P-Waves Are the Main Clues for Correct ECG Interpretation

  • Mirko Beltrame
  • Paolo Compagnucci
  • Alessandro Maolo


P-wave correct interpretation may be of main importance. Its morphology and duration may help to increase the ECG sensitivity to diagnose a left ventricular hypertrophy or a diastolic dysfunction. A wide spectrum of cardiovascular and systemic disorders may involve the atria; more recently, the old atrial cardiomyopathy concept has been resumed. An atrial cardiomyopathy may lead to ugly complications such as atrial fibrillation and stroke. Recent clinical data in patients with an implanted cardiac device did show a lack of time correlation between atrial fibrillation and stroke. Thus, atrial fibrillation could be just an epiphenomenon related to abnormal atrial substrate (atrial cardiomyopathy). A recently published meta-analysis (He et al., Stroke 48:2066–72, 2017) has confirmed the association of three left atrial abnormalities easily assessable by means of a surface ECG, namely, increased P-terminal force in the precordial lead V1 (PTFV1) >40 ms mm, prolonged P-wave duration (PWD) >120 ms reflecting interatrial block and greater maximum P-wave area (PWA). Those parameters were associated not only with an increased risk of atrial fibrillation and other supraventricular arrhythmias but also of stroke. Furthermore, in patients with QRS and even repolarization abnormalities, a normal P-wave may be a good sign in favour of pseudo-abnormalities.


