In order to evaluate if sinus node activity can be detected by surface ECG, at
least 200 sinus beats of 3 bipolar orthogonal leads (horizontal, vertical, and
sagittal position) were averaged in 33 consecutive patients (mean age: 58 ± 19
years). Each lead signal (0.5-300 Hz) was independently averaged triggering P
wave by the template-comparing method and then filtered (0.5-25 Hz) and
amplified. In 29 patients (88%), amplification revealed the presence of a progressive
upstroke slope beginning during the isoelectric line and ending at the
earliest observed atrial activation in the 3 nonamplified and nonfiltered leads
(mean voltage: 9.3 ± 6.4 pV). Such pre-P signal was always lost with 50-Hz
high-pass filtering, and could be present in 1 or more leads; in the latter case,
the longest duration was considered. The length of pre-P signal proved to be
strictly correlated (r = 0.9932, p < 0.001) with that contemporaneously furnished
by the direct intra-atrial recording of sinus node electrogram (0.05-35
Hz, mean of at least 20 measurements). Mean values of noninvasive and invasive
pre-P lengths were 76 ± 29 and 74 ± 30 ms, respectively. In conclusion,
it seems possible to detect from surface ECG a pre-P activity whose character
and timing are well correlated to those obtained by endocavitary recording of
sinus node signal. These findings suggest the possibility of a clinical use of
noninvasive sinus node activity recording for diagnostic purposes.