Skip to main content
NCBI home page
Annals of Noninvasive Electrocardiology logoLink to Annals of Noninvasive Electrocardiology
. 2023 Feb 24;28(3):e13053. doi: 10.1111/anec.13053

New electrocardiographic aspects of the P wave: Its value in clinical cardiology

Antoni Bayés‐de‐Luna 1,✉, Ljuba Bacharova 2
PMCID: PMC10196095  PMID: 36825831

Abstract

In this article, we will comment on new aspects of P‐wave morphology that help us to better diagnose atrial blocks and atrial enlargement, and their clinical implications. These include: (1) Atypical ECG patterns of advanced interatrial block; (2) The ECG diagnosis of left atrial enlargement versus interatrial block; (3) Atrial fibrillation and advanced interatrial block: The two sides of the same coin; and (4) P‐wave parameters: Clinical implications.

Keywords: advanced interatrial block, P‐wave parameters, risk factor of atrial fibrillation, stroke, dementia and death

In the present paper, we commented on the new electrocardiographic aspects of the P wave: its value in clinical cardiology. In this figure, we showed an atypical example of an advanced interatrial block that is diagnosed by the presence of the P wave with a duration ≥120 ms plus the P wave with ± morphology in leads II, III, and aVF.

graphic file with name ANEC-28-e13053-g005.jpg

1.

Clinical practice implication.

  • Atypical ECG patterns of advanced interatrial block: Atypical A‐IAB by morphology and Atypical A‐IAB by duration.

  • The ECG diagnosis of left atrial enlargement versus interatrial block. Although LAE and IAB present similar ECG criteria, we discussed the false positive and the false negative.

  • Atrial fibrillation and advanced interatrial block: The two sides of the same coin. We commented pathophysiological mechanisms relating A‐IAB and AF with stroke.

  • P‐wave parameters: Clinical implications. We commented the different parameters and their clinical implications.

2. ATYPICAL ECG PATTERNS OF ADVANCED INTERATRIAL BLOCK

An advanced interatrial block (A‐IAB) exists when there is evidence that at least part of the left atrium is activated retrogradely from the AV zone, as a consequence of complete block of sinus impulse in some part of the Bachmann bundle. This may be assured if the last part of lead aVF is negative because this represents that the last part of the P loop falls in the negative hemifield of lead aVF (beyond 0°) (Figures 1 and 2). This is the key point to assure that there is at least partially retrograde activation of the left atrial (LA).

FIGURE 1.

FIGURE 1

Open in a new tab

Typical ECG of A‐IAB (P wave ± in leads II, III, and aVF and duration ≥120 ms) in a patient with ischemic heart disease. When amplified (left), we can see the beginning and the end of the P wave in the three leads.

FIGURE 2.

FIGURE 2

Open in a new tab

(a) and (b): Normal P waves. In panel b, there is a biphasic (±) pattern in lead III. This is considered normal because the last part of the P loop falls in the negative hemifield of lead III, which starts at +30° but it is positive in leads II and aVF because the P loop falls in the positive hemifield of these leads. (c): Typical P loop in case of A‐IAB. The second part of the P loop falls in the negative hemifield of leads II, III, and aVF. (Taken partially from reference (Bayés de Luna, Escobar‐Robledo, et al., 2018).

The typical ECG patterns of A‐IAB (Figures 1 and 2c) were well described already in the 80s (Bayés de Luna et al., 1985) and were well recognized as a separate entity from left atrial enlargement, after the consensus paper published in 2012 (Bayés de Luna et al., 2012). In typical cases of A‐IAB (Figures 1 and 2c), the P‐wave morphology is positive/negative (±) in leads II, III, and aVF because the last part of the atrial activation falls in the negative hemifield of leads II, III, and aVF, and the duration of the P wave is ≥120 ms (Bayés de Luna et al., 1985; Bayés de Luna et al., 2012; Power et al., 2022).

However, during the review of thousands of ECGs belonging to different cohorts (Escobar‐Robledo et al., 2018; Martínez‐Sellés et al., 2016; Martínez‐Sellés et al., 2020; Massó‐van et al., 2017), it called to our attention that although some ECG that looks like A‐IAB because in lead aVF the last part of the P wave is negative did not perfectly accomplish all the ECG diagnostic criteria of this pattern and for that, these could be considered “atypical A‐IAB” (Bayés de Luna, Escobar‐Robledo, et al., 2018). The A‐IAB may be atypical: (a) due to two different variations of the P‐wave morphology stated in the 2012 consensus (Bayés de Luna et al., 2012); and (b) due to changes in P‐wave duration.

Therefore, there are atypical patterns of A‐IAB with some morphological changes in leads II, III, and/or aVF, but always with a final negative component in lead aVF and P‐wave duration ≥120 ms, and also, there are other atypical patterns of A‐IAB that present a P‐wave pattern positive/negative (±) in leads II, III, and aVF as the typical pattern but with a duration of P wave less than 120 ms.

2.1. Atypical A‐IAB due to changes in P‐wave morphology

(Figure 3a–c) (Bayés de Luna, Escobar‐Robledo, et al., 2018; de Luna et al., 2019)

  1. Type I: The terminal component of the P wave in lead II is “isodiphasic” (flat rather than negative) (Figure 3a). However, P wave in leads III and aVF remain biphasic (positive/negative).

  2. Type II: The second part of the P wave in lead II is negative and finally the P wave is positive because the loop falls in positive hemifield in lead II; therefore, the P wave is triphasic (positive/negative/positive (+ − +)) (Figure 3b).

