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. 2020 Nov 4;10(11):e033553.
doi: 10.1136/bmjopen-2019-033553.

Association between P wave polarity in atrial premature complexes and cardiovascular events in a community-dwelling population

Tomoyuki Kabutoya  1 , Yasushi Imai  2 , Shizukiyo Ishikawa  3 , Kazuomi Kario  2
Affiliations

Association between P wave polarity in atrial premature complexes and cardiovascular events in a community-dwelling population

Tomoyuki Kabutoya et al. BMJ Open. .

Abstract

Objective: To examine the association between polarity of atrial premature complexes (APCs) and stroke.

Design: A prospective study.

Setting and participants: A total of 11 092 participants in the Jichi Medical School cohort study were included after excluding patients with atrial fibrillation. We analysed stroke events in patients with (n=136) and without (n=10 956) APCs. With regard to polarity of APCs, patients were subcategorised into having (1) negative (n=39) or non-negative (n=97) P waves in augmented vector right (aVR), and (2) positive (n=28) or non-positive (n=108) P waves in augmented vector left (aVL).

Outcome measures: The primary endpoint was stroke.

Results: Patients with APCs were significantly older than those without APCs (64.1±9.2 vs 55.1±11.6 years, p<0.001). The mean follow-up period was 11.8±2.4 years. Stroke events were observed in patients with (n=13 events) and without (n=411 events) APCs. This difference was significant (log-rank 12.9, p<0.001); however, APCs were not an independent predictor of stroke after adjusting for age, sex, height, body mass index, current drinking, diabetes, systolic blood pressure, prior myocardial infarction, prior stroke and high-density lipoprotein-cholesterol (p=0.15). The incidence of stroke in patients with APCs and non-negative P wave in aVR was significantly higher than in patients without APCs (log-rank 20.1, p<0.001), and non-negative P wave in aVR was revealed to be an independent predictor of stroke (HR 1.84, 95% CI 1.02 to 3.30). The incidence of stroke in patients with APC with non-positive P wave in aVL was also significantly higher than in patients without APC (log-rank 15.3, p<0.001), and non-positive P wave in aVL was an independent predictor of stroke (HR 1.92, 95% CI 1.05 to 3.54).

Conclusions: The presence of APCs with non-negative P wave in aVR or non-positive P wave in aVL on 12-lead ECG was associated with a higher risk of incident stroke.

Keywords: P-wave; atrial premature complexes; stroke.

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Conflict of interest statement

Competing interests: TK has received scholarship funding from Mitsubishi Tanabe Pharma. KK has received research grants from A&D, Omron Healthcare, Roche Diagnostics KK, MSD KK, Astellas Pharma, Otsuka Holdings, Otsuka Pharmaceutical, Sanofi KK, Shionogi & Co, Sanwa Kagaku Kenkyusho, Daiichi Sankyo, Sumitomo Dainippon Pharma, Takeda Pharmaceutical, Mitsubishi Tanabe Pharma, Teijin Pharma, Boehringer Ingelheim Japan, Pfizer Japan and Fukuda Denshi.

Figures

Figure 1
Figure 1
Study protocol. APC, atrial premature complex; aVL, augmented vector left; aVR, augmented vector right; JMS, Jichi Medical School.
Figure 2
Figure 2
Definition of polarity in aVR and aVL. (A) A case of non-negative P wave in aVR and positive P wave in aVL. A clear unipolar positive P wave of an APC was observed in the aVR and aVL leads (black arrow). (B) A case of non-negative P wave in aVR and non-positive P wave in aVL. Neither the polarity of an APC in aVR nor that in aVL could be determined (white arrows). APCs, atrial premature complexes; aVL, augmented vector left; aVR, augmented vector right.
Figure 3
Figure 3
Stroke events according to APCs. Stroke events according to (A) APCs, (B) APC style in aVR, (C) APC style in aVL. Ischaemic stroke events according to APC. Ischaemic stroke events according to (D) APCs, (E) APC style in aVR and (F) APC style in aVL. APCs, atrial premature complexes; aVL, augmented vector left; aVR, augmented vector right; F/U, follow-up.
Figure 4
Figure 4
HR according to type of APCs. Adjusted for age, sex, height, body mass index, current drinking, diabetes, systolic blood pressure, prior myocardial infarction, prior stroke and high-density lipoprotein-cholesterol. (A) HR of stroke according to type of APCs. (B) HR of ischaemic stroke according to type of APCs. APCs, atrial premature complexes; aVL, augmented vector left; aVR, augmented vector right.
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