Assessing Atrial Fibrillation Substrates by P Wave Analysis: A Comprehensive Review
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REVIEW ARTICLE
Assessing Atrial Fibrillation Substrates by P Wave Analysis: A Comprehensive Review Francesca Palano1 · Carmen Adduci1 · Pietro Cosentino1 · Giacomo Silvetti1 · Francesca Boldini1 · Pietro Francia1 Received: 10 April 2020 / Accepted: 13 May 2020 © Italian Society of Hypertension 2020
Abstract Atrial fibrillation (AF) is the most common cardiac arrhythmia. Pharmacologic and non-pharmacologic rhythm control strategies impact on AF-related symptoms, while leaving largely unaffected the risk of stroke. Moreover, up to 20% of AF patients are asymptomatic during paroxysmal relapses of arrhythmia, thus underlying the need for early markers to identify at-risk patients and prevent cerebrovascular accidents. Indeed, non-invasive assessment of pre-clinical substrate changes that predispose to AF could provide early identification of at-risk patients and allow for tailored care paths. ECG-derived P wave analysis is a simple-to-use and inexpensive tool that has been successfully employed to detect AF-associated structural and functional atrial changes. Beyond standard electrocardiographic techniques, high resolution signal averaged electrocardiography (SAECG), by recording microvolt amplitude atrial signals, allows more accurate analysis of the P wave and possibly AF risk stratification. This review focuses on the evidence that support P wave analysis to assess AF substrates, predict arrhythmia relapses and guide rhythm-control interventions. Keywords P wave · Atrial fibrillation · Signal averaged electrocardiography · Atrial fibrillation ablation
1 Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia [1, 2]. Over the last 2 decades, our understanding of the mechanisms linking anatomic, neurohormonal and electrical substrates of AF has significantly grown [3]. Notwithstanding this, establishing the relative contribution of atrial structural and electrical substrates to the clinical heterogeneity of AF remains a challenge. Electrical triggers of AF are often combined with neurohormonal factors and structural abnormalities of the left atrium (LA). Pulmonary veins (PVs) have a crucial role in triggering AF through multiple localized re-entry circuits that rapidly extend to the atria, resulting in chaotic electrical activation. Central cores with spiral waves radiating from re-entry circuits (rotors) seem to contribute to persistence of AF [4, 5]. Moreover, atrial fibrosis promotes inhomogeneous electrical conduction and offers the ideal milieu for triggering and sustaining AF [6–9]. * Francesca Palano [email protected] 1
Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189 Rome, Italy
Pharmacologic and non-pharmacologic rhythm control strategies impact on AF-related symptoms [10], while leaving largely unaffected the risk of stroke [11, 12]. Of note, up to 20% of AF patients are asymptomatic [13, 14], underlying the need for markers to early identify at-risk patients and prevent cerebrovascular accidents.
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