The Signal-Averaged ECG: Clinical Applications

  • J. Anthony GomesEmail author


Although the standard ECG provides substantial information on cardiac electrical activity, it fails to record signals in the microvolt range. Signal averaging technique enables recording and identification of low amplitude signals by improving the signal-to-noise ratio. Thus, the signal-averaged ECG (SAECG) was initially used for noninvasive recording of His bundle potential and subsequently to detect “late potentials” (LPs) for risk assessment for sudden cardiac death (SCD) and/or VT in various clinical settings. However, the initial enthusiasm for the SAECG waned following the results of the MADIT-II Trial that opted the use of ejection fraction (EF) as the main risk stratifying modality. In this chapter, the role of the SAECG in other conditions such as infiltrative heart disease, right ventricular dysplasia, evaluation of syncope, tetralogy of Fallot-associated VT, the Brugada syndrome, post-ablation of VT, and atrial fibrillation is discussed.


Signal-averaged ECG Heart rate variability T wave alternans Fragmented QRS complex Cardiac sarcoidosis Chagas disease Amyloidosis Syncope Tetralogy of Fallot 


  1. 1.
    Perry NW, Childers DG. The human visual evoked response: method and theory. Charles C. Thomas: Springfield; 1969.Google Scholar
  2. 2.
    Hon EH, Lee ST. Noise reduction in fetal electrocardiography. Am J Obst Gynec. 1963;87:1086.Google Scholar
  3. 3.
    Brody DA, Woolsey MD, Arzbaecher RC. Application of computer techniques to the detection and analysis of spontaneous P wave variation. Circulation. 1967;36:359.PubMedGoogle Scholar
  4. 4.
    Berbari EJ, Lazarra R, Samet P, et al. Non-invasive technique for detection of electrical activity during the P-R segment. Circulation. 1963;48:1005.Google Scholar
  5. 5.
    Flowers NC, Hand RC, Orander PC, et al. Surface recording of electrical activity from the region of the His bundle. Am J Cardiol. 1974;133:384.Google Scholar
  6. 6.
    Boineau JP, Cox JL. Slow ventricular activation in acute myocardial infarction. A source of reentrant premature ventricular contractions. Circulation. 1978;40:702.Google Scholar
  7. 7.
    Waldo AL, Kaiser GA. Study of ventricular arrhythmias associated with acute myocardial infarction in the canine heart. Circulation. 1973;47:1222.PubMedGoogle Scholar
  8. 8.
    Scherlag BJ, El-Sherif N, Hope R, Lazzara R. Characterization and localization of ventricular arrhythmias resulting from myocardial ischemia and infarction. Circ Res. 1974;35:372.PubMedGoogle Scholar
  9. 9.
    El-Sherif N, Scherlag BJ, Lazzara R, Hope R. Reentrant ventricular arrhythmias in the late myocardial infarction period I. Conduction characteristics in the infarction zone. Circulation. 1977;56:225.PubMedGoogle Scholar
  10. 10.
    Wit AL, Allessie MA, Bonke FIM, et al. Electrophysiological mapping to determine the mechanism of experimental ventricular tachycardia initiated by premature impulses. Experimental approach and initial results demonstrating reentrant excitation. Am J Cardiol. 1982;49:166–85.PubMedGoogle Scholar
  11. 11.
    Mehra R, Zeiler RH, Gough WB, El-Sherif N. Reentrant ventricular arrhythmiasin the late myocardial infarction period 9. Electrophysiologic-anatomic correlation of reentrant circuits. Circulation. 1983;67:11–24.PubMedGoogle Scholar
  12. 12.
    El-Sherif N, Gough WB, Zeiler RH, Hariman R. Reentrant ventricular arrhythmias in the late myocardial infraction period. 12. Spontaneous versus induced reentry and intramural versus epicardial circuits. J Am Coll Cardiol. 1985;6:124–32.PubMedGoogle Scholar
  13. 13.
    Josephson ME, Horowitz LN, Farshidi A. Continuous local electrical activity. A mechanism of recurrent ventricular tachycardia. Circulation. 1978;57:659–65.PubMedGoogle Scholar
  14. 14.
    Berbari EJ, Scherlag BJ, Hope R, Lazzara R. Recording from ther body surface of arrhythmogenic ventricular activity during the ST segment. Am J Cardiol. 1978;41:697.PubMedGoogle Scholar
  15. 15.
