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Relation of Prolonged P-Wave Duration to Risk of Sudden Cardiac Death in the General Population (from the Atherosclerosis Risk in Communities Study)
The Journal of Emergency Medicine, Vol. 53, No. 2, pp. 277–283, 2017 0736-4679/$ - see front matter
Abstracts , RELATION OF PROLONGED P-WAVE DURATION TO RISK OF SUDDEN CARDIAC DEATH IN THE GENERAL POPULATION (FROM THE ATHEROSCLEROSIS RISK IN COMMUNITIES STUDY). Maheshwari A, Norby FL, Soliman EZ, et al. J Am Card 2017;119(9):1302-1306. While sudden cardiac deaths (SCDs) are most commonly associated with ventricular tachyarrhythmias, there is increasing evidence for a link between markers of abnormal atrial conduction, such as prolonged P-wave duration, and SCD. Prolonged P-wave conduction is a marker of left atrial abnormality and has been linked with atrial fibrillation, myocardial fibrosis, embolic stroke, cardiovascular death and all-cause death. This study hypothesized a link between prolonged P-wave conduction and SCD. After exclusions, a total of 15321 participants were analyzed from the Atherosclerosis Risk in Communities Study, a community based prospective cohort study. Prolonged P wave was defined as a P wave duration of >120ms, and was obtained from 12-lead electrocardiograms (ECG) obtained during 4 exams from 1987 to 1999. Fatal coronary heart disease events were identified as definite SCD, possible SCD, not SCD and unclassifiable. SCDs were classified as a sudden pulseless condition in a previously stable patient with no evidence for non-cardiac death. Cox proportional hazard models where used to examine the relationship between P-wave duration and SCD. Cardiovascular risk factors and preexisting conditions like atrial fibrillation and heart failure were adjusted for with covariate analysis. 268 SCDs where identified over a period of 12.5 years. The hazard ratio for SCDs in patients with a prolonged P-wave duration was 1.70 (95% CI 1.31-2.20). After adjusting for cardiovascular risk factors such as coronary artery disease, heart failure and atrial fibrillation, the association between prolonged P-wave duration and SCD decreased but remained significant: 1.35 (95% CI 1.04-1.76). While the association between P-wave duration and all-cause mortality has been shown previously, this study shows a specific association with SCD. While a proposed mechanism for this might include a propensity for the development of cardiovascular risk factors such as coronary artery disease, heart failure and atrial fibrillation, the association between prolonged P-wave duration and SCD remained significant after adjusting for traditional cardiovascular risk factors, suggesting that prolonged P-wave duration may warrant consideration in risk assessment for SCD. [Mario Andres Camacho, MD Denver Health Medical Center, Denver, CO]
salient case for a link between markers of abnormal atrial conduction and SCD. Interestingly, the association seems to extend beyond atrial fibrillation and other traditional cardiovascular risk factors. Before clinical implementation, further studies need to be done to validate the association and perhaps include it as part of an ECG risk stratification for SCD. For now, it remains in interesting ECG finding with uncertain clinical significance. , NOVEL ORAL ANTICOAGULANTS AND TRAUMA: THE RESULTS OF A PROSPECTIVE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA MULTI-INSTITUTIONAL TRIAL. Kobayashi L, Barmparas G, Bosarge P, et al. J Trauma Acute Care Surg 2017; 82(5):827-835. Trauma remains one of the leading causes of death in the United States. Additionally, the number of elderly trauma patients taking oral antithrombotics (OATs), including warfarin antiplatelet agents and novel oral anticoagulants (NOAs), has been steadily increasing. While patients on warfarin have been found to have poor outcomes following trauma, particularly after intracranial hemorrhage (ICH), trauma outcomes in patients taking NOAs are unknown. This was a prospective observational trial including any trauma patients admitted to the hospital taking dabigatran, rivaroxaban, apixaban, warfarin, aspirin, or clopidogrel. Enrollment occurred across 16 trauma centers over a 2-year period from July 2013 to June 2015. Demographics, comorbidities, injury severity scores (ISS), vital signs, laboratory values and interventions and mechanism of injuries were collected. Outcomes studied included ICH, progression of ICH, bleeding, angiographic or surgical interventions and death. Univariate and multivariate analysis were performed on patient groups. A total of 1847 patients were enrolled, with 50% on antiplatelet agents, 33% on warfarin, 10% on NOAs and 7% on a combination therapy or subcutaneous agent. Blunt trauma was the mechanism in 99% of patients, with a median injury severity score of 9. Patients taking NOAs as compared to traditional anticoagulants (warfarin and aspirin) were not at increased risk of ICH on univariate (24% vs 31%) or multivariate analysis (incidence rate ratio 0.78; 95% CI 0.61-1.01). Of those with ICH, ISS were not different between NOA and traditional anticoagulants, and there was no difference in the rate of progression of ICH. Additionally, there was no increase in death in patients taking NOAs on univariate (7 vs 7%) or multivariate analysis (OR 1.49; 95% CI 0.71-3.12). There was no significant difference in age, sex, injury mechanism, ISS or GCS between the groups.