  3. Type III (Figure 3c) is seen when the P‐wave morphology in leads III and aVF is completely negative, but with the first part of the P wave being isodiphasic, and is biphasic (±) in lead II (Figure 3c). Due to the presence of negative wave in leads III and aVF, the differential diagnosis with junctional rhythm needs to be done. If the polarity of the P waves in leads V5–V6 is positive; then atypical A‐IAB is diagnosed, while if it is negative, then the junctional rhythm is the final diagnosis (de Luna et al., 2019).

FIGURE 3.

FIGURE 3

Open in a new tab

(a) Atypical A‐IAB by morphology type I. The morphology of P in lead II with the final part isobiphasic is explained because the final part of the P loop below is located around −30°, which is the limit between the positive and negative hemifield of lead II. (b) Atypical A‐IAB by morphology type II. The morphology of the P in lead II is explained for the final clockwise rotation of the loop below that pass from negative to positive hemifield of lead II. (c) Atypical A‐IAB by morphology type III. We can see the P loop that explains the negative P wave in leads III and aVF, which make it necessary to check the P wave in left precordial leads to perform the differential diagnosis with junctional rhythm.

2.2. Atypical A‐IAB due to changes in P‐wave duration (Figure 4)

FIGURE 4.

FIGURE 4

Open in a new tab

A case of a 73‐year‐old man was found to have a large lipoma (4 × 5cm) located on the interatrial septum. Cardiac magnetic resonance imaging allowed for complete characterization. As the atrial fibrosis is not extended in all atria, the duration of P wave in spite of A‐IAB is <120 ms. (Taken from reference (Gentille‐Lorente et al., 2021).

IAB begins when the P wave lasts more than 120 ms (Bayés de Luna et al., 2012) (partial IAB), and it is advanced (A‐IAB) when the P‐wave morphology is positive/negative in leads II, III, and aVF. However, there is atypical IAB by duration when the morphology is of A‐IAB but the duration of the P wave is less than 120 ms.

Atypical patterns due to changes in duration occur when the morphology is of A‐IAB but the duration of the P wave is shorter than 120 ms, what was established starts the abnormal duration of P wave in the consensus document in 2012 (Bayés de Luna et al., 2012). In this consensus, a cut‐off for abnormal P‐wave duration starts at 120 ms to facilitate measurement, three grids in the ECG.

This atypical pattern is explained because in some A‐IAB, the sinus impulse has to follow a long way to reach the LA but in the absence important of fibrosis as happens, for instance, in rare circumstances as in presence of an atrial tumor that block the Bachmann bundle (Figure 4). In these cases, the morphology positive/negative (±) of A‐IAB may be explained by the presence of interatrial block in the Bachmann region due to tumor, but the duration of the P wave may still last less than 120 ms because there is not important fibrosis in the rest of the atria (Gentille‐Lorente et al., 2021).

2.3. Clinical implications

We have to look carefully the P waves of leads II, III, and aVF to perform the correct diagnosis of atypical pattern of A‐IAB, because at this moment (Elosua et al., 2021), we have the impression that the clinical implications of atypical A‐IAB are similar to the typical ones.

3. THE ECG DIAGNOSIS OF LEFT ATRIAL ENLARGEMENT VERSUS INTERATRIAL BLOCK

In fact, left atrial enlargement (LAE) and interatrial blocks (IAB) present some similar ECG criteria, especially the increase in the duration of P wave (≥ 120 ms). However, although the specificity is high, the sensitivity of the criteria for the diagnosis of LAE is usually low, as has been demonstrated by correlations of the ECG with imaging techniques (Bayés de Luna et al., 2022). Due to that, the AHA/ACC/HRA published in 2009 a consensus paper (Hancock et al., 2009) giving the recommendations that all abnormal P waves should usually be referred to as “atrial abnormalities” rather than atrial enlargement or atrial block.

However, just 3 years later in 2012, the International Society for Holter and Noninvasive Electrocardiology (ISHNE) published a consensus paper (Bayés de Luna et al., 2012) establishing that interatrial block was an independent and separate entity from left atrial enlargement. This was based especially on the fact that the pattern of interatrial block: (i) may be reproduced experimentally (Guerra et al., 2020; Waldo et al., 1971); (ii) may be transient (Bayés de Luna, Baranchuk, et al., 2018); and (iii) may be recorded in the absence of atrial enlargement or necrosis (Bayés de Luna et al., 1985).

The P wave seen in LAE usually has a longer than normal duration due to the long distance that the stimulus has to cover as a consequence of the dilated LA more than the hypertrophy of the LA mass itself (Josephson et al., 1977; Velury & Spodick, 1994). The enlarged left atrium first expands toward the back, so the vector of LAE points backward. Moreover, the longer P loops often acquire a figure‐of‐eight shape in the horizontal plane (HP). All that explains that the negative component of P wave in V1 is greater than the positive, and therefore, the P wave in lead V1, in case of LA enlargement, usually has a positive–negative morphology with a prominent negative component that exceeds the positive component (P‐terminal force in V1) (PtfV1) (Morris Jr. et al., 1964) (Figure 5a). An abrupt dilatation of the left atrium, which occurs in acute pulmonary edema, for example, may cause positive/negative (+/−) P‐wave morphology in V1. This disappears when the clinical situation improves (Heikila & Luomanmaki, 1970).

FIGURE 5.

FIGURE 5

Open in a new tab

(a) Normal and Abnormal, P‐terminal force in V1. (b) This is V1 lead of a healthy patient with normal left atrial size by echocardiography. V1 electrode placed in the normal location (4th ICS) (I), 3rd ICS (II), and in 2nd ICS (III). It is clear that the normal P wave in 4th ICS becomes progressively more negative (II and III) as the electrode of V1 is placed in a higher ICS. ICS = intercostal space (Adapted from reference (Morris Jr. et al., 1964).

