Prolonged atrial electromechanical delay and P-wave parameters in asymptomatic carotid artery stenosis: novel insights from a non-invasive evaluation

Yıl 2025, Cilt: 6 Sayı: 1, 20 - 26, 14.02.2025

Faruk Serhatlıoğlu , Şaban Keleşoğlu

https://doi.org/10.47582/jompac.1592028

Öz

Aims: Stroke is one of the top three causes of death in developed societies. Ischemic strokes are linked to carotid artery stenosis (CAS). Atrial fibrillation (AF) is a commonly encountered clinical arrhythmia. It has been shown that the prolongation of intra- and interatrial conduction times, known as atrial electromechanical delay (EMD), is associated with a higher risk of AF. We aimed to determine the correlation of atrial conduction abnormalities between surface electrocardiographic and TDI measurements in the CAS patient group.
Methods: The study included 76 patients diagnosed with extracranial internal carotid artery (ICA) stenosis. Asymptomatic severe CAS was defined as patients with 70-99% stenosis detected by carotid digital subtraction angiography (DSA). The longest P-wave and the longest atrial conduction time ACT were considered as the maximal P-wave duration. The difference between the longest P-wave (Pmax) and the shortest P-wave (Pmin) was accepted as PD. (PD=Pmax-Pmin). Atrial EMD was defined as the time interval from the onset of atrial electrical activity to the beginning of mechanical atrial contraction.
Results: The CAS group had significantly longer Pmax and PD values compared to the control group (Pmax 104.72±6.03 and 93.06±7.26 ms, p<0.001; PD 48.55±6.72 and 38.50±8.12 ms, p<0.001). In the TDI examination, the atrial EMD parameters (PA lateral, PA septum) were significantly longer in the CAS group compared to the control group. (77.88±5.13 vs 65.53±9.11 ms; p<0.0001; 63.77±3.95 vs 54.56±7.13 ms; p<0.001 respectively) Both interatrial and intra-atrial EMD times were found to be longer in the CAS group compared to the control group (31.72±7.39 vs 22.13±8.67 ms; p<0.001; 17.61±7.76 vs 11.16±7.76 vs 11.16±7.04 ms; p<0.001, respectively). In the correlation analysis, a positive relationship was found between interatrial and interatrial EMD and Pmax and PD (p<0.001, both).
Conclusion: We found that both intra-atrial and inter-atrial electromechanical conduction times were longer in CAS patients. This suggests that CAS patients are at risk for AF in their follow-up.

Anahtar Kelimeler

Carotid artery stenosis, atrial fibrillation, atrial conduction time

Asemptomatik karotid arter stenozunda uzamış atriyal elektromekanik gecikme ve P-dalga parametreleri: invaziv olmayan bir değerlendirmeden yeni görüşler

Öz

Arka Plan: İnme, gelişmiş toplumlarda ölümün ilk üç nedeninden biridir. İskemik inmeler karotis arter stenozu (KAS) ile bağlantılıdır. Atriyal fibrilasyon (AF), yaygın olarak karşılaşılan bir klinik aritmidir. Atriyal elektromekanik gecikme (EMD) olarak bilinen intratriyal ve interatriyal iletim sürelerinin uzamasının daha yüksek AF riski ile ilişkili olduğu gösterilmiştir. KAS hasta grubunda yüzey elektrokardiyografi ve doku Doppler ekokardiyografi görüntüleme(TDI) ölçümleri arasındaki atriyal iletim anormalliklerinin korelasyonunu belirlemeyi amaçladık.
Yöntemler: Çalışmaya ekstrakraniyal internal karotis arter (IKA) stenozu tanısı almış 76 hasta dahil edildi. Asemptomatik ciddi KAS, karotis dijital subtraction anjiyografisi (DSA) ile %60-99 stenoz tespit edilen hastalar olarak tanımlandı. En uzun P dalgası ve en uzun atriyal iletim süresi (ACT), maksimum P dalgası süresi olarak kabul edildi. En uzun P dalgası (Pmax) ile en kısa P dalgası (Pmin) arasındaki fark PD olarak kabul edildi. (PD=Pmax-Pmin). Atriyal EMD, atriyal elektriksel aktivitenin başlangıcından mekanik atriyal kasılmanın başlangıcına kadar geçen zaman aralığı olarak tanımlandı.
Sonuçlar: KAS grubunda Pmax ve PD değerleri kontrol grubuna kıyasla anlamlı derecede daha uzundu (Pmax 104,72±6,03 ve 93,06±7,26 ms, p<0,001; PD 48,55±6,72 ve 38,50±8,12 ms, p<0,001). TDI incelemesinde atriyal EMD parametreleri (PA lateral, PA septum) KAS grubunda kontrol grubuna kıyasla anlamlı derecede daha uzundu. (77,88 ±5,13 vs 65,53 ±9,11 ms; P <0,0001; 63,77 ±3,95 vs 54,56 ± 7,13 ms; P <0,0001 sırasıyla) Hem interatriyal hem de intra-atriyal EMD sürelerinin CAS grubunda kontrol grubuna göre daha uzun olduğu bulundu (31,72 ± 7,39 vs 22,13 ± 8,67 ms; P <0,0001; 17,61 ± 7,76 vs 11,16 ± 7,76 vs 11,16 ± 7,04 ms; p <0,001, sırasıyla). Korelasyon analizinde, interatriyal ve interatriyal EMD ile Pmax ve PD arasında pozitif bir ilişki bulundu. (p<0,001, her ikisi de)
Sonuç: KAS hastalarında hem intraatriyal hem de interatriyal elektromekanik iletim sürelerinin daha uzun olduğunu bulduk. Bu, KAS hastalarının takiplerinde AF riski altında olduğunu düşündürmektedir.

