Atrial fibrillation risk evaluation in patients with generalised anxiety disorders: the role of electrocardiographic parameters. Commentary to the article: “Atrial electromechanical delay analysed by tissue Doppler echocardiography is prolonged in patients with generalised anxiety disorders”

published in “Kardiologia Polska” 2017; 75, 6: 581–588 (doi: 10.5603/KP.a2017.0038)

Vincenzo Russo, Anna Rago, Andrea Antonio Papa, Gerardo Nigro

Chair of Cardiology, Second University of Naples – Monaldi Hospital, Naples, Italy

Address for correspondence:
Andrea Antonio Papa, MD, Chair of Cardiology, Second University of Naples – Monaldi Hospital, Naples, Italy, e-mail: andreaantoniopapa@libero.it

We have read with great interest the recent article by Oksuz et al. [1] entitled “Atrial electromechanical delay analysed by tissue Doppler echocardiography is prolonged in patients with generalised anxiety disorders”. The authors showed prolonged intra- and inter-atrial electromechanical delay and increased P-wave dispersion in patients with anxiety disorders, and found a positive correlation between these abnormalities and the severity of the disease, assessed by Hamilton Anxiety Rating Scale.

P-wave dispersion is considered to reflect the discontinuous and inhomogeneous propagation of sinus impulses and the prolongation of atrial conduction time, and it has been shown to be an independent risk factor for atrial fibrillation (AF) development [2].

Over many years, our research group has studied the electrocardiographic and echocardiographic indexes of AF risk in some other clinical conditions, such as obesity [3], beta-thalassemia major [4–7], congenital heart diseases [8], respiratory disease [9], and muscular dystrophies [10–12]. We showed that electrocardiogram (ECG) may be a feasible and low-cost method to early detect the presence of arrhythmogenic substrate and to identify the high-risk subgroup patients in need of careful electrocardiographic monitoring.

Furthermore, it should be noted that in other clinical scenarios, P-wave parameters other than P-wave dispersion are risk predictors of supraventricular arrhythmias and notably of stroke [13–16], as reported in the literature. Specifically, we refer to interatrial block (IAB), which is defined as prolonged conduction time between right and left atria due to impulse delay or blockage, probably most often, but not exclusively, in Bachmann bundle, resulting in prolonged P-wave duration (≥ 120 ms), often with a bifid notch representing the electrical gap between the two-atrium activation. We suggest the authors to analyse IAB, taking the opportunity to firstly report the prevalence of IAB in patients with generalised anxiety disorders.

The authors performed all electrocardiographic measurements manually. In our experience manual measurement on standard paper-printed ECGs is of limited accuracy and reproducibility. To achieve greater precision, we suggest that the authors scan and digitise the ECGs from paper records, in order to display and magnify them to 400% on a high-resolution computer screen. This measurement method allows the measurement of P-wave duration with the use of computer software from all 12 ECG leads without significant intra- and inter-observer coefficients of variation.

In order to integrate and complete the arrhythmological evaluation of patients with generalised anxiety disorders, we suggest that the authors assess the QT, JT, and Tpeak-end dispersion, non-invasive electrocardiographic parameters, to measure the inhomogeneity of regional and transmural ventricular repolarisation, which may represent the electrophysiological substrate for malignant arrhythmias in many clinical conditions [17–22]. Finally, it might be interesting to detect the occurrence of supraventricular arrhythmias in patients with generalised anxiety disorders through a 30-day external loop recorder monitoring and to evaluate a possible correlation between non-invasive risk parameters and arrhythmias. Thus, it might strengthen the data obtained in this valuable study.

Conflict of interest: none declared

References

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