    Fontain G, Gallais-Hamonoo F, Frank R, et al. High amplification electrocardiography in cardiac arrhythmias and conduction defects. In: Verenne A, editor. High amplification electro. Nice: JM Vidalm Crenaf; 1980.Google Scholar
  16. 16.
    Breithardt G, Becker R, Seipel L, Abendroth RR, Ostermeyer J. Noninvasive detection of late potentials in man. A new marker for ventricular tachycardia. Eur Heart J. 1981;2:1.PubMedGoogle Scholar
  17. 17.
    Simson MB. Use of signals in the terminal QRS complex to identify patients with ventricular tachycardia after myocardial infarction. Circulation. 1982;64:225–42.Google Scholar
  18. 18.
    Breithardt G, Borggrefe M, Schwarzmaier J, Karhenn U, Yeh HL, Seipel L. Clinical significance of ventricular late potentials. In: Hombach V, Hilger HH, editors. Signal averaging technique in clinical cardiology. Stuttgart-New York: Schattauer Verlag Publ; 1981. p. 219.Google Scholar
  19. 19.
    Rozanski JJ, Mortara D. Delayed depolarization in patients with recurrent ventricular tachycardia and left ventricular aneurysm. In: Hombach V, Hilger HH, editors. Signal averaging technique in clinical cardiology. Stuttgart-New York: F.K. Schattauer Verlag Publ; 1981. p. 205.Google Scholar
  20. 20.
    Gomes JA, Mehra R, Barreca P, et al. Quantitative analysis of the high-frequency components of signal-averaged QRS complex in patients with acute myocardial infarction: a prospective study. Circulation. 1985;72:105.PubMedGoogle Scholar
  21. 21.
    Breithardt G, Broggrefe M, Haerten K, Trampisch HGJ. Prognostic significance of programmed ventricular stimulation and non-invasive detection of ventricular late potentials in the post-infarction period. Z Kardiol. 1985;74:389.PubMedGoogle Scholar
  22. 22.
    Dennis AR, Richard DA, Cody DV, et al. Prognostic significance of ventricular tachycardia and fibrillation induced at programmed stimulation and delayed potentials detected on the signal-averaged electrocardiograms of survivors of acute myocardial infarction. Circulation. 1986;74:731.Google Scholar
  23. 23.
    Denes P, Santarelli O, Hauser RG, Uretz UF. Quantitative analysis of the high frequency components of the terminal portion of the body surface QRS in nornal subjects and in patients with ventricular tachycardia. Grculation. 1982;67:1129.Google Scholar
  24. 24.
    Gomes JA, Winters SL, Stewart D, et al. Optimal band pass filters or time-domain analysis of the signal-averaged electrocardiogram. Am J Cardiol. 1987;60:1290.PubMedGoogle Scholar
  25. 25.
    Winters SL, Stewart D, Targonski A, Gomes JA. Role of signal averaging of the surface QRS complex in selecting patients with nonsustained ventricular tachycardia and high-grade ventricular arrhythmias for programmed ventricular stimulation. J Am Coll Cardiol. 1988;12:1481–7.PubMedGoogle Scholar
  26. 26.
    Simson MB, Untereker WJ, Spielman SR, et al. Relations between late potentials on the body surface and directly recorded fragmented electrograms in patients with ventricular tachycardia. Am J Cardiol. 1983;57:105.Google Scholar
  27. 27.
    Marcus NH, Falcone RA, Harken AH, et al. Body surface late potentials: Effects of endocardial resection in patients with ventricular tachycardia. Circulation. 1984;70:632–7.PubMedGoogle Scholar
  28. 28.
    Kanovsky MS, Falcone RA, Dresden CA, et al. Identification of patients with ventricular tachycardia after myocardial infarction: Signal-averaged electrocardiogram, Holter monitoring and cardiac catheterization. Circulation. 1984;79:264.Google Scholar
  29. 29.
    Kuchar L, Thorburn CW, Sammel NL. Late potentials detected after myocardial infarction: natural history and prognostic significance. Circulation. 1987;74:1280.Google Scholar
  30. 30.
    Gomes JA, Winters SL, Stewart D, et al. A new noninvasive index to predict sustained ventricular tachycardia and sudden death in the first year after myocardial infarction: based on signal-averaged electrocardiogram, radionuclide ejection fraction and Holter monitoring. J Am ColI Cardiol. 1987;10:349.Google Scholar
  31. 31.
