Türk Kardiyol Dem Arş 2002; 30: 758-762
Increased P-Wave Duration and P-Wave Dispersion in Patients With Aortic St~nosis
Hasan TURHAN, M.D., Ertan
YETKİN*,M.D., Kubilay
ŞENEN,M.D., Mehmet
İLERi,M.D., Ramazan AT AK, M.D., Asuman
BİÇER,M.D., Hatice
ŞAŞMAZ,M. D., Sengül
ÇEHRELİ*,M.D., Erdal DURU, M.D., Emine KÜTÜK, M.D.
Turkey's Hospitalfor Advanced
Specialization, Ankara,
İnönüUniversity, Medical Faculty, Malatya*. Turkey
AORT DARLIKLI HASTALARDA
ARTMIŞP-DALGA
SÜRESİVE P-DALGA
DİSPERSİYONU
ÖZET
Maksimum ve minimum P-dalga süreleri
arasındakifark olarak
tamnı/ananP-dalgadispersiyonu
(PDD)'nwıpa- roksismal atriyal fibrilasyonu (AF) öngörmede
kullamş/ı olduğu bildirilmiştir.AF, aort
darlık/ı hastalardaen
sıkaritmidir ve klinik bo zulma için önemli bir prognostik göstergedir. Bu
çalışmadaamaç aort
darlıklthastalarda P-dalga dispersiyonunu
değerlendirmekti. Çalışmapopu- lasyonu iki grup içeriyordu. Grup I dejeneratif aort dar-
lık/ı
98 hasta (76 erkek,
22 kadın, yaş63±8
yıl)ve grup ll herhangi bir kardiyovasküler
hastalığı.bulunmayan
yaşve cinsiyet
açısındanbirebir
eşleştirilmiş98
sağlıklıbirey
içeriyordı1. Çalışmaya dalıiledilen
tüm
lıireylerin12-deri- vasyonlu
elektrokardiyogramıçekildi. Yüzeyel elektrokar- diyogramm
tüm derivasyonlannda P-dalgasüresi ölçül- dü. Maksimum ve minimum P-dalga süresi arasmdaki fark PDD olarak
tammlandı.Tüm hastalar ve kontrol bi- reyleri sol atrium
çapı,sol ventrikül ejeksiyonfraksiyonu, sol ventrikül duvar
kalınlıklan.maksimum ve ortalama aort gradiyenti ölçümü için ekokardiografi ile
değerlendirildi. Aynca hastalar dökümente paroksismal AF
varlığı acısından değerlendirildi.Grup /'e ait maksimum P-dalga süresi (126 ms) ve PDD grup 1/'den
anlamlıderecede da- ha yüksek bulundu (p<O.OOOI ). Buna ek olarak, paraksis- mal AF'u bulunan hastalar (130 ms) bulunmayanlara (1 21 ms) göre
anlamlıderecede daha yüksek maksimum P-dalga süresine ve PDD 'na sahipti (p<O.OOJ ). Minimum
P-dalga süresi açtsmdan ikigrup arasmda
anlamlıfark yoktu (p>0 .05). Ekokardiografik
değişkenler/ePDD'u
arasında anlamlı
korelasyon yoktu. Sonuç olarak,
artmış paroksisnıalAF riskini gösteren PDD'u aort
darlıklthas-
talarda, aort darlığıbulunmayan hastalardan
anlamlıde- recede daha y üksek bulundu.
