Increased P-wave dispersion predicts recurrent atrial fibrillation after cardioversion
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)
- et al.
Simple electrocardiographic markers for the prediction of paroxysmal idiopathic atrial fibrillation
Am. Heart J.
(1998) - et al.
Dispersion of refractoriness in patients with paroxysmal atrial fibrillation
J. Electrocardiol.
(2002) - et al.
Dispersion of atrial repolarization in patients with paroxysmal atrial fibrillation
Europace
(2001) - et al.
Changes in p-wave dispersion and p-wave duration after open heart surgery are associated with the peak incidence of atrial fibrillation
Heart Lung
(2001) - et al.
Seasonal variation of p-wave dispersion in healthy subjects
J. Electrocardiol.
(2002) - et al.
Transthoracic and transesophageal echocardiographic indices predictive of sinus rhythm maintenance after cardioversion of atrial fibrillation: an echocardiographic study during direct current shock
Echocardiography
(2001) - et al.
Lengthening of intraatrial conduction time in atrial fibrillation and its relation with early recurrence of atrial fibrillation
Jpn. Heart J.
(2001) - et al.
Clinical and electrocardiographic predictors of recurrent atrial fibrillation
Pacing Clin. Electrophysiol.
(2000)
Cited by (59)
Electromechanical Cycle Length Mapping for atrial arrhythmia detection and cardioversion success assessment
2023, Computers in Biology and MedicineClinical value of the combined use of P-wave dispersion and troponin values to predict atrial fibrillation recurrence in patients with paroxysmal atrial fibrillation
2021, Revista Portuguesa de CardiologiaCitation Excerpt :Previous studies have established the clinical value of left atrial size and premature atrial contraction, based on Holter recordings and echocardiography, as predictors of AF.3,4 Additionally, maximum P-wave duration (Pmax) and P-wave dispersion (PWD) have been used to assess the risk of AF.5–8 PWD is defined as the difference between Pmax and minimum P-wave duration (Pmin) recorded by 12-lead surface electrocardiography (ECG).6
P wave dispersion over two decades after its discovery. What the cardiologist should know
2021, REC: CardioClinicsCitation Excerpt :Based on this fact, in the late nineties Dilaveris et al. proposed that the interleads differences in terms of P wave duration could be expressed through a parameter they called P wave dispersion (PWD), which could predict paroxysmal AF in the absence of comorbidities.3 Multiple investigations demonstrate the utility of PWD in predicting AF (Table 1).3-15 In the pioneering study by Dilaveris et al. a cutoff value of 40 ms for PWD separated patients with paroxysmal AF with a sensitivity of 83% and specificity of 85%.3
P-wave Dispersion: Why Should we Turn the Page?
2023, Revista Cubana de Cardiologia y Cirugia CardiovascularStudy of P-wave dispersion in patients of psoriasis: An observational study
2023, IP Indian Journal of Clinical and Experimental Dermatology