Relation of Electrocardiographic Abnormal P-Wave Axis With Stroke Mortality in the General Population

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The link between abnormal P-wave axis (aPWA) and incident ischemic stroke is well established. However, studies examining the association between aPWA and fatal stroke are rare. We hypothesized that aPWA is associated with fatal stroke. We examined the association of abnormal aPWA with stroke mortality in 7,359 participants (60.0 ± 13.4 years, 51.9% women, 49.8% White) without cardiovascular (CV) disease (CVD) from the Third National Health and Nutrition Examination Survey. aPWA was defined as any value <0 or >75°. The National Death Index was used to identify the date and cause of death. Cox proportional hazard analysis was used to examine the association between baseline aPWA with stroke mortality. Over a median follow-up of 14 years, 189 stroke deaths occurred. During follow-up, stroke mortality was more common in those with aPWA than those without aPWA (3.5% vs 2.2%, respectively; p = 0.002). In a multivariable-adjusted model, aPWA was associated with a 44% increased risk of stroke mortality (hazard ratio [HR] 95% confidence interval [CI] 1.44 [1.05 to 1.99]). This association was stronger in men than in women (HR 95% CI 2.29 [1.42 to 3.67] vs 1.00 [0.64 to 1.55]), respectively; p-interaction = 0.04) and among non-Whites than Whites (HR 95% CI 2.20 [1.39 to 3.46] vs. 1.07 [0.68 to 1.69], respectively; p-interaction = 0.09). The annualized stroke death rates/1,000 participants across levels of CHA2DS2-VASc scores were higher in those with than without aPWA. In conclusion, aPWA, a marker of atrial cardiopathy, is associated with an increased risk of stroke mortality, especially among men and non-Whites. Whether intensive risk factor modifications in those with aPWA would reduce the risk of stroke and thus, stroke mortality needs further investigation.

Introduction

Each year, approximately 795,000 patients experience a new or recurrent stroke, and among all strokes, 87% are ischemic in nature.1,2 Significant racial/ethnic disparities exist in both stroke incidence and mortality, with higher rates among Blacks and Mexican-Americans than non-Hispanic Whites.2,3 Racial/ethnic disparities in stroke care are also well documented and contribute further to stroke-associated morbidity and mortality.4,5 Despite the major advances in patient care, significant gaps exist in our understanding of the mechanism of increased stroke risk. More recently, accumulating evidence of heightened risk of ischemic stroke in the presence of left atrial (LA) dysfunction or atrial cardiopathy has suggested that abnormal LA substrate increases the risk of thromboembolism and subsequent stroke, even in the absence of atrial fibrillation (AF). Notably, most of the studies focused on examining the link between markers of atrial cardiopathy and nonfatal stroke,6,7 whereas studies examining the association with fatal stroke are rare.8 Therefore, we examined the relation between abnormal P-wave axis (aPWA), an electrocardiographic marker of atrial cardiopathy,9 with stroke mortality. We also examined the effect modification of race, gender, and age on such an association and explored the rate of stroke deaths across CHA2DS2-VASc stratified by aPWA.

Section snippets

Methods

In this analysis, we used data from the Third National Health and Nutrition Examination Survey (NHANES-III), one of the NHANES periodic surveys of the noninstitutionalized civilian population in the United States. Its principal aim is to determine estimates of disease prevalence and health status of children and adults. The structure of the NHANES-III (1988 and 1994), its components, and resulting data are published elsewhere. The NHANES-III study was approved by the National Center for Health

Results

Among the 7,359 included in the analysis (60.0 ± 13.4 years, 51.9% women, 49.8% White), 23.5% participants (n = 1,730) had aPWA. Table 1 shows the baseline characteristics of the study participants with and without prevalent aPWA. Participants with aPWA were more likely to be older, smokers, and with more prevalent emphysema and chronic bronchitis.

During a median follow-up of 14 years, 189 stroke deaths occurred. Higher stroke death rates were observed in those with (3.5%) than those without

Discussion

The main findings from this analysis of community-dwelling US population comprising multiracial participants are as follows. First, we found a significant association between aPWA, a marker of atrial cardiopathy, and stroke mortality, even after rigorous adjustment for various risk factors. Second, this association was stronger among men than women and among non-Whites than Whites. Third, there was an increasing rate of stroke mortality with an increasing CHA2DS2-VASc score, especially in those

Disclosures

The authors have no conflicts of interest to declare.

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