How P-wave indices can improve AFib-related ischemic stroke prediction

Background: Current AFib management guidelines recommend ischemic stroke risk stratification with CHA₂DS₂-VASc score; however, emerging studies have highlighted limitations of this score.

Study design: Retrospective review of previously obtained prospective cohort study data.

Setting: Fourteen U.S. communities.

Synopsis: For the 2,929 individuals with new incident AFib without anticoagulant use in the prior year, study authors computed P-wave indices (including P-wave axis, P-wave duration, advanced interatrial block, and P-wave terminal force in lead V1) from the most recent sinus rhythm EKG prior to the diagnosis of AFib. Cox proportional hazard models estimated the hazard ratio between PWIs and ischemic stroke. Of the PWIs tested above, abnormal P-wave axis (hazard ratio, 1.88; 95% confidence interval, 1.36-2.61) and advanced interatrial block (HR, 2.93; 95% CI 1.78-4.81) were associated with increased risk of stroke after adjustment for individual CHA₂DS₂-VASc variables. A P₂-CHA₂DS₂-VASc score that incorporated abnormal P-wave axis measurements demonstrated superior discrimination, compared with the CHA₂DS₂-VASc score alone, and resulted in improvement in ischemic stroke risk classification.

Bottom line: Abnormal P-wave axis and advanced interatrial block measured during periods of sinus rhythm may be associated with increased risk of ischemic stroke in patients with atrial fibrillation; the P₂-CHA₂DS₂-VASc score incorporating abnormal P-wave axis may be superior to CHA₂DS₂-VASc in ischemic stroke risk classification.

Citation: Maheshwari A et al. Refining prediction of atrial fibrillation–­related stroke using the P₂-CHA₂DS₂-VASc score. Circulation. 2019 Jan 8;139:180-91.

Dr. Cooke is a hospitalist at Beth Israel Deaconess Medical Center.

Background: Current AFib management guidelines recommend ischemic stroke risk stratification with CHA₂DS₂-VASc score; however, emerging studies have highlighted limitations of this score.

Study design: Retrospective review of previously obtained prospective cohort study data.

Setting: Fourteen U.S. communities.

Synopsis: For the 2,929 individuals with new incident AFib without anticoagulant use in the prior year, study authors computed P-wave indices (including P-wave axis, P-wave duration, advanced interatrial block, and P-wave terminal force in lead V1) from the most recent sinus rhythm EKG prior to the diagnosis of AFib. Cox proportional hazard models estimated the hazard ratio between PWIs and ischemic stroke. Of the PWIs tested above, abnormal P-wave axis (hazard ratio, 1.88; 95% confidence interval, 1.36-2.61) and advanced interatrial block (HR, 2.93; 95% CI 1.78-4.81) were associated with increased risk of stroke after adjustment for individual CHA₂DS₂-VASc variables. A P₂-CHA₂DS₂-VASc score that incorporated abnormal P-wave axis measurements demonstrated superior discrimination, compared with the CHA₂DS₂-VASc score alone, and resulted in improvement in ischemic stroke risk classification.

Bottom line: Abnormal P-wave axis and advanced interatrial block measured during periods of sinus rhythm may be associated with increased risk of ischemic stroke in patients with atrial fibrillation; the P₂-CHA₂DS₂-VASc score incorporating abnormal P-wave axis may be superior to CHA₂DS₂-VASc in ischemic stroke risk classification.

Citation: Maheshwari A et al. Refining prediction of atrial fibrillation–­related stroke using the P₂-CHA₂DS₂-VASc score. Circulation. 2019 Jan 8;139:180-91.

Dr. Cooke is a hospitalist at Beth Israel Deaconess Medical Center.

Background: Current AFib management guidelines recommend ischemic stroke risk stratification with CHA₂DS₂-VASc score; however, emerging studies have highlighted limitations of this score.

Study design: Retrospective review of previously obtained prospective cohort study data.

Setting: Fourteen U.S. communities.

Synopsis: For the 2,929 individuals with new incident AFib without anticoagulant use in the prior year, study authors computed P-wave indices (including P-wave axis, P-wave duration, advanced interatrial block, and P-wave terminal force in lead V1) from the most recent sinus rhythm EKG prior to the diagnosis of AFib. Cox proportional hazard models estimated the hazard ratio between PWIs and ischemic stroke. Of the PWIs tested above, abnormal P-wave axis (hazard ratio, 1.88; 95% confidence interval, 1.36-2.61) and advanced interatrial block (HR, 2.93; 95% CI 1.78-4.81) were associated with increased risk of stroke after adjustment for individual CHA₂DS₂-VASc variables. A P₂-CHA₂DS₂-VASc score that incorporated abnormal P-wave axis measurements demonstrated superior discrimination, compared with the CHA₂DS₂-VASc score alone, and resulted in improvement in ischemic stroke risk classification.

Bottom line: Abnormal P-wave axis and advanced interatrial block measured during periods of sinus rhythm may be associated with increased risk of ischemic stroke in patients with atrial fibrillation; the P₂-CHA₂DS₂-VASc score incorporating abnormal P-wave axis may be superior to CHA₂DS₂-VASc in ischemic stroke risk classification.

Citation: Maheshwari A et al. Refining prediction of atrial fibrillation–­related stroke using the P₂-CHA₂DS₂-VASc score. Circulation. 2019 Jan 8;139:180-91.

Dr. Cooke is a hospitalist at Beth Israel Deaconess Medical Center.