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Electrocardiographic Risk Factors for a Common Cardiac Condition

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A patient in their 60s experienced a several-month history of recurrent dizziness and light-headedness. The spells were occasionally preceded by palpitation, nausea, and coning of the visual fields, prompting the patient to sit down. On the day of admission, the patient had an episode of frank syncope resulting in facial contusion. By the time of arrival to the emergency department, full consciousness was regained without postictal symptoms.

On presentation, the heart rate was 88 beats/min and slightly irregular, and the blood pressure was 138/84 mm Hg. Except for obesity and a distant first heart sound, findings of physical examination and results of routine blood tests, including electrolyte, thyrotropin, and cardiac troponin levels, were normal. The 12-lead electrocardiogram (ECG) is presented in the Figure, A. A subsequent echocardiogram showed moderate left ventricular hypertrophy without wall motion abnormalities. All chamber sizes, including the left atrial transverse diameter and left atrial volume index, were within normal limits. The estimated left ventricular ejection fraction was 60% to 65%. Because of dysrhythmia, evaluation of diastolic function was inconclusive.

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Atrial fibrillation is the most common sustained arrhythmia. Its prevalence increases with age and in the presence of structural heart disease.4 The most dreaded consequence of atrial fibrillation is stroke, which is often devastating. Unfortunately, even patients with silent, unrecognized atrial fibrillation are at risk of stroke.4,5 Today, prolonged ECG monitoring of patients with cryptogenic stroke (ie, those patients for whom detailed evaluation did not find a cause for the cerebrovascular event) is emerging as standard of care.6 There is less robust evidence that widespread monitoring of older adult patients with clinical risk factors but no prior cerebrovascular events is a cost-effective approach.7 In such patients, recognizing ECG risk factors for atrial fibrillation appears to be a crucial task.

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Article Information

Corresponding Author: Laszlo Littmann, MD, PhD, Department of Internal Medicine, Atrium Health Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232 (laszlo.littmann@atriumhealth.org).

Published Online: August 8, 2022. doi:10.1001/jamainternmed.2022.3304

Conflict of Interest Disclosures: None reported.

References
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Cheng  S , Keyes  MJ , Larson  MG ,  et al.  Long-term outcomes in individuals with prolonged PR interval or first-degree atrioventricular block.   JAMA. 2009;301(24):2571-2577. doi:10.1001/jama.2009.888PubMedGoogle ScholarCrossref
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Jung  M , Kim  JS , Song  JH ,  et al.  Usefulness of P wave duration in embolic stroke of undetermined source.   J Clin Med. 2020;9(4):1134. doi:10.3390/jcm9041134PubMedGoogle ScholarCrossref
3.
Wallmann  D , Tüller  D , Wustmann  K ,  et al.  Frequent atrial premature beats predict paroxysmal atrial fibrillation in stroke patients: an opportunity for a new diagnostic strategy.   Stroke. 2007;38(8):2292-2294. doi:10.1161/STROKEAHA.107.485110PubMedGoogle ScholarCrossref
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Morin  DP , Bernard  ML , Madias  C , Rogers  PA , Thihalolipavan  S , Estes  NA  III .  The state of the art: atrial fibrillation epidemiology, prevention, and treatment.   Mayo Clin Proc. 2016;91(12):1778-1810. doi:10.1016/j.mayocp.2016.08.022PubMedGoogle ScholarCrossref
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Lin  HJ , Wolf  PA , Benjamin  EJ , Belanger  AJ , D’Agostino  RB .  Newly diagnosed atrial fibrillation and acute stroke: the Framingham Study.   Stroke. 1995;26(9):1527-1530. doi:10.1161/01.STR.26.9.1527PubMedGoogle ScholarCrossref
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Schnabel  RB , Haeusler  KG , Healey  JS ,  et al.  Searching for atrial fibrillation poststroke: a white paper of the AF-SCREEN International Collaboration.   Circulation. 2019;140(22):1834-1850. doi:10.1161/CIRCULATIONAHA.119.040267PubMedGoogle ScholarCrossref
7.
Steinhubl  SR , Waalen  J , Edwards  AM ,  et al.  Effect of a home-based wearable continuous ECG monitoring patch on detection of undiagnosed atrial fibrillation: the mSToPS randomized clinical trial.   JAMA. 2018;320(2):146-155. doi:10.1001/jama.2018.8102PubMedGoogle ScholarCrossref
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Aizawa  Y , Watanabe  H , Okumura  K .  Electrocardiogram (ECG) for the prediction of incident atrial fibrillation: an overview.   J Atr Fibrillation. 2017;10(4):1724. doi:10.4022/jafib.1724PubMedGoogle ScholarCrossref
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Baranchuk  A , Torner  P , de Luna  AB .  Bayés syndrome: what is it?   Circulation. 2018;137(2):200-202. doi:10.1161/CIRCULATIONAHA.117.032333PubMedGoogle ScholarCrossref
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Ariyarajah  V , Apiyasawat  S , Fernandes  J , Kranis  M , Spodick  DH .  Association of atrial fibrillation in patients with interatrial block over prospectively followed controls with comparable echocardiographic parameters.   Am J Cardiol. 2007;99(3):390-392. doi:10.1016/j.amjcard.2006.08.043PubMedGoogle ScholarCrossref
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