Therefore, classically the most used ECG criteria for the diagnosis of LAE are the duration and usually the bimodal morphology of the P wave in the frontal plane and the value of PtfV1 in the horizontal plane (Morris Jr. et al., 1964). Making a comparison of these two criteria (P‐wave duration and PtfV1) with imaging correlation has been described that in the majority of cases, these criteria present a good specificity, but low or only moderate sensitivity.

Therefore, there is clear evidence that the P‐wave criteria for diagnosis of LAE have low sensitivity. In fact, the diagnosis of LAE presents the following false‐positive and false‐negative cases.

  • False positive:

  1. The abnormal increased value of PtfV1 when the electrode of V1 is highly located (Rasmussen et al., 2019; Sajeev et al., 2019) (Figure 5b). Therefore, we have to be sure that the electrode of V1 is well located.

  2. Many patients with thoracic abnormalities like pectus excavatum, or straight‐back syndrome present abnormal negative P wave in V1, a morphology that may be confused with LAE (Bayés de Luna & Baranchuk, 2017).

  • False negative:

  1. If important atrial fibrosis exists, only small and even unapparent P waves (concealed sinus rhythm) may be recorded, even in the presence of evident left atrial or bi‐atrial enlargement. This problem increases the number of false negatives (low sensitivity).

  2. In young people, especially athletes, has been demonstrated that may present LAE by echo, with P wave <120 ms (Herrera et al., 2021). This is explained because the stimulus in these cases may go with a higher speed and run more distance with less time. Because of this, the time it takes for the stimulus to travel through it is within normal limits.

Due to all that, the duration alone of the P wave ≥120 ms alone is a strong criterion for interatrial block than for LAE. However, the presence of P wave ≥120 ms is very useful for the diagnosis of LAE, when is associated with other criteria, such as bimodal and high P‐wave lead II, especially if P positive/negative (±) in leads II, III, and aVF, and the PtfV1 has a positive value if the electrode of V1 is well placed and the patient does not present thoracic abnormalities.

4. ATRIAL FIBRILLATION AND ADVANCED INTERATRIAL BLOCK: THE TWO SIDES OF THE SAME COIN

Till recently, it was considered that atrial fibrillation (AF) and advanced interatrial block (A‐IAB) are two separate entities that are clearly differentiated. AF was the consequence of the loss of normal sinus activity by an irregular atrial rhythm sometimes very fast, and A‐IAB was one type of IAB with different changes in the morphology of P wave that present biphasic positive/negative (±) P wave in leads II, III, and aVF due to a complete block in the Bachmann bundle, and consequently with retrograde activation of the left atrium.

4.1. Similarities between AF and A‐IAB (Figure 6)

FIGURE 6.

FIGURE 6

Open in a new tab

Pathophysiological events relating atrial fibrillation (AF) and advanced interatrial block (A‐IAB) to systemic embolism. CM = cardiomyopathy; LA = left atrium; LAA = left atrial appendage; PAC = premature atrial contractions; PAR = protease‐activated receptor (Taken from reference (Bayés de Luna et al., 2020).

However, there are many similarities between them. We can assure that for the following:

  1. The AF is not the final cause of stroke, it is just a risk factor as A‐IAB. It has been demonstrated that the onset of the stroke does not coincide with the appearance onset of crisis of paroxysmal AF (IMPACT, TRENDS, and ASSERT Trials) (Glotzer et al., 2009; Hohnloser et al., 2006; Martin et al., 2015).

  2. Blood stasis is not the cause of the embolism because blood stasis persists when the embolism disappears when given an anticoagulant.

  3. Fibrotic atrial cardiomyopathy (FACM) (Kottkamp, 2012) is the anatomic substrate of both cases, which favors atrial remodeling, hypercoagulation, and the development of the thrombotic cascade and systemic embolism.

  4. The best noninvasive technique to detect FACM is magnetic resonance (Marrouche et al., 2014). However, recently it has been demonstrated that speckle‐tracking echo may be an MRI surrogate (Montserrat et al., 2015). And also that surface ECG (A‐IAB) is a marker of the presence of fibrosis and left atrial dyssynchrony (Lacalzada‐Almeida et al., 2019).

4.2. Pathophysiological mechanisms relating A‐IAB and AF with stroke (Bayés de Luna et al., 2020)

The proposed pathophysiological mechanisms relating AF and A‐IAB with systemic embolism and stroke are depicted in Figure 6. The presence of atrial fibrosis and fatty infiltration is the anatomic substrate of both AF and A‐IAB. The prevalence of both processes is similar and increases significantly with age. Systemic embolization and especially stroke can be related to both AF and A‐IAB. In both cases, the final cause of stroke is usually the presence of FACM. As we have already commented, several trials have suggested that there is no temporal correlation between the crisis of paroxysmal AF and the occurrence of stroke (Glotzer et al., 2009; Hohnloser et al., 2006; Martin et al., 2015). Indeed, abnormal and sluggish LA jointly with decreased flow velocity in the LA appendage and atrial dyssynchrony may ultimately result in systematic embolism (stroke). In presence of A‐IAB, atrial dyssynchrony also contributes to the electrical heterogeneity in the left atrium and impaired LA mechanical function that induces susceptibility to AF (Ciuffo et al., 2018; Ciuffo et al., 2020).