    Zimmerman M, Adamec R, Simonin P, et al. Prognostic significance of ventricular late potentials in coronary artery disease. Am Heart J. 1985;109:725.Google Scholar
  32. 32.
    Freedman RA, Gillis AM, Keren AM, et al. Signal averaged electrocardiogram late potentials in patients with ventricular fibrillation or ventricular tachycardia: correlation with clinical arrhythmias and electrophysiologic study. Am J Cardial. 1985;55:1350.Google Scholar
  33. 33.
    Nalos PC, Gang ES, Mandel WJ. The signal-averaged electrocardiogram as a screening test for inducibility of sustained ventricular tachycardia in high risk patients: a prospective study. J Am Coll Cardial. 1987;9:539.Google Scholar
  34. 34.
    Buckingham TA, Ghosh S, Homan SM, et al. Independent value of signal averaged electrocardiography and left ventricular function in identifying patients with sustained ventricular tachycardia with coronary artery disease. Am J Cardiol. 1987;159:568.Google Scholar
  35. 35.
    Buckingham TA, Thessen CC, Stevens LL, Redd RM, Kennedy HL. Effect of conduction defects on the signal averaged electrocardiographic determination of late potentials. Am J Cardiol. 1988;61:1265–71. (Change reference to book and read the chapter).PubMedGoogle Scholar
  36. 36.
    Breithardt G, Cain M. EI-SherifN, Flowers NC et at standards for analysis of ventricular late potentials using high resolution or signal averaged electrocardiography, a statement by a Task Force Committee of the European Society of Cardiology, The American Heart Association and The American College of Cardiology. Circulation. 1991;83:1481.PubMedGoogle Scholar
  37. 37.
    Cain ME, Ambos RD, Witkoski FX. Sobel BR Fast-Fourier transform analysis of signal averaged electrocardiograms for identification of patients prone to sustained ventricular tachycardia. Circulation. 1984;69:711.PubMedGoogle Scholar
  38. 38.
    Turitto G, Caref EB, Macina G, et al. Time course of ventricular arrhythmias and the signal averaged electrocardiogram in the post-infarction period: a prospective study of correlation. Br Heart J. 1988;60:17–22.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Haberl R, Tilge CA, Pulter R, Steinbeck G. Spectral mapping of the electrocardiogram in the Fourier transform for identification of patients with sustained ventricular tachycardia and coronary artery disease. Eur Heart J. 1989;10:316.PubMedGoogle Scholar
  40. 40.
    Gatzoulis KA, Carlson MD, Biblo LA, et al. Time domain analysis of the signal averaged electrocardiogram in patients with a conduction defect or a bundle branch block. Eur Heart J. 1995;16:1912–9.PubMedGoogle Scholar
  41. 41.
    Marchlinski FE, Callans DJ, Gottlieb CD, Zado E. Linear ablation lesions for control of unmappable ventricular tachycardia in patients with ischemic and nonischemic cardiomyopathy. Circulation. 2000;101:1288–96.PubMedGoogle Scholar
  42. 42.
    Hsia HH, Marchlinski FE. Characterization of the electroanatomic substrate for monomorphic ventricular tachycardia in patients with nonischemic cardiomyopathy. J Pacing Clin Electophys. 2002;26(7):1114–27.Google Scholar
  43. 43.
    Hsia HH, Lin D, Sauer WH, et al. Anatomic characterization of endocardial substrate for hemodynamically stable reentrant ventricular tachycardia: identification of endocardial conducting channels. Heart Rhthm. 2006;3:503–12.Google Scholar
  44. 44.
    Moss AJ, Zareba W, Hall WJ, et al. Multicenter automatic defibrillator implantation trial II investigators. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346:877–83. [PMID: 11907286].PubMedPubMedCentralGoogle Scholar
  45. 45.
    Bailey JJ, Berson AS, Handelsman H, Hodges M. Utility of current risk stratification tests for predicting major arrhythmic events after myocardial infarction. J Am Coll Cardiol. 2001;38:1902–11.PubMedGoogle Scholar
  46. 46.
    Gomes JA, Cain ME, Buxton AE, Josephson ME, Lee KL, Hafley GE. Prediction of long-term outcomes by signal-averaged electrocardiography in patients with nonsustained ventricular tachycardia, coronary artery disease, and left ventricular dysfunction. Circulation. 2001;104:306–441.Google Scholar
  47. 47.
