictors of perioperative atrial fibrillation. For paroxysmal forms, the data are less convincing. Root mean square voltages of the P wave can be useful. Combining the P wave duration with other data often improves the diagnostic value of signal averaging. Standardization of the techniques appears to be necessary.