The Prognostic Importance of Isolated P‐Wave Abnormalities

Abstract

Background: While certain P-Wave morphologies have been associated with abnormal atrial size and either pulmonary or cardiovascular (CV) disease, their relationship to mortality and specific cause of death has not been reported. Methods: Analyses were performed on the first digitally recorded electrocardiogram (ECG) on 43 903 patients at the Palo Alto Veterans Administration Medical Center since 1987. After appropriate exclusions, 40 020 patients remained. Using computerized algorithms, P-wave amplitude and duration in 12 leads as well as several standardized ECG interpretations were extracted. The main outcome measures were pulmonary and CV mortality. Results: During a mean follow-up of 6 years there were 3417 CV and 1213 pulmonary deaths. After adjusting for age and heart rate in a Cox regression model, P-wave amplitude in the inferior leads was the strongest predictor of pulmonary death (hazard ratio [HR]: 3.0, 95% confidence interval [CI]: 2.3-3.9, P < .0001 for an amplitude >2.5 mm), outperforming all other ECG criteria. The depth of P-wave inversion in leads V 1 or V 2 and P-wave duration were strong predictors of CV death (HR: 1.7, 95% CI: 1.5-2.0, P < 0.0001 for a P-wave inversion deeper than 1 mm), outperforming many previously established ECG predictors of CV death. Conclusions: P-wave amplitude in the inferior leads is the strongest independent predictor of pulmonary death while P-wave duration and the depth of P-wave inversion in leads V 1 or V 2 significantly predict CV death. These measurements can be obtained easily and should be considered as part of clinical risk stratification.

Prevalence and Prognostic Significance of Abnormal P Terminal Force in Lead V 1 of the ECG in the General Population

“…2,3 This provides 1 explanation for why we and others [6][7][8][9] have found an association between abnormal PTF and adverse outcomes, given that LAE is linked to death, stroke, congestive heart failure, AF, and left ventricular diastolic dysfunction. 28 As LAE is associated with incident AF, it is possible that the adverse effect of PTF on mortality is mediated solely by increased risk of AF, given the 2-fold risk of death and over 3-fold risk of heart failure and stroke generally associated with AF.…”

“…7 It has also been shown in a large ECG-archive-based study on male veterans that PTF predicts cardiovascular deaths (HR, 1.47) 8 and the relationship strengthens when PTF presents with electrocardiographic LVH (HR, 3.5). 9 However, because of the design of these studies, no adjustments for baseline clinical status could be made.…”

“…A pathological PTF is associated with adverse prognosis after myocardial infarction. 6,7 It has also been shown to be associated with cardiac deaths in male veterans 8 and with increased mortality in male veterans in the presence of signs of left ventricular hypertrophy in the ECG. 9 On the other hand, PTF is a relatively common finding in apparently healthy middle-aged men, 10 male junior elite athletes, 11 and in healthy military recruits.…”

Prognostic significance of P‐wave morphology in patients with coronary artery disease

“…PTF has been shown to predict all‐cause mortality, CV and ischemic heart disease, as well as atrial fibrillation in the general population, and P‐wave axis and P‐wave duration all‐cause and CV mortality in general population. P‐wave abnormalities, such as P‐wave duration and the depth of P‐wave inversion in leads V1 or V2, have been linked with the risk of CV death in male veterans . PTF, P‐wave axis, and P‐wave duration have been shown to predict CV and cardiac event in stroke patients, and P‐wave duration stroke mortality in patients with type 2 diabetes and prevalent nonmajor macrovascular disease .…”

Interatrial block vs left atrial enlargement

“…5,6 Furthermore, the widened P wave has been shown in many clinical studies to be associated with enlarged left atrium, elevated intraleft atrial pressure, elevated left ventricular end-diastolic pressure, reduced cardiac function, and increased mortality. 7 In this journal issue, a group of 12 international experts of ECG presents an article challenging all electrocardiographers with their 2 views: although IAB and LAE frequently coexist, these 2 are 2 separate entities; there are 3 grades of IAB. 8 In this process, important clinical vignettes are presented; IAB, which is a delayed conduction between right and left atria, is a most frequent form of atrial block; IAB occurs in the presence as well as in the absence of left atrial enlargement-and yet, IAB is rarely covered as a separate entity in ECG textbooks.…”