Ağıraort
darlık/ıhastalarda paroksismal AF'u
öngördiirnıedePDD'mm klinik kullam-
labilirliğinin
daha ileri
değerlendirilmesiiçin daha uzun dönem prospektif
çalışmalara ihtiyaç vardır. Tiirk Kardiyol Dem Arf 2002; 30: 758-762Atıalıtar kelime/er:
Aort
darlığı,P-dalga dispersiyonu, atriyal fibrilasyon
Received date: 1 May 2002, Accep,ted date: 1 1 December 2002 Corresponding address: Hasan Turhan,
Türkocağıcad. 20. sok., no:2/2 Balgat, 06520 Ankara, Turkey
Phone: +90 312 286 76 58 e-mail: drhturhan@yahoo.com
758
P wave dispersion (PWD), defined as the difference between m aximum and minimum P wave duration, is a new electrocardiographic marker that has been associated with inhomogeneous and di scontinuous propagation of sinus impul ses (1,2). The co rrelation between the presence of inte ratria l and intraatrial conduction abnormalities and the induction of pa- roxysmal atrial fibrillation (AF) has been well docu- mented (3.4). In addition, prolonged P wave duration and increased PWD are commonly found in patie nts with a history of paroxysmal AF (2,5,6). AF, whether chronic or paroxysmal, is the most common sus tai- ned arrhythmia encountered in the elinical practice that produces subs tantial excess cardiovascular mor- bidity and mortality (7,8). Th e estimation of the pro- bability of a patient developing frequent AF pa- roxysm s might guide the elinician in the m anage- ment of paroxysmal AF. Aortic s tenosis (AS) is the m ost common ca use of left ventric ular outflow tract obstruction (9). AF is the m ost common
arrhythnıiaseen in patients with sever e AS (10).
Furthernıore,it is an important prognostic indicator for elinical dete- rioration in patients with AS (9).
The aim of the present study was to investigate a new electrocardiogr aphic marker, PWD, in patients w ith severe AS. To our knowledge, this is the
firsıstudy on the effects of AS on PWD.
METHODS Study population
This prospective study consisted of two groups: Group
:consisted of 98 patients w ith degenerative AS (76 men,
2~women; aged 63±8 years) and group II consisted of 98
agıand sex matched subjects (76 men, 22 women; aged
62±~years) wh o underwent coronary angiography in our cardio logy clinic and considered as healthy subjects without
an~cardiovascular disease. All patients underwe nt selectivc coronary angiography. At the time of electrocardiographi<
recording, all subjects were in sinus rhythm, and non e o
H. Tur/ımı er al.: lncreased P-Wave Duration and P-Wave Dispersion in Patiems Wir/ı Aortic Stenosis
them were taking any type of antiarrhythmic agent. Pati- enis who had coronary artery disease, hypertension, mode- rate to severe aorıic regurgitation, more than mild mitral regurgitation, mitral stenosis, diabetes mellitus, hyperth- yroidism, pericardial effusion, chronic obstructive pulmo-
. nary disease, ventricular preexcitation, atrioventricular
conduction abnormalities, or abnormal serum electrolytes were excluded from the study.
Electrocardiographic measurement
Twelve-lead elecırocardiogram was recorded for each su b- . ject at a rate of 50 mm/s in the supine posiiion by a 6- channel recorder (Hewlett Packard page writer, Model M I 772A, USA). Electrocardiograms were coded and all an- notations were masked. The measurements of the P wave duralian were performed manually by two of the investi- gators w ithout knowledge of the elinical status of the pati- enis and controls. To improve accuracy, measurements were performed w ith calipers and magnifying lens for de- fining the electrocardiographic deflection. P wave duration was measured from the onset to the offset of the P wave.
The onset and offset of the P wave were defined as the junction between the P wave pattern and isoelectric line.
After completion of the measurements, all electrocardiog- rams were decoded. PWD was defined as the difference
bcıween maximum and minimum P wave duration (2), Int- raobserver and interobserver coefficients of variation were
~ound to be 4.1% and 4.4% for PWD, respectively. All pa- tients were evaluated for the presence of documented pa- roxysmal AF on a 12-lead electrocardiogram during their
pası medical history. Electrocardiographic diagnosis of pa-
roxysınal AF was made according to Bellet's definition (lll.
Paroxysmal AF was diagnosed in a patient with a history of rccurrent episodes of AF tasıing >2 minules and < 7 day s.
Echocardiographic evaluation
Transthoracic echocardiographic examination was perfor- med for each subject. Maximum and mean aortic gradienıs
were calculated by Doppler studies. Color flow Doppler was used to detect the presence of mitral and aortic regur- gitation. Lefı atrial diameıer, left ventricular end diastolic and end sistolic diameters, left ventricular ejection fracti- on, and left ventricular wall thicknesses were measured by M-mode echocardiography. Pulıno-
enıs with AS. A p value < 0.05 was considered statistically significant.