In addition, the abnormal characteristics of LA contraction favor atrial remodeling, blood stasis, hypercoagulation, and, through the activation of protease‐activated receptors induce thrombosis. These mechanisms may aggravate atrial fibrosis and atrial remodeling, perpetuating AF and favoring the progression of A‐IAB to AF, ultimately triggering the thrombogenic cascade resulting in systemic embolism and stroke (Figure 6).

5. P‐WAVE PARAMETERS: CLINICAL IMPLICATIONS

At this moment, the list of P‐wave parameters (Chen et al., 2022), named indices by Magnani (Magnani et al., 2010), include the following: (a) Changes in P‐wave duration and morphology (IAB); (b) P‐terminal force in V1 (PtfV1); (c) P axis; (d) P voltage; (e) P area; and (f) P dispersion.

It has been demonstrated that an important relationship exists between changes in some of these parameters and the presence of AF, stroke, dementia, mortality, and left atrial enlargement.

5.1. Partial and advanced interatrial block (Figures 1, 2, 3, 4)

Already in 1988 (Bayés de Luna et al., 1988), we published that patients with heart disease of any type who presented A‐IAB compared to those in the control group with P‐IAB presented atrial fibrillation within a few months of follow‐up. Many other authors have published that the presence of A‐IAB is also associated with a higher incidence of AF, stroke (Escobar‐Robledo et al., 2018; Martínez‐Sellés et al., 2016; Martínez‐Sellés et al., 2017; Martínez‐Sellés et al., 2020; O'Neal et al., 2016), dementia (Gutierrez et al., 2019; Martínez‐Sellés et al., 2016), and death (Maheshwari, Norby, Soliman, Alraies, et al., 2017). This association is known as Bayés Syndrome (Bacharova & Wagner, 2015; Conde & Baranchuk, 2014; Power et al., 2022).

5.2. P‐terminal force in V1 (Figure 5)

We have previously commented (Josephson et al., 1977; Morris Jr. et al., 1964; Velury & Spodick, 1994) on the limitations of this criterion for the diagnosis of left atrial enlargement, due to the morphology changes that the same patient may present in the P wave in V1 depending on the placement of the electrode. This also may explain the negative PtfV1 with respect to the incidence of stroke that has recently been published (Rasmussen et al., 2019; Sajeev et al., 2019).

5.3. P‐wave axis

It represents the location of the P wave in the space. It is normal when it is located between 0° and +75° in the frontal plane.

The P‐wave axis cannot be calculated in presence of A‐IAB due to the positive/negative (±) morphology of the P wave in leads II, III, and aVF. Therefore, if exist A‐IAB may be considered that the patient has an abnormal P‐wave axis.

This parameter, alone or as a part of a score, has been used very much in the last years, especially for epidemiologists principally of ARIC cohort (Maheshwari, Norby, Soliman, Koene, et al., 2017), with great success as a marker of risk of future AF, stroke, and dementia.

5.4. P‐wave voltage

The paper of Park et al. (Park et al., 2016) systematically evaluates the pathophysiologic meaning of P‐wave amplitude in patients with paroxysmal AF. P‐wave amplitude <0.1mv in lead I was independently associated with the clinical recurrence of AF, after ablation. Therefore, it is considered abnormal if the P‐wave voltage is ≤0.1mv in lead I. Recently, this parameter as a part of a score has been demonstrated to be also useful to predict the new onset of AF (Alexander et al., 2019).

5.5. P‐wave area

It may be calculated in lead II with the formula: P‐wave area = Half duration of P wave x voltage of P ≥ 4 ms/mv. Till now, as much as we know, this parameter has not been used as a marker of AF and stroke. Abnormal P‐wave area is defined as ≥ 4 ms x mV and has been found to be associated with LAE. P‐wave area is calculated in lead II using this formula: P‐wave area = ½ P‐wave duration x P‐wave voltage (Chen et al., 2022).

5.6. P‐wave dispersion

P‐wave dispersion is defined as the difference between P‐wave maximum and P‐wave minimum duration on the12‐lead ECG. Studies have shown that greater P‐wave dispersion is associated with incident AF and AF recurrence after cardioversion (Dilaveris et al., 2000) and severity of coronary artery disease (Yilmaz & Demirbag, 2005). Furthermore, in a study of patients with cryptogenic stroke who received an implantable loop recorder, the only independent predictor of AF was P‐wave dispersion of 40 ms (Marks et al., 2021).

5.7. The use of scores

Recently, it has been considered that the use of score of different P‐wave indices (Alexander et al., 2019) or P indices associated with CHA2DS2‐Vasc (Dilaveris et al., 2000) may detect better marker or risk factor of AF and stroke. It is advisable to perform more studies trying to find the best score to be used in clinical practice and in epidemiological studies.

6. CONCLUSION

We have described in this article new electrocardiographic aspects of the P wave of great clinical impact, which allows us to presume that the P wave has become a Princess of ECG from Cinderella.

AUTHOR CONTRIBUTIONS

Both authors have participated in writing and editing the manuscript, although Antoni Bayés‐de‐Luna has made the first draft.

CONFLICT OF INTEREST STATEMENT

None declared.

ETHICS APPROVAL

None declared.

ACKNOWLEDGMENTS

We thank the contribution from the following authors who have participated in the previous papers on this topic: Delicia Gentille‐Lorente, Günter Breithardt, Luis Alberto Escobar‐Robledo, Danilo Weir Restrepo, David Aristizabal, Manuel Martínez‐Sellés, Adrián Baranchuk, Antoni Bayés‐Genís, and Juan Lacalzada‐Almeida. We thank Fundación Jesús Serra for its support.