Anahtar Kelimeler

Karotid arter stenozu, atriyal fibrilasyon, atriyal iletim süresi

Kaynakça

• Safian RD. Treatment strategies for carotid stenosis in patients at increased risk for surgery. Prog Cardiovasc Dis. 2011;54(1):22-28. doi:10. 1016/j.pcad.2011.03.004
• Heck D, Jost A. Carotid stenosis, stroke, and carotid artery revascularization. Prog Cardiovasc Dis. 2021;65:49-54. doi:10.1016/j.pcad.2021.03.005
• Schindler A, Schinner R, Altaf N, et al. Prediction of stroke risk by detection of hemorrhage in carotid plaques: meta-analysis of individual patient data. JACC Cardiovasc Imaging. 2020;13(2 Pt 1):395-406. doi:10. 1016/j.jcmg.2019.03.028
• Lloyd-Jones D, Adams RJ, Brown TM, et al. Executive summary: heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation. 2010;121(7):948-954. doi:10.1161/CIRCULATIONAHA.109.192666
• Wolowacz SE, Samuel M, Brennan VK, Jasso-Mosqueda JG, Van Gelder IC. The cost of illness of atrial fibrillation: a systematic review of the recent literature. Europace. 2011;13(10):1375-1385. doi:10.1093/europace/eur194
• January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e1-76. doi:10.1016/j.jacc.2014.03.022
• Chiquete E, Torres-Octavo B, Cano-Nigenda V, et al. [Characterisation of factors associated with carotid stenosis in a population at high risk]. Rev Neurol. 2014;58(12):541-547. doi:10.33588/rn.5812.2013226
• Deniz A, Sahiner L, Aytemir K, et al. Tissue Doppler echocardiography can be a useful technique to evaluate atrial conduction time. Cardiol J. 2012;19(5):487-493. doi:10.5603/cj.2012.0089
• Daubert JC, Pavin D, Jauvert G, Mabo P. Intra- and interatrial conduction delay: implications for cardiac pacing. Pacing Clin Electrophysiol. 2004; 27(4):507-525. doi:10.1111/j.1540-8159.2004.00473.x
• Pozios I, Vouliotis AI, Dilaveris P, Tsioufis C. Electro-mechanical alterations in atrial fibrillation: structural, electrical, and functional correlates. J Cardiovasc Dev Dis. 2023;10(4):149. doi:10.3390/jcdd 10040149
• Tükek T, Akkaya V, Demirel S, et al. Effect of Valsalva maneuver on surface electrocardiographic P-wave dispersion in paroxysmal atrial fibrillation. Am J Cardiol. 2000;85(7):896-899, A10. doi:10.1016/s0002-9149(99)00891-7
• Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: the sixth joint task force of the European society of cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European association for cardiovascular prevention & rehabilitation (EACPR). Eur Heart J. 2016;37(29):2315-2381. doi:10.1016/j.atherosclerosis.2016.05.037
• Kawano S, Hiraoka M, Sawanobori T. Electrocardiographic features of P-waves from patients with transient atrial fibrillation. Jpn Heart J. 1988;29(1):57-67. doi:10.1536/ihj.29.57
• Dilaveris PE, Gialafos EJ, Sideris SK, et al. Simple electrocardiographic markers for the prediction of paroxysmal idiopathic atrial fibrillation. Am Heart J. 1998;135(5 Pt 1):733-738. doi:10.1016/s0002-8703(98)70030-4
• Lu Y, Sun Y, Cai L, et al. Non-traditional risk factors for atrial fibrillation: epidemiology, mechanisms, and strategies. Eur Heart J. 2024;ehae887. doi:10.1093/eurheartj/ehae887
• Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European association for cardio-thoracic surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European society of cardiology (ESC) developed with the special contribution of the European heart rhythm association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373-498. doi:10.1093/eurheartj/ehaa612
