Abstract
Background: Measurements by P‐wave signal‐averaged electrocardiogram (P‐SAECG) of P‐wave duration and P‐wave voltage integral are higher in patients with atrial fibrillation (AF) than in those with sinus rhythm. Hypertension is perhaps the most common cardiovascular antecedent cause of AF, and particularly a disproportionate cause of morbidity and mortality among blacks. The purpose of this study was to examine the effect of hypertension and ethnicity on P‐SAECG parameters in patients without AF.
Hypothesis: It was hypothesized that P‐SAECG parameters can identify hypertensives, and are disproportionately higher in hypertensive blacks.
Methods: in all, 234 normotensives and 84 hypertensives underwent P‐SAECG analysis. in an ancillary study group of 34 hypertensive black men, the relationship between severity of hypertension and measured parameters of P‐SAECG was evaluated.
Results: Mean filtered P‐wave duration and total P‐wave voltage integral for normotensives of both ethnic groups were similar. Hypertensive blacks had greater increase in P‐wave duration (138 ± 16 vs. 132 ± 12 ms; p< 0.01, N 42:42) and total P‐wave voltage integral (922 ± 285 vs. 764 ± 198 μV‐ms; p < 0.001) than white hypertensives. Filtered P‐wave duration and total P‐wave voltage integral increased with severity of hypertension.
Conclusions: Patients at very early stages of hypertension have demonstrable evidence of prolonged atrial conduction by P‐SAECG and, thus, cardiac electrical remodeling. P‐wave duration and total P‐wave voltage integral increase with severity of hypertension. Hypertensive blacks manifest a greater increase in P‐SAECG parameters than whites. This may portend an increased cardiovascular risk for black patients with hypertension.
Keywords: hypertension, hypertrophy, ethnic, high resolution, atrial conduction, left ventricular hypertrophy
Full Text
The Full Text of this article is available as a PDF (597.2 KB).
References
- 1. Guidera SA, Steinberg JS: The signal averaged P‐wave duration, a rapid and noninvasive marker of risk of atrial fibrillation. J Am Coll Cardiol 1993; 21: 1645–1651 [DOI] [PubMed] [Google Scholar]
- 2. Fukunami M, Yamada T, Ohmori M, Kumagai K, Umemoto K, Sakai A, Kondoh N, Minamino T, Hoki N: Detection of patients at risk for paroxysmal atrial fibrillation during sinus rhythm by P‐wave‐triggered signal‐averaged electrocardiogram. Circulation 1991; 83: 162–169 [DOI] [PubMed] [Google Scholar]
- 3. Stafford PJ, Turner I, Vincent R: Quantitative analysis of signal‐averaged P waves in idiopathic paroxysmal atrial fibrillation. Am J Cardiol 1991; 68: 751–755 [DOI] [PubMed] [Google Scholar]
- 4. Opolski G, Stanislawska J, Stomka K, Kraska T: Value of the atrial signal‐averaged electrocardiogram in identifying patients with paroxysmal atrial fibrillation. Int J Cardiol 1991;30:315–319 [DOI] [PubMed] [Google Scholar]
- 5. Gondo N, Kumagai K, Matsuo K, Ogawa M, Annoura M, Moroe K, Arakawa K: The best criterion for discrimination between patients with and without paroxysmal atrial fibrillation on signal‐averaged electrocardiogram. Am J Cardiol 1995;75:93–95 [DOI] [PubMed] [Google Scholar]
- 6. Steinberg JS, Zelenkofske S, Wong SC, Gelernt M, Sciacca R, Menchavez E: Value of P wave signal‐averaged ECG for predicting atrial fibrillation after cardiac surgery. Circulation 1993; 88 (6): 2618–2622 [DOI] [PubMed] [Google Scholar]
- 7. Klein M, Evans SJ, Blumberg S, Cataldo L, Bodenheimer MM: Use of P‐wave triggered, P‐wave signal‐averaged electrocardiogram to predict atrial fibrillation after coronary artery bypass surgery. Am Heart J 1995; 129: 895–901 [DOI] [PubMed] [Google Scholar]
- 8. Stafford PJ, Kolvekar S, Cooper J: Signal averaged P wave compared with standard electrocardiography or echocardiography for prediction of atrial fibrillation after coronary bypass grafting. Heart 1997; 77: 407–411 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Waldo AL: Mechanism of atrial fibrillation, atrial flutter, and ectopic atrial tachycardia: A brief review. Circulation 1987; 75 (4 Pt. 2):III, 37–40 [PubMed] [Google Scholar]