Bayés‐de‐Luna, A. , & Bacharova, L. (2023). New electrocardiographic aspects of the P wave: Its value in clinical cardiology. Annals of Noninvasive Electrocardiology, 28, e13053. 10.1111/anec.13053

DATA AVAILABILITY STATEMENT

Data available on request from the authors

REFERENCES

  1. Alexander, B. , Milden, J. , Hazim, B. , Haseeb, S. , Bayés‐Genís, A. , Elosua, R. , Martínez‐Sellés, M. , Yeung, C. , Hopman, W. , Bayes de Luna, A. , & Baranchuk, A. (2019). New electrocardiographic score for the prediction of atrial fibrillation: The MVP ECG risk score (morphology‐voltage‐P wave duration). Annals of Noninvasive Electrocardiology, 24, e12669. 10.1111/anec.12669 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bacharova, L. , & Wagner, G. S. (2015). The time for naming the interatrial block syndrome: Bayes syndrome. Journal of Electrocardiology, 48, 133–134. 10.1016/j.jelectrocard.2014.12.022 [DOI] [PubMed] [Google Scholar]
  3. Bayés de Luna, A. , & Baranchuk, A. (2017). Clinical Arrhythmology (Second ed.). Wiley‐Blackwell; ISBN: 978‐1‐119‐21275‐1. [Google Scholar]
  4. Bayés de Luna, A. , Baranchuk, A. , Niño, P. C. , Martínez‐Sellés, M. , Bayés‐Genís, A. , Elosua, R. , & Elizari, M. V. (2018). Second‐degree Interatrial block: Brief review and concept. Annals Of Noninvasive Electrocardiology, 23, e12583. 10.1111/anec.12583 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Bayés de Luna, A. , Cladellas, M. , Oter, R. , Torner, P. , Guindo, J. , Martí, V. , Rivera, I. , & Iturralde, P. (1988). Interatrial conduction block and retrograde activation of the left atrium and paroxysmal supraventricular tachyarrhythmia. European Heart Journal, 9, 1112–1118. 10.1093/oxfordjournals.eurheartj.a062407 [DOI] [PubMed] [Google Scholar]
  6. Bayés de Luna, A. , Escobar‐Robledo, L. A. , Aristizabal, D. , Weir, R. D. , Mendieta, B. G. , Massó‐van, R. A. , Elosua, R. , Bayés‐Genís, A. , Martínez‐Sellés, M. , & Baranchuk, A. (2018). Atypical advanced interatrial block: Definition electrocardiographic recognition. Journal of Electrocardiology, 51, 1091–1093. 10.1016/j.jelectrocard.2018.09.004 [DOI] [PubMed] [Google Scholar]
  7. Bayés de Luna, A. , Fiol‐Sala, M. , Bayés‐Genís, A. , & Baranchuk, A. (2022). Clinical electrocardiography: A textbook (5th ed., p. 108). Wiley‐Blackwell. [Google Scholar]
  8. Bayés de Luna, A. , Fort de Ribot, R. , Trilla, E. , Júlia, J. , García, J. , Sadurní, J. , Riba, J. , & Sagués, F. (1985). Electrocardiographic and vectorcardiographic study of interatrial conduction disturbances with left atrial retrograde activation. Journal of Electrocardiology, 18, 1–13. 10.1016/s0022-0736(85)80029-7 [DOI] [PubMed] [Google Scholar]
  9. Bayés de Luna, A. , Martínez‐Sellés, M. , Elosua, R. , Bayés‐Genís, A. , Mendieta, G. , Baranchuk, A. , & Breithardt, G. (2020). Relation of advanced interatrial block to risk of atrial fibrillation and stroke. The American Journal of Cardiology, 125, 1745–1748. 10.1016/j.amjcard.2020.02.034 [DOI] [PubMed] [Google Scholar]
  10. Bayés de Luna, A. , Platonov, P. , García‐Cosio, F. , Cygankiewicz, I. , Pastore, C. , Baranowski, R. , Stern, S. , & Spodick, D. (2012). Interatrial blocks. A separate entity from left atrial enlargement: A consensus report. Journal of Electrocardiology, 45, 445–451. 10.1016/j.jelectrocard.2012.06.029 [DOI] [PubMed] [Google Scholar]
  11. Chen, L. Y. , Pinho, R. A. , Platonov, P. G. , Cygankiewicz, I. , Soliman, E. Z. , Gorenek, B. , Ikeda, T. , Vassilikos, V. P. , Steinberg, J. S. , Varma, N. , Bayés de Luna, A. , & Baranchuk, A. (2022). P‐wave parameters and indices: A critical appraisal of clinical utility, challenges, and future research‐a consensus document endorsed by the International Society of Electrocardiology and the international society for Holter and noninvasive Electrocardiology. Circulation. Arrhythmia and Electrophysiology, 15, e010435. 10.1161/CIRCEP.122.010435 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Ciuffo, L. , Bruña, V. , Martínez‐Sellés, M. , Doria de Vasconcellos, H. , Tao, S. , Zghaig, T. , Nazarian, S. , Spragg, D. D. , Marine, J. , Berger, R. D. , Lima, J. A. C. , Calkins, H. , Bayés‐de‐Luna, A. , & Ashikaga, H. (2020). Association between interatrial block, left atrial fibrosis, and mechanical dyssynchrony: Electrocardiography‐magnetic resonance imaging correlation. Journal of Cardiovascular Electrophysiology, 31, 1719–1725. 10.1111/jce.14608 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Ciuffo, L. , Inoue, Y. Y. , Tao, S. , Ipek, E. G. , Balouch, M. , Lima, J. A. C. , Nazarian, S. , Spragg, D. D. , Marine, J. E. , Berger, R. D. , Calkins, H. , & Ashikaga, H. (2018). Mechanical dyssynchrony of the left atrium during sinus rhythm is associated with history of stroke in patients with atrial fibrillation. European Heart Journal ‐ Cardiovascular Imaging, 19, 433–441. 10.1093/ehjci/jex156 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Conde, D. , & Baranchuk, A. (2014). Bloqueo interauricular como sustrato anatómico‐eléctrico de arritmias supraventriculares: Síndrome de Bayés. Archivos de Cardiología de México, 84(1), 32–40. 10.1016/j.acmx.2013.10.004 [DOI] [PubMed] [Google Scholar]
