P Wave Duration/P Wave Voltage Ratio Plays a Promising Role in the Prediction of Atrial Fibrillation: A New Player in the Game.

BACKGROUND: Atrial fibrillation (AF) is the most common sustained arrhythmia in clinical practice. Identification of patients at risk for developing AF and the opportunity for early targeted intervention might have a significant impact on morbidity and mortality. Prolonged P wave duration and decreased P wave voltage have been shown to be independent predictors of AF. The present study aimed to investigate the role of P wave duration/P wave voltage in predicting new-onset AF. METHODS: We screened a total of 640 consecutive patients who admitted to cardiology outpatient clinic with a complaint of palpitation between 2012 and 2014. 24-h Holter monitoring, echocardiography, and electrocardiography (ECG) recordings were reviewed to identify new-onset AF. Patients were assigned into two groups based on presence (n = 150) and absence (n = 490) of new-onset AF. Previous ECGs with sinus rhythm were analyzed. P wave duration was measured in inferior leads, and P wave voltage was measured in lead one. P wave duration/P wave voltage was also calculated for each patient. RESULTS: One hundred fifty subjects (23.4%) had new-onset AF among 640 patients. P wave duration (123.27 ± 12.87 vs. 119.33 ± 17.39 ms, p=0.024) and P wave duration/P wave voltage (1284.70 ± 508.03 vs. 924.14 ± 462.06 ms/mV, p < 0.001) were higher, and P wave voltage (0.12 ± 0.04 vs. 0.13 ± 0.04 mV, p < 0.001) was significantly lower in the new-onset AF group compared with non-AFs. P wave duration/P wave voltage, with a cut off of 854.5 ms/mV, had 83.3% sensitivity and 62.0% specificity in a receiver operating characteristic curve (AUC 0.728, 95% CI 0.687-0.769; p < 0.001). Their negative and positive predictive values were 78.7% and 68.6%, respectively. In a univariate regression analysis, age, smoking, C-reactive protein, brain natriuretic peptide, left atrial diameter, left atrial volume index, P wave duration, P wave voltage, and P wave duration/P wave voltage were significantly associated with the development of new-onset AF. Moreover, smoking (OR 4.008, 95% CI 1.707-9.409; p=0.001), left atrial volume index (OR 7.108, 95% CI 4.400-11.483; p < 0.001), and P wave duration/P wave voltage (OR 1.002, 95% CI 1.000-1.003; p=0.044) were found to be significant independent predictors of new-onset AF in a multivariate analysis, after adjusting for other risk parameters. CONCLUSION: The P wave duration/P wave voltage ratio is a practical, easy-to-use, cheap, and reliable electrocardiographic parameter, which can play a promising role for both in predicting and elucidating a mechanism of new-onset AF.

Impact of postdischarge care fragmentation on clinical outcomes and survival following transcatheter aortic valve replacement.

BACKGROUND: The study aimed to evaluate the prognostic impact of postdischarge care fragmentation in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS: A total of 266 patients undergoing TAVR due to severe aortic stenosis were included in this retrospective cohort study. Patients were assigned to one of two groups based on presence (n = 104) and absence (n = 162) of postdischarge care fragmentation. Fragmented care was defined as at least one readmission to a site other than the implanting TAVR center within 90 days. Prognostic impact of care fragmentation on clinical outcomes and predictors of long-term mortality were investigated. RESULTS: Increased major vascular complication (16.3 vs 8.0%, p = 0.037), permanent pacemaker implantation (14.4 vs 6.2%, p = 0.025), and acute kidney injury (22.1 vs 14.2%, p < 0.001) were reported in the fragmented care group. Although early mortality (6.7 vs 4.3%, p = 0.152) was similar between groups, there was a significant difference in 5­year mortality (66.3 vs 45.7%, p < 0.001). In a univariate regression analysis fragmented care, age, chronic obstructive pulmonary disease, pulmonary artery systolic pressure, and paravalvular leakage were significantly associated with 5­year mortality. Fragmented care (hazard ratio [HR] 1.510, 95% confidence interval [CI] 1.080-2.111; p = 0.016), age (HR 1.024, 95% CI 1.001-1.048; p = 0.045), paravalvular leakage (HR 1.863, 95% CI 1.076-3.228; p = 0.026), and chronic obstructive pulmonary disease (HR 1.616, 95% CI 1.114-2.344; p = 0.012) were found to be significant independent predictors of 5­year mortality in a multivariate analysis, after adjusting for other risks. CONCLUSION: Fragmented care has a significant prognostic impact on clinical outcomes and survival.