- 10. Abe Y, Fukunami M, Yamada T, Ohmori M, Shimonagata T, Kumagai K, Kim J, Sanada S, Hori M, Hoki N: Prediction of transition to chronic atrial fibrillation in patients with paroxysmal atrial fibrillation by signal‐averaged electrocardiography: A prospective study. Circulation 1997; 96 (8): 2612–2616 [DOI] [PubMed] [Google Scholar]
- 11. Kubara I, Ikeda H, Hiraki T, Yoshida T, Ohga M, Imaizumi T: Dispersion of filtered P wave duration by P wave signal‐averaged ECG mapping system: Its usefulness for determining efficacy of disopyramide on paroxysmal atrial fibrillation. J Cardiovasc Electrophys 1999; 10 (5): 670–679 [DOI] [PubMed] [Google Scholar]
- 12. Telichowski A, Banasiak W, Wiech K, Zeborowski J, Pierog M, Ponikowski P, Kalka D, Lacheta W, Fuglewicz A, Telichowski C: The effect of sotalol hydrochloride therapy on atrial signal‐averaged ECG in patients with paroxysmal atrial fibrillation. Polski Merkurius Lekarski 1996; l(5): 303–3O9 (in Polish) [PubMed] [Google Scholar]
- 13. Aytemir K, Aksoyek S, Yildirir A, Ozer N, Oto A: Prediction of atrial fibrillation recurrence after cardioversion by P wave signal‐averaged electrocardiography. Int J Cardiol 1999; 70 (1): 15–21 [DOI] [PubMed] [Google Scholar]
- 14. Opolski G, Scislo P, Stanislawska J, Gorecki A, Steckiewicz R, Torbicki A: Detection of patients at risk for recurrence of atrial fibrillation after successful electrical cardioversion by signal‐averaged P‐wave ECG. Int J Cardiol 1997; 60 (2): 181–185 [DOI] [PubMed] [Google Scholar]
- 15. Kannel W, Abbot R, Savage D: Epidemiologic predictors of atrial fibrillation: Framingham study. N Engl J Med 1982; 17: 1018–1022 [DOI] [PubMed] [Google Scholar]
- 16. Tarazi RC, Miller A, Frohlich ED, Dustan HP: Electrocardiographic changes reflecting left atrial abnormality in hypertension. Circulation 1966; 34: 818–822 [DOI] [PubMed] [Google Scholar]
- 17. Romhilt DW, Bove KE, Norris RJ, Conyers E, Conradi S, Rowlands DT, Scott RC: A critical appraisal of the electrocardiographic criteria for the diagnosis of LVH. Circulation 1969: 40: 185–195 [DOI] [PubMed] [Google Scholar]
- 18. The fifth report of the Joint National Committee on Detection , Evaluation, and Treatment of High Blood pressure (JNC V). Arch Intern Med 1993; 153 lpar;2): 154–183 [PubMed] [Google Scholar]
- 19. Opolski G, Kraska T, Piatkowska‐Janko E, Slomka K, Gorecki A, Stanislawska J, Scislo P, Piatkowski A, Cieciura M: P‐wave EKG averaging technique: A new method of selecting patients with paroxysmal atrial fibrillation. Polski Tygodnik Lekarski 1995; 50 (40–44): 39–41 (in Polish) [PubMed] [Google Scholar]
- 20. Xue Q, Reddy S, Dhala A: High resolution P‐wave averaged ECG for evaluation of patients prone to atrial fibrillation In Electrocardiology, p. 139–142. Singapore: World Scientific Publishers, 1996. [Google Scholar]
- 21. Frank E: An accurate clinically practical system for spatial VCG. Circulation 1956; 13: 737–749 [DOI] [PubMed] [Google Scholar]
- 22. Engel TR, Vallone N, Windle J: Signal‐averaged electrocardiograms in patients with atrial fibrillation of flutter. Am Heart J 1988; 115: 592–597 [DOI] [PubMed] [Google Scholar]
- 23. Howard WT: Heart hypertrophy: An analysis of 105 cases of heart hypertrophy from the autopsy records of Johns Hopkins Hospital. The Johns Hopkins Hospital Reports 1893; 3: 265–300 [Google Scholar]
- 24. Kannel WB, Gordon T, Offutt D: Left ventricular hypertrophy by electrocardiogram: Prevalence, incidence, and mortality in the Framingham Study. Ann Intern Med 1969; 71: 89–105 [DOI] [PubMed] [Google Scholar]
- 25. Agabiti‐Rosei E, Muiesan ML: Left ventricular hypertrophy: How to influence an important risk factor in hypertension. J Hypertens 1998. (); 16 (suppl l): S53–58 [PubMed] [Google Scholar]
