[Skip to Content]

Claim CME

Cardiology

Noteworthy P Waves in an Elderly Woman

To identify the key insights or developments described in this article

1 Credit CME

JAMA Internal Medicine

Published Online: November 21, 2022

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Gaopin Wang, MD¹;

Qinghua Chang, MD¹;

Renguang Liu, MD¹

Author Affiliations

¹Cardiovascular Institute of the First Affiliated Hospital of Jinzhou Medical University in Jinzhou, Jinzhou, Liaoning Province, China

Read article on JAMA Network

Read Case Claim CME Answer

A patient in their 70s was referred to the emergency department for worsening shortness of breath, chest tightness, and episodes of palpitations. The patient’s medical history was remarkable for hypertension and kidney insufficiency. Initial evaluation revealed a heart rate of 53 beats/min, blood pressure of 221/85 mm Hg. Laboratory test results revealed that the patient’s B-type natriuretic peptide level was 838.6 pg/mL (normal level, <300 pg/mL). The initial 12-lead electrocardiogram (ECG) is presented in the Figure, A. Transthoracic echocardiography showed left atrial enlargement (52 mm), normal left ventricular wall thickness, and mild pulmonary hypertension.

Claim CME

Please finish quiz first before checking answer.

A patient in their 70s was referred to the emergency department for worsening shortness of breath, chest tightness, and episodes of palpitations. The patient’s medical history was remarkable for hypertension and kidney insufficiency. Initial evaluation revealed a heart rate of 53 beats/min, blood pressure of 221/85 mm Hg. Laboratory test results revealed that the patient’s B-type natriuretic peptide level was 838.6 pg/mL (normal level, <300 pg/mL). The initial 12-lead electrocardiogram (ECG) is presented in the Figure, A. Transthoracic echocardiography showed left atrial enlargement (52 mm), normal left ventricular wall thickness, and mild pulmonary hypertension.

Questions: What are the noteworthy findings on the patient’s initial ECG? What is the clinical significance?

Sign in to take quiz and track your certificates

Buy This Activity

Article Information

Corresponding Author: Renguang Liu, The Cardiovascular Institute of the First Affiliated Hospital of Jinzhou Medical University, Renmin Street, Jinzhou 121000, Liaoning Province, China (liurenguanglaoshi@126.com).

Published Online: November 21, 2022. doi:10.1001/jamainternmed.2022.4813

Conflict of Interest Disclosures: None reported.

References

Baranchuk A , Torner P , de Luna AB . Bayés syndrome: what is it? Circulation. 2018;137(2):200-202. doi:10.1161/CIRCULATIONAHA.117.032333 PubMed Google Scholar Crossref

Bacharova L , Wagner GS . The time for naming the interatrial block syndrome: Bayes syndrome. J Electrocardiol. 2015;48(2):133-134. doi:10.1016/j.jelectrocard.2014.12.022 PubMed Google Scholar Crossref

Power DA , Lampert J , Camaj A , et al. Cardiovascular Complications of interatrial conduction block: JACC state-of-the-art review. J Am Coll Cardiol. 2022;79(12):1199-1211. doi:10.1016/j.jacc.2022.01.030 PubMed Google Scholar Crossref

Bayés de Luna A , Platonov P , Cosio FG , et al. Interatrial blocks. a separate entity from left atrial enlargement: a consensus report. J Electrocardiol. 2012;45(5):445-451. doi:10.1016/j.jelectrocard.2012.06.029 PubMed Google Scholar Crossref

Platonov PG . Atrial fibrosis: an obligatory component of arrhythmia mechanisms in atrial fibrillation? J Geriatr Cardiol. 2017;14(4):233-237. doi:10.11909/j.issn.1671-5411.2017.04.008 PubMed Google Scholar

Schotten U , Verheule S , Kirchhof P , Goette A . Pathophysiological mechanisms of atrial fibrillation: a translational appraisal. Physiol Rev. 2011;91(1):265-325. doi:10.1152/physrev.00031.2009 PubMed Google Scholar Crossref

Zhao J , Butters TD , Zhang H , et al. An image-based model of atrial muscular architecture: effects of structural anisotropy on electrical activation. Circ Arrhythm Electrophysiol. 2012;5(2):361-370. doi:10.1161/CIRCEP.111.967950 PubMed Google Scholar Crossref

Chen LY , Ribeiro ALP , Platonov PG , et al. P Wave parameters and indices: a critical appraisal of clinical utility, challenges, and future research-a consensus document endorsed by the International Society of Electrocardiology and the International Society for Holter and Noninvasive Electrocardiology. Circ Arrhythm Electrophysiol. 2022;15(4):e010435. doi:10.1161/CIRCEP.121.010435 PubMed Google Scholar

O’Neal WT , Zhang ZM , Loehr LR , Chen LY , Alonso A , Soliman EZ . Electrocardiographic advanced interatrial block and atrial fibrillation risk in the general population. Am J Cardiol. 2016;117(11):1755-1759. doi:10.1016/j.amjcard.2016.03.013 PubMed Google Scholar Crossref

Skov MW , Ghouse J , Kühl JT , et al. Risk prediction of atrial fibrillation based on electrocardiographic interatrial block. J Am Heart Assoc. 2018;7(11):e008247. doi:10.1161/JAHA.117.008247 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.