  1. 1.
    Obbiassi M, Secchi MB, Mariotti G, et al. P wave analysis for the electrocardiographic diagnosis of left ventricular hypertrophy. A study of a population with arterial hypertension. G Ital Cardiol. 1979;9(10):1118–25.PubMedGoogle Scholar
  2. 2.
    Okin PM, Gerdts E, Wachtell K, et al. Relationship of left atrial enlargement to persistence or development of ECG left ventricular hypertrophy in hypertensive patients: implications for the development of new atrial fibrillation. J Hypertens. 2010;28(7):1534–40.CrossRefGoogle Scholar
  3. 3.
    Nagle RE, Smith B, Williams DO. Familial atrial cardiomyopathy with heart block. Br Heart J. 1972;34:205.CrossRefGoogle Scholar
  4. 4.
    Capucci A, Bracchetti D, Magnani B. Permanent atrial paralysis: clinical and instrumental study of a case. Boll Soc Ital Cardiol. 1977;22(1):45–9.PubMedGoogle Scholar
  5. 5.
    Zipes DP. Atrial fibrillation. A tachycardia induced atrial cardiomyopathy. Circulation. 1997;95:562–4.CrossRefGoogle Scholar
  6. 6.
    Goette A, Kalman JM, Aguinaga L, et al. EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterisation, and clinical implication. J Arrhythm. 2016;32(4):247–78.CrossRefGoogle Scholar
  7. 7.
    Lip GYH, Halperin J. Improving stroke risk stratification in atrial fibrillation. Am J Med. 2010;123:484–8.CrossRefGoogle Scholar
  8. 8.
    Brambatti M, Connolly SJ, Gold MR, ASSERT Investigators, et al. Temporal relationship between subclinical atrial fibrillation and embolic events. Circulation. 2014;129:2094–9.CrossRefGoogle Scholar
  9. 9.
    Kamel H, Okin PM, Elkind MS, et al. Atrial fibrillation and mechanisms of stroke: time for a new model. Stroke. 2016;47(3):895–900.CrossRefGoogle Scholar
  10. 10.
    Puech P. L’activite´ electrique auriculaire normale et pathologuique. Paris: Masson; 1956. p. 206.Google Scholar
  11. 11.
    Chhabra L, Devadoss R, Chaubey VK, et al. Interatrial block in the modern era. Curr Cardiol Rev. 2014;10:181–9.CrossRefGoogle Scholar
  12. 12.
    Baye’s de Luna A, Cladellas M, Oter R, et al. Interatrial conduction block and retrograde activation of the left atrium and paroxysmal supraventricular tachyarrhythmia. Eur Heart J. 1988;9:1112–8.CrossRefGoogle Scholar
  13. 13.
    Castillo P, Vernant P. Troubles de la conduction interauriculaire par bloc du faisceau de Bachmann. Arch Mal Coeur. 1971;64:1490.PubMedGoogle Scholar
  14. 14.
    Bacharova L, Wagner GS. The time for naming the interatrial block syndrome: Bayes syndrome. J Electrocardiol. 2015;48:133–4.CrossRefGoogle Scholar
  15. 15.
    Ariyarajah V, Puri P, Apiyasawat S, et al. Interatrial block: a novel risk factor for embolic stroke? Ann Noninvasive Electrocardiol. 2007;12:15–20.CrossRefGoogle Scholar
  16. 16.
    He J, Tse G, Korantzopoulos P, et al. P-wave indices and risk of ischemic stroke a systematic review and meta-analysis. Stroke. 2017;48:2066–72.CrossRefGoogle Scholar
  17. 17.
    Guichard JB, Nattel S. Atrial cardiomyopathy: a useful notion in cardiac disease management or a passing fad? J Am Coll Cardiol. 2017;70(6):756–65.CrossRefGoogle Scholar
  18. 18.
    Blanche C, et al. Value of P-wave signal averaging to predict atrial fibrillation recurrences after pulmonary vein isolation. Europace. 2013;15(2):198–204.CrossRefGoogle Scholar
  19. 19.
    Steinberg SA, Guidera JS. The signal-averaged P wave duration: a rapid and noninvasive marker of risk of atrial fibrillation. J Am Coll Cardiol. 1993;21:1645–51.CrossRefGoogle Scholar
  20. 20.
    Budeus M, et al. Detection of atrial late potentials with P wave signal-averaged electrocardiogram among patients with paroxysmal atrial fibrillation. Z Kardiol. 2003;92(5):362–9.CrossRefGoogle Scholar
  21. 21.
    Maolo A, Contadini D. Difficult interpretation of ECG: small clues may make the difference. The role of the P-wave. In: Capucci A, editor. Clinical cases in cardiology. Cham: Springer; 2015.Google Scholar
  22. 22.
    Gatzoulis MA, Munk MD, Merchant N, et al. Isolated congenital absence of the pericardium: clinical presentation, diagnosis, and management. Ann Thorac Surg. 2000;69:1209–15.CrossRefGoogle Scholar
  23. 23.
    Abbas AE, Appleton CP, Liu PT, et al. Congenital absence of the pericardium: case presentation and review of literature. Int J Cardiol. 2005;98(1):21–5.CrossRefGoogle Scholar
  24. 24.
    Connolly HM, Click RL, Schattenberg TT, et al. Congenital absence of the pericardium: echocardiography as a diagnostic tool. J Am Soc Echocardiogr. 1995;8:87–92.CrossRefGoogle Scholar
  25. 25.
    Salem DN, Hymanson AS, Isner JM, et al. Congenital pericardial defect diagnosed by computed tomography. Catheter Cardiovasc Diagn. 1985;11:75–9.CrossRefGoogle Scholar
  26. 26.
    Shiavone W. Congenital absence of the left position of parietal pericardium demonstrated by nuclear magnetic resonance imaging. Am J Cardiol. 1985;55:1439.CrossRefGoogle Scholar
  27. 27.
    Rais-Bahrami K, Granholm T, Short BL, et al. Absence of pericardium in an infant with congenital diaphragmatic hernia. Am J Perinatol. 1995;12:172–3.CrossRefGoogle Scholar
  28. 28.
    Spodik D. Congenital abnormalities of the pericardium. The pericardium: a comprehensive review. 1st ed. New York: Marcel Dekker; 1997. p. 65–75.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Mirko Beltrame
    • 1
  • Paolo Compagnucci
    • 1
  • Alessandro Maolo
    • 1
  1. 1.Clinica di Cardiologia e AritmologiaUniveristà Politecnica delle MarcheAnconaItaly

Personalised recommendations