- 26. Mosterd A D'Agostino RB, Silbershatz H, Sytkowski PA, Kannel WB, Grobbee DE, Levy D: Trends in the prevalence of hypertension, antihypertensive therapy, and left ventricular hypertrophy from 1950 to 1989. N Engl J Med 1999; 340 lpar;16): 1221–1227 [DOI] [PubMed] [Google Scholar]
- 27. Schulman DS, Flores AR, Tugoen J, Dianzumba S, Reichek N: Antihypertensive treatment in hypertensive patients with normal left ventricular mass is associated with left ventricular remodeling and improved diastolic function. Am J Cardiol 1996; 78 lpar;1): 56–60 [DOI] [PubMed] [Google Scholar]
- 28. Miller JT O'Rourke RA, Crawford MH: Left atrial enlargement: An early sign of hypertensive heart disease. Am Heart J 1988; 116 (4): 1048–1051 [DOI] [PubMed] [Google Scholar]
- 29. Vainer J, Cheriex EC van der Steld B, Dassen WR, Smeets JL, Wellens HJ: Effects of acute volume changes on P wave characteristics: Correlation with echocardiographic findings in healthy men. J Cardiovasc Electrophys 1994; 5 lpar;12): 999–1005 [DOI] [PubMed] [Google Scholar]
- 30. Linden RJ: The size of the heart. Cardioscience 1994; 5 lpar;4): 225–233 [PubMed] [Google Scholar]
- 31. Messerli FH: The Heart and Hypertension. New York: Yorke Medical Books, 1987. [Google Scholar]
- 32. Dulhoste MN, Dos Santos P, Cauchi G, Lemouroux A, Cheradame I, Clementy J: Study and value of high amplification atrial signal in arterial hypertension. Arch Mal Coeur Vaiss 1992: 85 lpar;8): 1119–1122 (in French) [PubMed] [Google Scholar]
- 33. Graettinger WF, Cheung DG, Weber MA: P‐wave configuration as an indicator of echocardiographic indices of cardiac structure and function in normotensive adolescents. Chest 1990; 97 lpar;4): 896–900 [DOI] [PubMed] [Google Scholar]
- 34. Genovesi‐Ebert A, Marabotti C, Palombo C, Ghione S: Electrocardiographic signs of atrial overload in hypertensive patients: Indexes of abnormality of atrial morphology or function? Am Heart J 1991; 121 (4Pt. 1): 1113–1118 [DOI] [PubMed] [Google Scholar]
- 35. Niwano S, Aizawa Y: Fragmented atrial activity in patients with transient atrial fibrillation. Am Heart J 1991; 121 (1 Pt 1): 62–67 [DOI] [PubMed] [Google Scholar]
- 36. Janse MJ: Why does atrial fibrillation occur? Eur Heart J 1997; 18 (suppl C): C12–C18 [DOI] [PubMed] [Google Scholar]
- 37. Lee DK, Marantz PR, Devereux RB, Kligfield P, Alderman MH: Left ventricular hypertrophy in black and white hypertensives. Standard electrocardiographic criteria overestimate racial differences in prevalence. J Am Med Assoc 1992; 267 lpar;24): 3294–3299 [PubMed] [Google Scholar]
- 38. Chapman JN, Mayet J, Chang CL, Foale RA, Thorn SA, Poulter NR: Ethnic differences in the identification of left ventricular hypertrophy in the hypertensive patient. Am J Hypertens 1999; 12 (5); 437–442 [DOI] [PubMed] [Google Scholar]
- 39. Mayet J, Shahi M, Poulter NR, Sever PS, Foale RA, Thorn SA: Left ventricular geometry in presenting untreated hypertension. J Hum Hypertens 1997; 11 lpar;9): 593–594 [DOI] [PubMed] [Google Scholar]
- 40. Olutade BO, Gbadebo TD, Porter VD, Wilkening B, Hall WD: Racial differences in ambulatory blood pressure and echocardiographic left ventricular geometry. Am J Med Sci 1998; 315 lpar;2): 101–109 [DOI] [PubMed] [Google Scholar]
- 41. Beltman FW, Heesen WF, Kok R: Predictive value of ambulatory blood pressure shortly after withdrawal of antihypertensive drugs in primary care patients. Br Med J 1996; 313 lpar;7054): 404–406 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42. VA Cooperative Study Group : Return of elevated blood pressure after withdrawal of antihypertensive drugs. Circulation 1975; 51 (6): 1107–1113 [DOI] [PubMed] [Google Scholar]
- 43. Gonzalez‐Fernandez RA, Altieri PI, Fernandez‐Martinez J: Reduction in cardiac conduction velocity delay by angiotensin converting enzyme inhibition in hypertensive patients with ventricular hypertrophy. Detection by signal averaged electrocardiography. Am J Hypertens 1992; 5 (12 Pt. 1): 896–899 [DOI] [PubMed] [Google Scholar]