A combination of P wave electrocardiography and plasma brain natriuretic peptide level for predicting the progression to persistent atrial fibrillation: comparisons of sympathetic activity and left atrial size
Development of atrial fibrillation (AF) is complexly associated with electrical and structural remodeling and other factors every stage of AF development. We hypothesized that P wave electrocardiography with an elevated brain natriuretic peptide (BNP) level would be associated with the progression to persistence from paroxysmal AF.
P wave electrocardiography such as a maximum P wave duration (MPWD) and dispersion by 12-leads ECG, heart/mediastinum (H/M) ratio by delayed iodine-123 metaiodobenzylguanidine scintigraphic imaging, left ventricular ejection fraction (LVEF), and left atrial dimension (LAD) by echocardiography, and plasma BNP level were measured to evaluate the electrical and structural properties and sympathetic activity in 71 patients (mean ± standard deviation, age: 67 ± 13 years, 63.4 % males) with idiopathic paroxysmal AF.
Over a 12.9-year follow-up period, AF developed into persistent AF in 30 patients. A wider MPWD (>129 ms) (p = 0.001), wider P wave dispersion (>60 ms) (p = 0.001), LAD enlargement (>40 mm) (p = 0.001), higher BNP level (>72 pg/mL) (p = 0.002), lower H/M ratio (≤2.7) (p = 0.025), and lower LVEF (≤60 %) (p = 0.035) were associated with the progression to persistent AF, and the wide MPWD was an independently powerful predictor of the progression to persistent AF with a hazard ratio (HR) of 5.49 [95 % confidence interval (CI) 2.38–12.7, p < 0.0001] after adjusting for potential confounding variables, such as age and sex. The combination of wide MPWD and elevated BNP level was additive and incremental prognostic power with 13.3 [2.16–13, p < 0.0001].
The wide MPWD with elevated BNP level was associated with the progression to persistent AF.
KeywordsP wave duration Brain natriuretic peptide Electrical remodeling Sympathetic nervous system innervation Paroxysmal atrial fibrillation Persistent atrial fibrillation
- 1.Calkins, H., Kuck, K. H., Cappato, R., Brugada, J., Camm, A. J., Chen, S. A., et al. (2012). 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace, 14, 528–606.PubMedCrossRefGoogle Scholar
- 4.Anné, W., Willems, R., Holemans, P., Beckers, F., Roskams, T., Lenaerts, I., et al. (2007). Self-terminating AF depends on electrical remodeling while persistent AF depends on additional structural changes in a rapid atrially paced sheep model. Journal of Molecular and Cellular Cardiology, 43, 148–158.PubMedCrossRefGoogle Scholar
- 6.Todd, D. M., Fynn, S. P., Walden, A. P., Hobbs, W. J., Arya, S., & Garratt, C. J. (2004). Repetitive 4-week periods of atrial electrical remodeling promote stability of atrial fibrillation: time course of a second factor involved in the self-perpetuation of atrial fibrillation. Circulation, 109, 1434–39.PubMedCrossRefGoogle Scholar
- 11.Kallergis, E. M., Manios, E. G., Kanoupakis, E. M., Mavrakis, H. E., Goudis, C. A., Maliaraki, N. E., et al. (2010). Effect of sinus rhythm restoration after electrical cardioversion on apelin and brain natriuretic peptide prohormone levels in patients with persistent atrial fibrillation. The American Journal of Cardiology, 105, 90–4.PubMedCrossRefGoogle Scholar
- 13.Magnani, J. W., Johnson, V. M., Sullivan, L. M., Gorodeski, E. Z., Schnabel, R. B., Lubitz, S. A., et al. (2011). P wave duration and risk of longitudinal atrial fibrillation in persons ≥60 years old (from the Framingham Heart Study). The American Journal of Cardiology, 107, 917–21.PubMedCrossRefGoogle Scholar
- 14.Vassilikos, V., Dakos, G., Chatzizisis, Y. S., Chouvarda, I., Karvounis, C., Maynard, C., et al. (2011). Novel non-invasive P wave analysis for the prediction of paroxysmal atrial fibrillation recurrences in patients without structural heart disease: a prospective pilot study. International Journal of Cardiology, 153, 165–72.PubMedCrossRefGoogle Scholar
- 15.Aytemir, K., Amasyali, B., Kose, S., Kilic, A., Abali, G., Oto, A., et al. (2004). Maximum P-wave duration and P-wave dispersion predict recurrence of paroxysmal atrial fibrillation in patients with Wolff-Parkinson-White syndrome after successful radiofrequency catheter ablation. Journal of Interventional Cardiac Electrophysiology, 11, 21–7.PubMedCrossRefGoogle Scholar
- 20.Tsang, T. S., Gersh, B. J., Appleton, C. P., Tajik, A. J., Barnes, M. E., Bailey, K. R., et al. (2002). Left ventricular diastolic dysfunction as a predictor of the first diagnosed nonvalvular atrial fibrillation in 840 elderly men and women. Journal of the American College of Cardiology, 40, 1636–44.PubMedCrossRefGoogle Scholar