    Bigger JT Jr, Whang W, Rottman JN, et al. Mechanisms of death in the CABG Patch trial: a randomized trial of implantable cardiac defibrillator prophylaxis in patients at high risk of death after coronary artery bypass graft surgery. Circulation. 1999;99:1416–21.PubMedGoogle Scholar
  48. 48.
    Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Circulation. 2018;138(13):e210–71. Scholar
  49. 49.
    Breithardt G, Cain ME, El-Sherif N, et al. Standards for analysis ofventricular late potentials using high-resolution or signal-averaged electrocardiography: a statement by a task force committee of the European Society of Cardiology, the American Heart Association, and the American College of Cardiology. J Am Coll Cardiol. 1991;17:999–1006.PubMedGoogle Scholar
  50. 50.
    Winters SL, Cohen M, Greenberg S, et al. Sustained ventricular tachycardia associated with sarcoidosis: assessment of the underlying cardiac anatomy and the prospective utility of programmed ventricular stimulation, drug therapy and an implantable antitachycardia device. J Am Coll Cardiol. 1991;18:937–43.PubMedGoogle Scholar
  51. 51.
    Yodogawa K, Seino Y, Ohara T, et al. Non-invasive detection of latent cardiac conduction abnormalities in patients with pulmonary sarcoidosis. Circ J. 2007;71:540–5.PubMedGoogle Scholar
  52. 52.
    Yodogawa K, Seino Y, Ohara T, et al. Prognostic significance of ventricular late potentials in patients with pulmonary sarcoidosis. Heart Rhythm. 2018;15:798–802.PubMedGoogle Scholar
  53. 53.
    Chagas C. ArchivfuirSchifs-und Tropenhygiene. 1909;13:120–2.Google Scholar
  54. 54.
    Lewinsohn R. Carlos Chagas and the discovery of Chagas’s disease (American trypanosomiasis). J R Soc Med. 1981;74:451–5.PubMedPubMedCentralGoogle Scholar
  55. 55.
    Ribeiro AL, Cavalvanti PS, Lombardi F. Prognostic value of signal-averaged electrocardiogram in Chagas disease. J Cardiovasc Electrophysiol. 2008 May;19(5):502–9.PubMedGoogle Scholar
  56. 56.
    Reisinger J, Dubrey SW, Lavalley M, et al. Electrophysiologic abnormalities in AL (primary) amyloidosis with cardiac involvement. Am Coll Cardiol. 1997;30:1046–51.Google Scholar
  57. 57.
    Simon W. Dubrey, Seth Bilazarian Michael La Valley. Signal-averaged electrocardiography in patients with AL (primary) amyloidosis. Am Heart J 1997;134 (6):994–1001.Google Scholar
  58. 58.
    Bussani R, De-Giorgio F, Abbate A, Silvestri F. Cardiac metastases. J Clin Pathol. 2007;60:27–34.PubMedPubMedCentralGoogle Scholar
  59. 59.
    Bruce CJ. Cardiac tumours: diagnosis and management. Heart. 2011;97:151–60.PubMedGoogle Scholar
  60. 60.
    Yusuf SW, Bathina JD, Qureshi S, et al. Cardiac tumors in a tertiary care cancer hospital: clinical features, echocardiographic findings, treatment and outcomes. Heart Int. 2012;7:e4.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Al-Mamgani A, Baaijens BL, et al. Cardiac metastases. Int J Clin Oncol. 2008;13:369–72.PubMedGoogle Scholar
  62. 62.
    Reynen K, Köckeritz U, Strasser RH. Metastases to the heart. Ann Oncol. 2004;15:375–81.PubMedGoogle Scholar
  63. 63.
    Butany J, Leong SW, Carmichael K, Komeda M. A 30-year analysis of cardiac neoplasms at autopsy. Can J Cardiol. 2005;21:675–80.PubMedGoogle Scholar
  64. 64.
    Marcus FI, McKenna WJ, Sherrill D, et al. Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria. Circulation. 2010;121:1533–41.PubMedPubMedCentralGoogle Scholar
  65. 65.
    Nava A, Folino AF, Bauce B, et al. Signal-averaged electrocardiogram in patients with arrhythmogenic right ventricular cardiomyopathy and ventricular arrhythmias. Eur Heart J. 2000;21:58–65.PubMedGoogle Scholar
  66. 66.
    Protonotarios N, Tsatsopoulou A, Anastasakis A, et al. Genotypephenotype assessment in autosomal recessive arrhythmogenic right ventricular cardiomyopathy (Naxos disease) caused by a deletion in plakoglobin. J Am Coll Cardiol. 2001;38:1477–84.PubMedGoogle Scholar
  67. 67.