Comment: While the most common cause of sudden cardiac deaths is due to ventricular tachyarrhythmias, this study makes a 277
Abstracts , RELATION OF PROLONGED P-WAVE DURATION TO RISK OF SUDDEN CARDIAC DEATH IN THE GENERAL POPULATION (FROM THE ATHEROSCLEROSIS RISK IN COMMUNITIES STUDY). Maheshwari A, Norby FL, Soliman EZ, et al. J Am Card 2017;119(9):1302-1306. While sudden cardiac deaths (SCDs) are most commonly associated with ventricular tachyarrhythmias, there is increasing evidence for a link between markers of abnormal atrial conduction, such as prolonged P-wave duration, and SCD. Prolonged P-wave conduction is a marker of left atrial abnormality and has been linked with atrial fibrillation, myocardial fibrosis, embolic stroke, cardiovascular death and all-cause death. This study hypothesized a link between prolonged P-wave conduction and SCD. After exclusions, a total of 15321 participants were analyzed from the Atherosclerosis Risk in Communities Study, a community based prospective cohort study. Prolonged P wave was defined as a P wave duration of >120ms, and was obtained from 12-lead electrocardiograms (ECG) obtained during 4 exams from 1987 to 1999. Fatal coronary heart disease events were identified as definite SCD, possible SCD, not SCD and unclassifiable. SCDs were classified as a sudden pulseless condition in a previously stable patient with no evidence for non-cardiac death. Cox proportional hazard models where used to examine the relationship between P-wave duration and SCD. Cardiovascular risk factors and preexisting conditions like atrial fibrillation and heart failure were adjusted for with covariate analysis. 268 SCDs where identified over a period of 12.5 years. The hazard ratio for SCDs in patients with a prolonged P-wave duration was 1.70 (95% CI 1.31-2.20). After adjusting for cardiovascular risk factors such as coronary artery disease, heart failure and atrial fibrillation, the association between prolonged P-wave duration and SCD decreased but remained significant: 1.35 (95% CI 1.04-1.76). While the association between P-wave duration and all-cause mortality has been shown previously, this study shows a specific association with SCD. While a proposed mechanism for this might include a propensity for the development of cardiovascular risk factors such as coronary artery disease, heart failure and atrial fibrillation, the association between prolonged P-wave duration and SCD remained significant after adjusting for traditional cardiovascular risk factors, suggesting that prolonged P-wave duration may warrant consideration in risk assessment for SCD. [Mario Andres Camacho, MD Denver Health Medical Center, Denver, CO]
salient case for a link between markers of abnormal atrial conduction and SCD. Interestingly, the association seems to extend beyond atrial fibrillation and other traditional cardiovascular risk factors. Before clinical implementation, further studies need to be done to validate the association and perhaps include it as part of an ECG risk stratification for SCD. For now, it remains in interesting ECG finding with uncertain clinical significance. , NOVEL ORAL ANTICOAGULANTS AND TRAUMA: THE RESULTS OF A PROSPECTIVE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA MULTI-INSTITUTIONAL TRIAL. Kobayashi L, Barmparas G, Bosarge P, et al. J Trauma Acute Care Surg 2017; 82(5):827-835. Trauma remains one of the leading causes of death in the United States. Additionally, the number of elderly trauma patients taking oral antithrombotics (OATs), including warfarin antiplatelet agents and novel oral anticoagulants (NOAs), has been steadily increasing. While patients on warfarin have been found to have poor outcomes following trauma, particularly after intracranial hemorrhage (ICH), trauma outcomes in patients taking NOAs are unknown. This was a prospective observational trial including any trauma patients admitted to the hospital taking dabigatran, rivaroxaban, apixaban, warfarin, aspirin, or clopidogrel. Enrollment occurred across 16 trauma centers over a 2-year period from July 2013 to June 2015. Demographics, comorbidities, injury severity scores (ISS), vital signs, laboratory values and interventions and mechanism of injuries were collected. Outcomes studied included ICH, progression of ICH, bleeding, angiographic or surgical interventions and death. Univariate and multivariate analysis were performed on patient groups. A total of 1847 patients were enrolled, with 50% on antiplatelet agents, 33% on warfarin, 10% on NOAs and 7% on a combination therapy or subcutaneous agent. Blunt trauma was the mechanism in 99% of patients, with a median injury severity score of 9. Patients taking NOAs as compared to traditional anticoagulants (warfarin and aspirin) were not at increased risk of ICH on univariate (24% vs 31%) or multivariate analysis (incidence rate ratio 0.78; 95% CI 0.61-1.01). Of those with ICH, ISS were not different between NOA and traditional anticoagulants, and there was no difference in the rate of progression of ICH. Additionally, there was no increase in death in patients taking NOAs on univariate (7 vs 7%) or multivariate analysis (OR 1.49; 95% CI 0.71-3.12). There was no significant difference in age, sex, injury mechanism, ISS or GCS between the groups.
Comment: While the most common cause of sudden cardiac deaths is due to ventricular tachyarrhythmias, this study makes a 277