Increased P-wave dispersion predicts recurrent atrial fibrillation after cardioversion

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Abstract

Atrial fibrillation (AF) will recur in a number of patients treated with cardioversion. Being able to identify reliable risk factors would be useful for making management decisions. P-wave dispersion (PWD) is an electrocardiographic measurement, which reflects a disparity in atrial conduction. P-wave dispersion has been shown to be increased in patients with paroxysmal AF. This pilot study aims to determine the role of PWD in predicting AF recurrence in patients who underwent elective cardioversion. Forty-five patients who were successfully cardioverted for persistent AF were included for study. Eighteen patients had a PWD greater than 80 ms; of these 13 had AF recurrence. Of the 25 patients with PWD less than 80 milliseconds, 12 had recurrent AF. P-wave dispersion values greater than 80 milliseconds were found more frequently in patients with AF recurrence (P = .05), supporting the use of this parameter in predicting return of AF. Larger studies are needed for further evaluation.

Introduction

Synchronized cardioversion for atrial fibrillation (AF) has an initial high rate of success, but at least half of these patients will revert to AF. Up to 57% of AF recurrences after cardioversion take place during the first 30 days after direct current shock therapy [1]. Akyurek and colleagues [2] demonstrated that intraatrial conduction delay may be an important factor in atrial electrical remodeling and thus be responsible for the induction or maintenance of AF.

The prolongation of intraatrial and interatrial conduction time and the nonhomogeneous propagation of sinus impulses are thought to be increased in patients with paroxysmal AF. P-wave dispersion (PWD) is the difference between the maximum and minimum P-wave duration calculated on a standard 12-lead electrocardiogram (ECG); a prolonged value may reflect nonuniform intra- and interatrial conduction. Dilaveris et al [3], [4] and Tukek et al [5] concluded that a PWD of 40 milliseconds separated patients with paroxysmal AF from control subjects, with a sensitivity of 83% and a specificity of 85%. Andrikopolous et al [6] also found that a PWD greater than 40 milliseconds was characteristic of patients with idiopathic AF. Tukek and colleagues determined that PWD was increased in patients with paroxysmal AF and normal-sized atria, whereas normal counterparts with enlarged atrial chambers had only an elevation in PWD. In the paroxysmal AF group the PWD was found to be 62 ± 12 milliseconds [7].

We sought to determine whether PWD obtained immediately after cardioversion for AF was able to predict recurrence. Manios et al [8] had suggested that the changes in the electrical properties of the atria might take place after cardioversion. To date the predictive role of PWD in patients cardioverted for persistent AF remains unknown.

Section snippets

Methods

From October 1999 to July 2002, the records of all patients who underwent elective cardioversion for AF were reviewed. Patients with persistent AF were included for study if they were successfully cardioverted to sinus rhythm. Subjects who failed cardioversion were excluded. The 12-lead ECGs used to measure PWD were obtained after the cardioversion immediately after or on the same day. P-wave dispersion was measured manually across all 12 leads with a magnifying lens. This value was calculated

Results

The records of 81 patients were reviewed. Thirty-six patients failed cardioversion; the remaining 45 patients were successfully cardioverted to sinus rhythm. These patients comprised the study group. Sixty-four percent of these subjects had AF for greater than 6 months. All patients were men, which reflects the patient population of this type of facility. The mean age was 67.4 ± 10 years. The most prevalent comorbidity was hypertension. Baseline demographics are described in Table 1. Class 3

Discussion

The premise of a prolonged PWD is to measure the heterogeneity in atrial refractoriness, which may reflect vulnerability to AF. Invasive studies have demonstrated a disparity in atrial refractoriness in patients with AF [9], [10]. In our series, a value of 80 milliseconds or greater was both a univariate and independent predictor for AF recurrence. Indirect clinical studies support this basis of nonhomogenous conduction and refractoriness measured in the form of an increased PWD serving as a

Conclusions

Prolonged PWD might represent altered atrial substrate. Although the study is comparatively small, we can surmise that a PWD greater than 80 milliseconds correlates with a higher risk of AF after cardioversion, but a larger prospective study is needed.

References (16)

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