• Adamsson Eryd S, Östling G, Rosvall M, et al. Carotid intima-media thickness is associated with incidence of hospitalized atrial fibrillation. Atherosclerosis. 2014;233(2):673-678. doi:10.1016/j.atherosclerosis.2014. 01.050
• Willeit K, Pechlaner R, Egger G, et al. Carotid atherosclerosis and incident atrial fibrillation. Arterioscler Thromb Vasc Biol. 2013;33(11):2660-2665. doi:10.1161/ATVBAHA.113.302272
• Heeringa J, van der Kuip DAM, Hofman A, et al. Subclinical atherosclerosis and risk of atrial fibrillation: the rotterdam study. Arch Intern Med. 2007;167(4):382-387. doi:10.1001/archinte.167.4.382
• Luo F, Sun L, Li J, et al. Impact of carotid atherosclerosis on arrhythmia recurrence following atrial fibrillation catheter ablation. Pacing Clin Electrophysiol. 2023;46(4):332-340. doi:10.1111/pace.14679
• Chen LY, Foo DC, Wong RC, et al. Increased carotid intima-media thickness and arterial stiffness are associated with lone atrial fibrillation. Int J Cardiol. 2013;168(3):3132-3134. doi:10.1016/j.ijcard.2013.04.034
• Yilmaz R, Demirbag R. P-wave dispersion in patients with stable coronary artery disease and its relationship with severity of the disease. J Electrocardiol. 2005;38(3):279-284. doi:10.1016/j.jelectrocard.2005.02. 003
• Ozer N, Aytemir K, Atalar E, et al. P-wave dispersion in hypertensive patients with paroxysmal atrial fibrillation. Pacing Clin Electrophysiol. 2000;23(11 Pt 2):1859-1862. doi:10.1111/j.1540-8159.2000.tb07038.x
• Aytemir K, Ozer N, Atalar E, et al. P-wave dispersion on 12-lead electrocardiography in patients with paroxysmal atrial fibrillation. Pacing Clin Electrophysiol. 2000;23(7):1109-1112. doi:10.1111/j.1540-8159.2000.tb00910.x
• Turhan H, Yetkin E, Senen K, et al. Effects of percutaneous mitral balloon valvuloplasty on P-wave dispersion in patients with mitral stenosis. Am J Cardiol. 2002;89(5):607-609. doi:10.1016/s0002-9149(01)02307-4
• Turhan H, Yetkin E, Atak R, et al. Increased P-wave duration and P-wave dispersion in patients with aortic stenosis. Ann Noninvasive Electrocardiol. 2003;8(1):18-21. doi:10.1046/j.1542-474x.2003.08104.x
• Keleşoğlu Ş, Yılmaz Y, Keleşoğlu Ş, Yılmaz Y. New electrocardiographic parameters and risk of atrial arrhythmias in INOCA patients. J Cardiol Cardiovasc Surg. 2023;1(4):86-89. doi:110.51271/JCCVS-0022
• Ergün G, Özkan E, Demirci E, Gökay F, Yilmaz Y. Evaluation of the risk of developing atrial fibrillation with new electrocardiographic parameters in patients with primary hyperparathyroidism. Anatolian Curr Med J. 2023;5(4):459-463. doi:10.38053/acmj.1344172
• Cui QQ, Zhang W, Wang H, et al. Assessment of atrial electromechanical coupling and influential factors in nonrheumatic paroxysmal atrial fibrillation. Clin Cardiol. 2008;31(2):74-78. doi:10.1002/clc.20162
• Bakirci EM, Demirtas L, Degirmenci H, et al. Relationship of the total atrial conduction time to subclinical atherosclerosis, inflammation and echocardiographic parameters in patients with type 2 diabetes mellitus. Clinics (Sao Paulo). 2015;70(2):73-80. doi:10.6061/clinics/2015(02)01