    Gomes JA, Winters SL, Martinson M. Signal averaged ECG in the diagnosis of syncope. In: Gomes JA, editor. Signal averaged electrocardiography. Concepts, methods and applications. London: Kluwer Academic Publishers; 1993.Google Scholar
  68. 68.
    Steinberg JS, Prystowsky E, Freedman RA, et al. Use of the signal-averaged electrocardiogram for predicting inducible ventricular tachycardia in patients with unexplained syncope: Relation to clinical variables in a multivariate analysis. J Am Coll Cardiol. 1994;23(1):99–106.PubMedGoogle Scholar
  69. 69.
    Brili S, Aggeli C, Gatzoulis K, et al. Echocardiographic and signal averaged ECG indices associated with non-sustained ventricular tachycardia after repair of tetralogy of Fallot. Heart. 2001;85:57–60.PubMedPubMedCentralGoogle Scholar
  70. 70.
    Stelling JA, Danford DA, Kugler JD, et al. Late potentials and inducible ventricular tachycardia in surgically repaired congenital heart disease. Circulation. 1990;82:1690–6.PubMedGoogle Scholar
  71. 71.
    Ikeda T, Sakurada H, Sakabe K, et al. Assessment of noninvasive markers in identifying patients at risk in the Brugada syndrome: insight into risk stratification. J Am Coll Cardiol. 2001;37:1628–34.PubMedGoogle Scholar
  72. 72.
    Sacher F, Jesel L, Jais P, Haissaguerre M. Insight into the mechanism of Brugada syndrome: epicardial substrate and modification during ajmaline testing. Heart Rhythm. 2014;11:732–4.PubMedGoogle Scholar
  73. 73.
    Szel T, Antzelevitch C. Abnormal repolarization as the basis for late potentials and fractionated electrograms recorded from epicardium in experimental models of Brugada syndrome. J Am Coll Cardiol. 2014;63:2037–45.PubMedPubMedCentralGoogle Scholar
  74. 74.
    Abe A, Kobayashi K, Yuzawa H, et al. Comparison of late potentials for 24 hours between Brugada syndrome and arrhythmogenic right ventricular cardiomyopathy using a novel signal-averaging system based on Holter ECG. Circ Arrhythm Electrophysiol. 2012;5:789–95.PubMedGoogle Scholar
  75. 75.
    Yoshioka K, Amino M, Zareba W, et al. Identification of high-risk Brugada syndrome patients by combined analysis of late potential and T-wave amplitude variability on ambulatory electrocardiograms. Circ J. 2013;77:610–8.PubMedGoogle Scholar
  76. 76.
    Morita M, Zipes DP, Morita ST, Lopshire JC, Wu J. Epicardial ablation eliminates ventricular arrhythmias in an experimental model of Brugada syndrome. Heart Rhythm. 2009;6:665–71.PubMedGoogle Scholar
  77. 77.
    Nademanee K, Veerakul G, Chandanamattha P, et al. Prevention of ventricular fibrillation episodes in Brugada syndrome by catheter ablation over the anterior right ventricular outflow tract epicardium. Circulation. 2011;123:1270–9.PubMedGoogle Scholar
  78. 78.
    Brugada J, Pappone C, Berruezo A, et al. Brugada syndrome phenotype elimination by epicardial substrate ablation. Circ Arrhythm Electrophysiol. 2015;8:1373–81.PubMedGoogle Scholar
  79. 79.
    Nademanee K, Raju H, De Noronha S, et al. Fibrosis, connexin 43, and conduction abnormalities in the Brugada syndrome. J Am Coll Cardiol. 2015;66:1976–86.PubMedPubMedCentralGoogle Scholar
  80. 80.
    Zhang P, Tung R, Zhang Z, et al. Characterization of the epicardial substrate for catheter ablation of Brugada syndrome. Heart Rhythm. 2016;13:2151–8.PubMedGoogle Scholar
  81. 81.
    Breithard G, Seipel L, Ostermeyer L, et al. Effects of antiarrhythmic surgery on late ventricular potentials recorded by precordial signal averaging in patients with ventricular tachycardia. Am Heart J. 1982;104:996–1003.Google Scholar
  82. 82.
    Denniss AR, Johnson DC, Richards DA, et al. Effect of excision of ventricular myocardium on delayed potentials detected by the signal averaged electrocardiogram in patients with ventricular tachycardia. Am J Cardiol. 1987;59:591–5.PubMedGoogle Scholar
  83. 83.