  15. de Luna, A. B. , Platonov, P. G. , García‐Niebla, J. , & Baranchuk, A. (2019). Atypical advanced Interatrial block or junctional rhythm? Journal of Electrocardiology, 5, 85–86. 10.1016/j.jelectrocard.2019.03.014 [DOI] [PubMed] [Google Scholar]
  16. Dilaveris, P. , Gialafos, E. , Andrikopoulos, G. K. , Richter, D. J. , Papanikolau, V. , Poralis, K. , & Gialafos, J. E. (2000). Clinical and electrocardiographic predictors of recurrent atrial fibrillation. Pacing and Clinical Electrophysiology, 23, 352–358. 10.1111/j.1540-8159.2000.tb06761.x [DOI] [PubMed] [Google Scholar]
  17. Elosua, R. , Escobar‐Robledo, L. A. , Massó‐van, R. A. , Martínez‐Sellés, M. , Baranchuk, A. , & Bayés‐de‐Luna, A. (2021). ECG patterns of typical and atypical advanced interatrial block: Prevalence and clinical relevance. Revista Española de Cardiología (Engl Ed), 74(9), 807–810. 10.1016/j.rec.2021.02.008 [DOI] [PubMed] [Google Scholar]
  18. Escobar‐Robledo, L. A. , Bayés de Luna, A. , Lupón, J. , Baranchuk, A. , Moliner, P. , Martínez‐Sellés, M. , Zamora, E. , De Antonio, M. , Domingo, M. , Cediel, G. , Villota, J. N. , Santiago‐Vacas, E. , & Bayés‐Genís, A. (2018). Advanced Interatrial block predicts new‐onset atrial fibrillation and ischemic stroke in patients with heart failure: The “Bayes syndrome‐HF” study. International Journal of Cardiology, 271, 174–180. 10.1016/j.ijcard.2018.05.050 [DOI] [PubMed] [Google Scholar]
  19. Gentille‐Lorente, D. I. , Scott, L. , Escobar‐Robledo, L. A. , Mesa‐Maya, M. A. , Carreras‐Costa, F. , Baranchuk, A. , Martínez‐Sellés, M. , Elosua, R. , Bayés‐Genís, A. , & Bayés‐de‐Luna, A. (2021). Atypical advanced interatrial block due to giant atrial lipoma. Pacing and Clinical Electrophysiology, 44(4), 737–739. 10.1111/pace.14210 [DOI] [PubMed] [Google Scholar]
  20. Glotzer, T. V. , Daoud, E. G. , Wyse, D. G. , Singer, D. E. , Ezekowitz, M. D. , Hilker, C. , Miller, C. , Dongfeng Qi, D. , & Ziegler, P. D. (2009). The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: The TRENDS Study. Circulation: Arrhythmia and Electrophysiology, 2, 474–480. 10.1161/CIRCEP.109.849638 [DOI] [PubMed] [Google Scholar]
  21. Guerra, J. , Vilahur, G. , Bayés de Luna, A. , Cabrera, J. A. , Martínez‐Sellés, M. , Mendieta, G. , Baranchuk, A. , & Sánchez‐Quintana, D. (2020). Interatrial block can occur in the absence of left atrial enlargement: New experimental model. Pacing and Clinical Electrophysiology, 43, 427–429. 10.1111/pace.13895 [DOI] [PubMed] [Google Scholar]
  22. Gutierrez, A. , Norby, F. L. , Maheshwari, A. , Rooney, M. R. , Gottesman, R. F. , Mosley, T. H. , Lutsey, P. L. , Oldenburg, N. , Soliman, E. Z. , Alonso, A. , & Chen, L. Y. (2019). Association of abnormal P‐wave indices with dementia and cognitive decline over 25 years: ARIC‐NCS (the atherosclerosis risk in communities neurocognitive study). Journal of the American Heart Association, 8, e014553. 10.1161/JAHA.119.014553 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Hancock, E. W. , Deal, B. J. , Mirvis, D. M. , Okin, P. , Kligfield, P. , & Gettes, L. S. (2009). AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram part V: Electrocardiogram changes associated with cardiac chamber hypertrophy a scientific Statement from the American Heart Association electrocardiography and arrhythmias committee, council on clinical cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: Endorsed by the International Society for Computerized Electrocardiology. Circulation, 119, e251–e261. 10.1161/CIRCULATIONAHA.108.191097 [DOI] [PubMed] [Google Scholar]
  24. Heikila, J. , & Luomanmaki, K. (1970). Value of serial P wave changes in indication left heart failure in myocardial infarction. British Heart Journal, 32, 510–517. 10.1136/hrt.32.4.510 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Herrera, C. , Bruña, V. , Comella, A. , de la Rosa, A. , Díaz‐González, L. , Ruíz‐Ortiz, M. , Lacalzada‐Almeida, J. , Lucía, A. , Boraita, A. , Bayés‐de‐Luna, A. , & Martínez‐Sellés, M. (2021). Dilatación de la aurícula izquierda en deportistas de alta competición y electrofisiología auricular. Left atrial enlargement in competitive Athletes and atrial electrophysiology. Revista Española de Cardiología (Engl. Ed.), 75(5), 421–428. 10.1016/j.rec.2021.05.020 [DOI] [PubMed] [Google Scholar]