RESULTS
There was no statistically significant difference bet- ween 2 groups in respec t to age a nd gender (P>0.05 ). Eight patients (8%) were d iagnosed as ha- ving doc ume nted paroxysmal AF with the eval ua ti- on of their pas t medical histo ry. Echocardiographic variables were simila r in patients with and without pa roxysmal AF (table 1). Maximum P wave duration and PWD of gro up I were found to be signifi cantly highe r than th ose of group II (p<O.O OO 1, tab le 2).
However, the re was no s tatistically s ignifica nt d iffe- rence between group I a nd grou p II regarding mini- mum P wave duration (p> 0.05, table 2). Patients with AS and paroxysmal AF had higher maximum P wave duration and PWD than those without paroxy- sma l AF (p<O.O OI, table 3). There was no statisti- cally significant d iffe rence between the val ues of minimum P wave duratio n in patients with and wit- hout paroxysmal AF (p>0.05, table 3). We found no s ignificant correlation between PW D and echocardi- ographic variables inclu ding left atrial diameter, ma- ximum and mean aortic grad ie nts, left ventricular posterior wall and interventricular septal thicknesses and left ventricular ejection fraction (p>0.05 for all).
DISCUSSION
In this study, we found that patients w ith AS have longer maximum P wave d urat ion a nd higher PWD than healthy control s ubjects . Besides, pa tients with AS an'd paroxysmal AF have higher values of maxi-
nary artery systolic pressure was calculated by the help of continuous wave Doppler studies using the Bernoulli equaıion.
Table 1. Echocardiographic variables of patients wiUı and without paroxysmal atrial
fıbrillation
Statistical analysis
All nuıneric variabtes were expres- sed as ınean±sd and categorical va- riables were expressed as percenta- ge. Statistical analysis was perfor- med using unpaired t test, Mann- Whitney U test and Chi-square test where appopriate, and Pearson cor- relation test was used to deıermine
the carretatian between PWD and echocardiographic variabtes in pati-
Variable
Maximum aorıic gradient (mmHg) Mean aortic gradient (mmHg)
Thickness of iııterventricular septum (cııı)
Thickness of posıerior wall (cm) Lcft atrial diameter (cm)
Lefı ventricular ejection fracıioıı (%)
AF: Atrial fibrillation, NS: Nonsignificant
Patients with paroxysmal AF
(n=8)
82±7 43±6 1.43±0.12 1.34±0.14 3.8±0.52 66±5
Patients without paroxysmal AF p
(n=90)
78±6 NS
42±7 NS
1.38±0.14 NS 1.32±0.09 NS 3.8±0.65 NS
66±6 NS
Tiirk Kardiyol Dem Arş 2002; 30: 758-762
Table 2. Electrocardiographic variables in patients with aortic ste-
nosis and in healthy control subjectsVariable Control Patient with subjects aortic stenosis
P minimum (m s) 76±8 78±7
P maximum (m s) 1 08±7 1 26±8 P -w ave dispersion (m s) 32±5 48± 5
NS: Nonsignificant, P minimum: Minimum P-wave duration, P maxinwm: Maximum P-wave durationp
NS
<0.0001
<0.0001
Tab1e
3.E1 ectrocardiographic variabtes in patients with and without paroxysma1 atrial fibrillation
Variable Paroxysmal Paroxysma1
AF(-) AF(+)
p
P
minimum ( ms) 78±8 78±7 NS
P
m aximum (m s) 1 21 ±8 1 30±8 <0.001
P-wave
dispersion (ms) 43.L5 52±5 <0.0 01
AF: Atrialjibrillation, NS: Nonsignificall/, P minimımı: MinimumP-ıvave duration, P maximum: Maximum P-wave duration
muın
P wave duration and PWD than those w
ithoutparoxysmal AF. An interestin g findin g of thi s study is that there is no signif icant correlation between PWD and echocardiogra phic variables .
