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      P-wave Dispersion for Predicting Paroxysmal Atrial Fibrillation in Acute Ischemic Stroke

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          Abstract

          Background: Detection of paroxysmal atrial fibrillation (PAF) in acute ischemic stroke patients poses diagnostic challenge. The aim of this study was to predict the presence of PAF by means of 12-lead ECG in patients with acute ischemic stroke. Our hypothesis was that P-wave dispersion (P d) might be a useful marker in predicting PAF in patients with acute ischemic stroke.

          Methods: 12-lead resting ECGs, 24-hour Holter recordings and echocardiograms of 400 patients were analyzed retrospectively. PAF was detected in 40 patients on 24-hour Holter monitoring. Forty out of 360 age and gender matched patients without PAF were randomly chosen and assigned as the control group. Demographics, P-wave characteristics and echocardiographic findings of the patients with and without PAF were compared.

          Results: Maximum P-wave duration (p=0.002), P d (p<0.001) and left atrium diameter (p=0.04) were significantly higher in patients with PAF when compared to patients without PAF. However, in binary logistic regression analysis P d was the only independent predictor of PAF. The cut-off value of P d for the detection of PAF was 57.5 milliseconds (msc). Area under the curve was 0.80 (p<0.001). On a single 12-lead ECG, a value higher than 57.5 msc predicted the presence of PAF with a sensitivity of 80% and a specificity of 73%.

          Conclusion: P d on a single 12-lead ECG obtained within 24 hours of an acute ischemic stroke might help to predict PAF and reduce the risk of recurrent strokes.

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          Most cited references21

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          The meaning and use of the area under a receiver operating characteristic (ROC) curve.

          J A Hanley, B J McNeil, Marnix van Holsbeeck (1982)
          A representation and interpretation of the area under a receiver operating characteristic (ROC) curve obtained by the "rating" method, or by mathematical predictions based on patient characteristics, is presented. It is shown that in such a setting the area represents the probability that a randomly chosen diseased subject is (correctly) rated or ranked with greater suspicion than a randomly chosen non-diseased subject. Moreover, this probability of a correct ranking is the same quantity that is estimated by the already well-studied nonparametric Wilcoxon statistic. These two relationships are exploited to (a) provide rapid closed-form expressions for the approximate magnitude of the sampling variability, i.e., standard error that one uses to accompany the area under a smoothed ROC curve, (b) guide in determining the size of the sample required to provide a sufficiently reliable estimate of this area, and (c) determine how large sample sizes should be to ensure that one can statistically detect differences in the accuracy of diagnostic techniques.
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            Statistical methods for assessing agreement between two methods of clinical measurement.

            J Bland, D Altman (1986)
            In clinical measurement comparison of a new measurement technique with an established one is often needed to see whether they agree sufficiently for the new to replace the old. Such investigations are often analysed inappropriately, notably by using correlation coefficients. The use of correlation is misleading. An alternative approach, based on graphical techniques and simple calculations, is described, together with the relation between this analysis and the assessment of repeatability.
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              Left atrial volume: important risk marker of incident atrial fibrillation in 1655 older men and women.

              B G Petty, Christina Marra, Yvonne T. Tsang … (2001)
              To evaluate the contribution of left atrial (LA) volume in predicting atrial fibrillation (AF). In this retrospective cohort study, a random sample of 2200 adults was identified from all Olmsted County, Minnesota, residents who had undergone transthoracic echocardiographic assessment between 1990 and 1998 and were 65 years of age or older at the time of examination, were in sinus rhythm, and had no history of AF or other atrial arrhythmias, stroke, pacemaker, congenital heart disease, or valve surgery. The LA volume was measured off-line by using a biplane area-length method. Clinical characteristics and the outcome event of incident AF were determined by retrospective review of medical records. Echocardiographic data were retrieved from the laboratory database. From this cohort, 1655 patients in whom LA size data were available were followed from baseline echocardiogram until development of AF or death. The clinical and echocardiographic associations of AF, especially with respect to the role of LA volume in predicting AF, were determined. A total of 666 men and 989 women, mean +/- SD age of 75.2 +/- 7.3 years (range, 65-105 years), were followed for a mean +/- SD of 3.97 +/- 2.75 years (range, < 1.00-10.78 years); 189 (11.4%) developed AF. Cox model 5-year cumulative risks of AF by quartiles of LA volume were 3%, 12%, 15%, and 26%, respectively. With Cox proportional hazards multivariate models, logarithmic LA volume was an independent predictor of AF, incremental to clinical risk factors. After adjusting for age, sex, valvular heart disease, and hypertension, a 30% larger LA volume was associated with a 43% greater risk of AF, incremental to history of congestive heart failure (hazard ratio [HR], 1.887; 95% confidence interval [CI], 1.230-2.895; P = .004), myocardial infarction (HR, 1.751; 95% CI, 1.189-2.577; P = .004), and diabetes (HR, 1.734; 95% CI, 1.066-2.819; P = .03). Left atrial volume remained incremental to combined clinical risk factors and M-mode LA dimension for prediction of AF (P < .001). This study showed that a larger LA volume was associated with a higher risk of AF in older patients. The predictive value of LA volume was incremental to that of clinical risk profile and conventional M-mode LA dimension.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Int J Med Sci
                Journal ID (publisher-id): ijms
                Title: International Journal of Medical Sciences
                Publisher: Ivyspring International Publisher (Sydney )
                ISSN (Electronic): 1449-1907
                Publication date Collection: 2012
                Publication date (Electronic): 17 December 2011
                Volume: 9
                Issue: 1
                Pages: 108-114
                Affiliations
                1. Selcuk University, Meram School of Medicine, Cardiology Department, Meram, Konya, 42080, TURKEY.
                2. Selcuk University, Meram School of Medicine, Neurology Department, Meram, Konya, 42080, TURKEY.
                Author notes
                ✉ Corresponding author: Selcuk University, Meram School of Medicine, Cardiology Department, Meram, Konya, 42080, TURKEY. E-mail: umuttandogan@ 123456gmail.com , Phone: +903322237506/+905335200191, Fax: +903322236181.

                Conflict of Interest: The authors have declared that no conflict of interest exists.

                Article
                Publisher ID: ijmsv09p0108
                PMC ID: 3245420
                PubMed ID: 22211098
                SO-VID: a30c0550-7124-4c78-9b3a-b01124bbe379
                Copyright © © Ivyspring International Publisher. This is an open-access article distributed under the terms of the Creative Commons License (http://creativecommons.org/licenses/by-nc-nd/3.0/). Reproduction is permitted for personal, noncommercial use, provided that the article is in whole, unmodified, and properly cited.
                History
                Date received : 18 October 2011
                Date accepted : 8 December 2011
                Categories
                Subject: Research Paper

                ScienceOpen disciplines: Medicine
                Keywords: 24- hour holter monitoring.,paroxysmal atrial fibrillation,acute ischemic stroke,p-wave dispersion,12-lead ecg
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: 24- hour holter monitoring., paroxysmal atrial fibrillation, acute ischemic stroke, p-wave dispersion, 12-lead ecg

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