    Dinov B, Bode K, Koenig S, et al. Signal-averaged electrocardiography as a noninvasive tool for evaluating the outcomes after radiofrequency catheter ablation of ventricular tachycardia in patients with ischemic heart disease: reassessment of an old tool. Circ Arrhythm Electrophysiol. 2016;9:e003673.PubMedGoogle Scholar
  84. 84.
    Ogawa H, Inoue T, Yoshida A, et al. The signal averaged electrocardiogram of P wave in patients with documented atrial fibrillation or flutter and in patients with left or right atrial overload without atrial fibrillation. Jpn Heart J. 1993;34:29.PubMedGoogle Scholar
  85. 85.
    Stafford PJ, Turner I, Vincent R. Quantitative analysis of signal-averaged P waves in idiopathic paroxysmal atrial fibrillation. Am J Cardiol. 1991;68:751.PubMedGoogle Scholar
  86. 86.
    Guidera SA, Steinberg JS. The signal-averaged P wave duration: a rapid and non-invasive marker of risk of atrial fibrillation. J Am Coll Cardiol. 1993;21:1645.PubMedGoogle Scholar
  87. 87.
    Chan EKY, Steinberg JS, Santoni-Rugiu F, et al. P wave signal averaged electrocardiography techniques. Ann Noninvasive Electrocardiol. 1998;3:147.Google Scholar
  88. 88.
    Yamada T, Fukunami M, Ohmori M, et al. Characteristics of frequency content of atrial signal-averaged electrocardiograms during sinus rhythm in patients with paroxysmal atrial fibrillation. J Am Coll Cardiol. 1992;19:559.PubMedGoogle Scholar
  89. 89.
    Ehrlich JR, Zhang GQ, Israel CW, Hohnloser SH. P-wave signal averaging-ECG: normal values and reproducibility. Z Kardiol. 2001 Mar;90(3):170–6.PubMedGoogle Scholar
  90. 90.
    Fukunami M, Yamada T, Ohmori M, et al. Detection of patients at risk for paroxysmal atrial fibrillation during sinus rhythm by P wave-triggered signal-averaged electrocardiogram. Circulation. 1991 Jan;83(1):162–9.PubMedGoogle Scholar
  91. 91.
    Abe Y, Fukunami M, Yamada T, et al. Prediction of transition to chronic atrial fibrillation in patients with paroxysmal atrial fibrillation by signal- averaged electrocardiography. Circulation. 1997;96:2612.PubMedGoogle Scholar
  92. 92.
    Barbosa EC, Benchimol-Barbosa PR, de Souza Bomfim A, et al. Reversal atrial electrical remodeling following cardioversion of long-standing lone atrial fibrillation. Arq Bras Cardiol. 2009;93(3):199–205.Google Scholar
  93. 93.
    Raitt MH, Kusumoto W, Giraud G, McAnulty JH. Reversal of electrical remodeling after cardioversion of persistent atrial fibrillation. J Cardiovasc Electrophysiol. 2004;15:507–12.PubMedGoogle Scholar
  94. 94.
    Guo XH, Gallagher MM, Poloniecki J, Yi G, Camm AJ. Prognostic significance of serial P wave signal-averaged electrocardiograms following external electrical cardioversion for persistent atrial fibrillation: a prospective study. Pacing Clin Electrophysiol. 2003;26:299–304.PubMedGoogle Scholar
  95. 95.
    Chalfoun N, Harnick D, Pe E, Undavia M, Mehta D, Gomes JA. Reverse electrical remodeling of the atria post cardioversion in patients who remain in sinus rhythm assessed by signal averaging of the P-wave. Pacing Clin Electrophysiol. 2007;30:502–9.PubMedGoogle Scholar
  96. 96.
    Steinberg JS, Zelenkofske S, Wong SC, et al. The value of the P wave signal-averaged electrocardiogram for predicting atrial fibrillation after cardiac surgery. Circulation. 1993;88:2618.PubMedGoogle Scholar
  97. 97.
    Niemerovsky D, Hutter R, Gomes JA. The electrical substrate of vagal atrial fibrillation as assessed by the signal-averaged electrocardiogram. PACE. 2008;31:308–13.Google Scholar

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Authors and Affiliations

  1. 1.Icahn School of MedicineMount Sinai HospitalNew YorkUSA

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