  26. Hohnloser, S. H. , Capucci, A. , Fain, E. , Gold, M. R. , van Gelder, J. C. , Healey, J. , Israel, C. W. , Lau, C. P. , Morillo, C. , Connolly, J. , & ASSERT investigators and committees . (2006). Asymptomatic atrial fibrillation and stroke evaluation in pacemaker patients and the atrial fibrillation reduction atrial pacing trial (ASSERT). American Heart Journal, 152, 442–447. 10.1016/j.ahj.2006.02.016 [DOI] [PubMed] [Google Scholar]
  27. Josephson, M. E. , Kastorm, J. A. , & Morganroth, J. (1977). ECG left atrial enlargement: Electrophysiologic, echocardiographic and hemodynamic correlates. The American Journal of Cardiology, 39, 967–971. 10.1016/s0002-9149(77)80209-9 [DOI] [PubMed] [Google Scholar]
  28. Kottkamp, H. (2012). Fibrotic atrial cardiomyopathy: A specific disease/syndrome supplying substrates for atrial fibrillation, atrial tachycardia, sinus node disease, AV node disease, and thromboembolic complications. Journal of Cardiovascular Electrophysiology, 23, 797–799. 10.1111/j.1540-8167.2012.02341.x [DOI] [PubMed] [Google Scholar]
  29. Lacalzada‐Almeida, J. , Izquierdo‐Gómez, M. M. , García‐Niebla, J. , Elosua, R. , Jiménez‐Sosa, A. , Baranchuk, A. , & Bayés de Luna, A. (2019). Advanced interatrial block is a surrogate for left atrial strain reduction which predicts atrial fibrillation and stroke. Annals of Noninvasive Electrocardiology, 24, e12632. 10.1111/anec.12632 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Magnani, J. W. , Johnson, V. M. , Sullivan, L. M. , Lubitz, S. A. , Schnabel, R. B. , Ellinor, P. T. , & Benjamin, E. J. (2010). P‐wave indices: Derivation of reference values from the Framingham heart study. Annals of Noninvasive Electrocardiology, 15, 344–352. 10.1111/j.1542-474X.2010.00390.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Maheshwari, A. , Norby, F. L. , Soliman, E. , Koene, R. J. , Rooney, M. R. , O'Neal, W. T. , Alonso, A. , & Chen Lin, Y. (2017). Abnormal P‐wave axis and ischemic stroke: The atherosclerosis risk in communities study. Stroke, 48, 2060–2065. 10.1161/STROKEAHA.117.017226 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Maheshwari, A. , Norby, F. L. , Soliman, E. Z. , Alraies, M. C. , Adabag, S. , O'Neal, W. T. , Alonso, A. , & Chen, L. Y. (2017). Relation of prolonged P‐wave duration to risk of sudden cardiac death in the general population (from the atherosclerosis risk in communities study). The American Journal of Cardiology, 119, 1302–1306. 10.1016/j.amjcard.2017.01.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Marks, D. , Ho, R. , Then, R. , Weinstock, J. L. , Teklemariam, E. , Kakadia, B. , Collins, J. , Andriulli, J. , Hunter, K. , Ortman, M. , & Russo, A. M. (2021). Real‐world experience with implantable loop recorder monitoring to detect subclinical atrial fibrillation in patients with cryptogenic stroke: The value of p wave dispersion in predicting arrhythmia occurrence. International Journal of Cardiology, 327, 86–92. 10.1016/j.ijcard.2020.11.019 [DOI] [PubMed] [Google Scholar]
  34. Marrouche, N. F. , Wilber, D. , Hindricks, G. , Jais, P. , Akoum, N. , Marchilinski, F. , Kholmovski, E. , Burgon, N. , Hu, N. , Mont, L. , Deneke, T. , Duytschaever, M. , Neumann, T. , Mansour, M. , Mahnkopf, C. , Herweg, B. , Daoud, E. , Wissner, E. , Bansmann, P. , & Brachmann, J. (2014). Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation. The DECAAF study. JAMA, 311, 498–506. 10.1001/jama.2014.3 [DOI] [PubMed] [Google Scholar]
  35. Martin, D. T. , Bersohn, M. M. , Waldo, A. L. , Wathen, M. S. , Choucair, W. K. , Lip, G. Y. , Ip, J. , Holcomb, R. , Akar, J. G. , Halperin, J. L. , & IMPACT investigators . (2015). Randomized trial of atrial arrhythmia monitoring to guide anticoagulation in patients with implanted defibrillator and cardiac resynchronization devices. European Heart Journal, 36(26), 1660–1668. 10.1093/eurheartj/ehv115 [DOI] [PubMed] [Google Scholar]