PWD is a new electrocardiographic marker that has been associated with the inhomogeneous and discon- tinuous propagation of sin us im pulses (1 ,2). Prolon- gation of intraatrial and
interatrialconduc tion time and inhomogeneous propagation of sinus impulses are well known electrophysiologic characteris tics in patients w ith paroxysma
lAF
(1,2).M oreover, the correlation betw een th e presenc e of intraa tria
lco- duction abnormalities and the induction of paroxy- smal AF has bee n we ll docume nted (3, 1 2). This elect- rophysiologic characteris tic results
in increasedPWD on electrocardiographic measure ments . The re- fore, PWD can be used to
separate patients with a high risk of AF durin g sin us rhythm
(12).Degene rative calcific AS is now the most comme n c ause of Jeft ventricular outflow tract o bstru cti on in adults (9)_ AF is the most common arrhythmia and an important prognostic indicator for elinical de r eriora- tion in patients with aorti c stenosis (9,10,1 3)_ AF in a patient with severe AS res ults in
Joss of the atrial contribution to
left ventricular fillin g, which causes a pr ecipitous decline in cardiac output and aggrevati-
760
on of symptoms (9). The esrimation of the probabi-
lity of a patient developing frequ ent AF paroxysms might guide the clinicia n in the management of pa- roxysmal AF.
P wave duration and PWD have been re ported to be influe nced by the auton omic to ne, whic h indu- ces changes in the velocity of
inıpulsepropagation (14). Furthermore, AF, either
interınittentor chro- n
ic, may be influenced by autonomic activity
(15).
Ra mirez-Gil et al
(16)have shown increased symp athetic activity in patients with AS. In add iti- on, Somsen et al (17) have reported that in a ca ndi- tion of cardiac pressu re or volume overload, sympathetic activity is enhanced. Furthermore, Tü- kek et al (1 8)
have reported thatincreased sympat- hetic activity causes a significant increase in PWD.
As a result of this findings, we can suggest th at increased sympathetic activity may be the underl- ying cause of higher PWD in patie nts with severe AS.
The elevation of left ventric ular end-dias
tolic pres~sure , which is characteristic of severe AS, often ref- lects diminished complia nce of the hypertro ph ied left ventricul ar wall (1 9,20). Increased left ventricular end-diastolic pressure in patie nts with severe aortic stenos is causes elevation of the left atrial pressure.
A s in all ca rdiac chambers, elevated intracavita ry pressure may results in hypertrophy of that cav ity.
The development of myocardi al fibrosis has been shown in hypertens ive patie nts (21). Therefore, AS may alte r the anatomic structures and electrical acti- vity of the atrium as in hyperte ns ive patie nts
(22).Myocardial fibrosis may be responsible of heteroge- neity of struc tural and electrophysiologic pro perties of the atrial myocardium. Consequently, propagation of s inus
İnıpulsesmay become inh omogeneous and discontinuous, resulring in prolonged P-wave
duratİon and inc reased PWD.
We found no s ignificant corre lation between PWD
and echocardiographic variables (left atrial di ameter,
leftventricular ejectio n fraction, thickness of inter-
ve ntricular septum and posterior wall, maximum and
mean
acıticgradients). In addi tion, patie nts with
andwithout paro xysmal AF had similar echocardiograp-
hic variab les (table 1 ). Previous
authorshave sug-
gested that left atrial dimension (23-26), left ventricu-
lar dysfunction (23), and presence of organic heart di
-H. Turhan et al.: lncreased P-Wave D uration and P-Wave Dispersion in Patienrs W ith Aorric Stenosis
sease
(27)could predict paroxysmal AF. However, our patients had a preserved left ventric ular function, and a more or less normal mean left atrial max imal diameter. Recently, we have reported that PWD in patie nts with mitral stenosis is not relate d with left atrial diameter and the decrease in PWD after PMBV is not correlated with the improvement in le ft atrial diam eter, mitral valve area, mean mitral gradi- ent and left atrial pressure
(28).Although some aut- hors
(18,26)reported that left atrial di ameter is a sig- nificant predictor of AF episodes, some others
(1,29,30)
have reported that left atrial maximal
dİameter is not a significant predictor of paroxysmal AF.
In conclusion, PWD, indicating increased risk for paroxysmal AF, is s ig nificantly higher in patients with AS than in healthy control subjects. In addition, PWD in patients with AS assoc iated with paroxy- smal AF is signi ficantly higher than those without paroxysmal AF. Further assessment of the elinical utility of PWD for the prediction of paroxysmal AF in patients with severe AS will require longer pros- p ective studies.
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