• Ermiş N, Açıkgöz N, Yaşar E, et al. [Evaluation of atrial conduction time by P-wave dispersion and tissue Doppler echocardiography in prehypertensive patients]. Turk Kardiyol Dern Ars. 2010;38(8):525-530.
• Ozer N, Yavuz B, Can I, et al. Doppler tissue evaluation of intra-atrial and interatrial electromechanical delay and comparison with P-wave dispersion in patients with mitral stenosis. J Am Soc Echocardiogr. 2005; 18(9):945-948. doi:10.1016/j.echo.2005.01.015
• Calapkorur B, Kelesoglu S, Sarli B, Turasan A, Arinc H, Kaya MG. Atrial electromechanical delay is impaired in patients with psoriasis. Med Princ Pract. 2015;24(1):30-35. doi:10.1159/000365760
• Keleşoğlu Ş, Yilmaz Y, Gökay F, Simsek Y, Calapkorur B, Elcik D. Atrial electromechanical delay is impaired in patients with primary hyperparathyroidism. Endokrynol Pol. 2021;72(5):550-557. doi:10.5603/EP.a2021.0044
• Nucifora G, Schuijf JD, Tops LF, et al. Prevalence of coronary artery disease assessed by multislice computed tomography coronary angiography in patients with paroxysmal or persistent atrial fibrillation. Circ Cardiovasc Imaging. 2009;2(2):100-106. doi:10.1161/CIRCIMAGING.108.795328
• Sinno H, Derakhchan K, Libersan D, Merhi Y, Leung TK, Nattel S. Atrial ischemia promotes atrial fibrillation in dogs. Circulation. 2003;107(14): 1930-1936. doi:10.1161/01.CIR.0000058743.15215.03
• Iwakiri T, Yano Y, Sato Y, et al. Usefulness of carotid intima-media thickness measurement as an indicator of generalized atherosclerosis: findings from autopsy analysis. Atherosclerosis. 2012;225(2):359-362. doi:10.1016/j.atherosclerosis.2012.10.033
• Cha YM, Dzeja PP, Shen WK, et al. Failing atrial myocardium: energetic deficits accompany structural remodeling and electrical instability. Am J Physiol Heart Circ Physiol. 2003;284(4):H1313-1320. doi:10.1152/ajpheart.00337.2002
• Leite-Moreira AF, Correia-Pinto J, Gillebert TC. Afterload induced changes in myocardial relaxation: a mechanism for diastolic dysfunction. Cardiovasc Res. 1999;43(2):344-353. doi:10.1016/s0008-6363(99)00099-1
• Mitchell GF, Vasan RS, Keyes MJ, et al. Pulse pressure and risk of new-onset atrial fibrillation. JAMA. 2007;297(7):709-715. doi:10.1001/jama. 297.7.709
• Vaziri SM, Larson MG, Lauer MS, Benjamin EJ, Levy D. Influence of blood pressure on left atrial size. The framingham heart study. Hypertension. 1995;25(6):1155-1160. doi:10.1161/01.hyp.25.6.1155
• Dilaveris PE, Gialafos EJ, Chrissos D, et al. Detection of hypertensive patients at risk for paroxysmal atrial fibrillation during sinus rhythm by computer-assisted P-wave analysis. J Hypertens. 1999;17(10):1463-1470. doi:10.1097/00004872-199917100-00015
• Tükek T, Akkaya V, Atılgan D, et al. Changes in P-wave dispersion, left atrial size and function in hypertensive patients with paroxysmal atrial fibrillation. Turk Kardiyol Dern Ars. 2000;28(9):538-542.
• Aboyans V, Ricco JB, Bartelink MLEL, et al. 2017 ESC Guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European society for vascular surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries Endorsed by: the European stroke organization (ESO) the task force for the diagnosis and treatment of peripheral arterial diseases of the European society of cardiology (ESC) and of the European Society for vascular surgery (ESVS). Eur Heart J. 2018;39(9):763-816. doi:10.1093/eurheartj/ehx095