  36. Martínez‐Sellés, M. , Baranchuk, A. , Elosua, R. , & Bayés de Luna, A. (2017). Rationale and design of the BAYES (Interatrial block and yearly events) registry. Clinical Cardiology, 40, 196–199. 10.1002/clc.22647 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Martínez‐Sellés, M. , Elosua, R. , Ibarrola, M. , de Andrés, M. , Díez‐Villanueva, P. , Bayés‐Genís, A. , Baranchuk, A. , Bayés de Luna, A. , & BAYES Registry Investigators . (2020). Advanced interatrial block and P‐wave duration are associated with atrial fibrillation and stroke in older adults with heart disease: The BAYES registry. Europace, 22, 1001–1008. 10.1093/europace/euaa114 [DOI] [PubMed] [Google Scholar]
  38. Martínez‐Sellés, M. , Massó‐van, R. A. , Álvarez‐García, J. , García de la Villa, B. , Cruz‐Jentoft, A. , Vidán, M. T. , Felix Redondo, F. J. , Durán Guerrero, J. M. , Bayes‐Genis, A. , Bayés de Luna, A. , & Investigators of the Cardiac and Clinical Characterization of Centenarians (4C) registry . (2016). Interatrial block and atrial arrhythmias in centenarians: Prevalence, associations, and clinical implications. Heart Rhythm, 13, 645–651. 10.1016/j.hrthm.2015.10.034 [DOI] [PubMed] [Google Scholar]
  39. Massó‐van, R. A. , Escobar‐Robledo, L. A. , Dégano, I. R. , Grau, M. , Sala, J. , Ramos, R. , Marrugat, J. , Bayés de Luna, A. , & Elosua, R. (2017). Analysis of the association between electrocardiographic P‐wave characteristics and atrial fibrillation in the REGICOR study. Revista Española de Cardiología, 70, 841–847. 10.1016/j.rec.2017.02.019 [DOI] [PubMed] [Google Scholar]
  40. Montserrat, S. , Gabrielli, L. , Bijnens, B. , Borrás, R. , Berruezo, A. , Poyatos, S. , Brugada, J. , Mont, L. , & Sitges, M. (2015). Left atrial deformation predicts success of first and second percutaneous atrial fibrillation ablation. Heart Rhythm, 12, 11–18. 10.1016/j.hrthm.2014.08.032 [DOI] [PubMed] [Google Scholar]
  41. Morris, J. J., Jr. , Estes, E. H., Jr. , Whalen, R. E. , Thompson, H. K., Jr. , & Mcintosh, H. D. (1964). P wave analysis in valvular heart disease. Circulation, 29, 242–252. 10.1161/01.cir.29.2.242 [DOI] [PubMed] [Google Scholar]
  42. O'Neal, W. T. , Kamel, H. , Zhang, Z. M. , Chen, L. Y. , Alonso, A. , & Soliman, E. Z. (2016). Advanced interatrial block and ischemic stroke. The atherosclerosis risk in communities study. Neurology, 87(4), 352–356. 10.1212/WNL.0000000000002888 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Park, J. K. , Park, J. , Uhm, J. S. , Joung, B. , Lee, M. H. , & Pak, H. N. (2016). Low P‐wave amplitude (<0,1mV) in lead I is associated with displaced inter‐atrial conduction and clinical recurrence of paroxysmal atrial fibrillation after radiofrequency catheter ablation. Europace, 18, 384–391. 10.1093/europace/euv028 [DOI] [PubMed] [Google Scholar]
  44. Power, D. , Lampert, J. , Camaj, A. , Bienstock, S. W. , Kocovic, N. , Bayés‐Genís, A. , Miller, M. A. , Bayés de Luna, A. , & Fuster, V. (2022). Cardiovascular complications of interatrial conduction block: JACC state‐of‐the‐art review. Journal of the American College of Cardiology, 79, 1119–1211. 10.1016/j.jacc.2022.01.030 [DOI] [PubMed] [Google Scholar]
  45. Rasmussen, M. U. , Fabricius‐Bjerre, A. , Kumarathurai, P. , Larsen, B. S. , Domínguez, H. , Kanters, J. K. , & Sajadieh, A. (2019). Common source of miscalculation and misclassification of P‐wave negativity and P‐wave terminal force in lead V1. Journal of Electrocardiology, 53, 85–88. 10.1016/j.jelectrocard.2019.01.088 [DOI] [PubMed] [Google Scholar]
  46. Sajeev, J. K. , Koshy, A. N. , Dewey, H. , Kalman, J. M. , Bhatia, M. , Roberts, L. , Cooke, J. C. , Frost, T. , Denver, R. , & Teh, A. W. (2019). Poor reliability of P‐wave terminal force V1 in ischemic stroke. Journal of Electrocardiology, 52, 47–52. 10.1016/j.jelectrocard.2018.11.007 [DOI] [PubMed] [Google Scholar]
  47. Velury, V. , & Spodick, D. (1994). Axial correlates of PV1 of left atrial enlargement and relation to intraatrial block. The American Journal of Cardiology, 73, 998–999. 10.1016/0002-9149(94)90155-4 [DOI] [PubMed] [Google Scholar]
  48. Waldo, A. , Bush, H. L., Jr. , Gelband, H. , Zorn, G. L. , Vitikainen, K. J. , & Hoffman, B. F. (1971). Effects on the canine P wave of discrete lesions in the specialized atrial tracts. Circulation Research, 29, 452–467. 10.1161/01.res.29.5.452 [DOI] [PubMed] [Google Scholar]
  49. Yilmaz, R. , & Demirbag, R. (2005). P‐wave dispersion in patients with stable coronary artery disease and its relationship with severity of the disease. Journal of Electrocardiology, 38, 279–284. 10.1016/j.jelectrocard.2005.02.003 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data available on request from the authors

Articles from Annals of Noninvasive Electrocardiology are provided here courtesy of International Society for Holter and Noninvasive Electrocardiology, Inc. and Wiley Periodicals, Inc.

RESOURCES