Use of the signal-averaged electrocardiogram in arrhythmia evaluation and management
- Sanjiv M Narayan, MD, PhD
Sanjiv M Narayan, MD, PhD
- Professor of Medicine
- Stanford University School of Medicine
- Michael E Cain, MD
Michael E Cain, MD
- Vice President for Health Sciences, Dean of the Jacobs School of Medicine and Biomedical Sciences
- University at Buffalo, Buffalo
Sudden cardiac death affects over 300,000 individuals per year in the United States alone, with ventricular tachycardia (VT) or ventricular fibrillation (VF) being major causes [1,2]. The signal-averaged electrocardiogram (SAECG) is a noninvasive technique that enables detection of the substrate for reentrant arrhythmias, particularly VT.
In patients with the substrate for VT, slow conduction through myocardium disrupted by inflammation, edema, fibrosis, or scar tissue results in electrical potentials that extend beyond the activation time of normal surrounding myocardium, but which are too small for detection on the surface ECG [3,4]. The SAECG uses computerized averaging of ECG complexes, obtained during sinus rhythm, to facilitate the detection of these small microvolt level signals, recorded as ventricular late potentials (figure 1). It is possible that the signals identified by the SAECG, which are related to late potentials identified in patients with structural heart disease and used to guide VT ablation, may also be identified by novel techniques [5,6]. (See "Technical aspects of the signal-averaged electrocardiogram".)
The potential clinical applications for the SAECG are diverse. An American College of Cardiology (ACC) consensus task force provided a guide to the settings in which the SAECG is of proven value, possible value, and not indicated .
This topic will review the use of the SAECG with an emphasis on the efficacy of antiarrhythmic medications, evaluation of the results of arrhythmia surgery, and identification of individuals with paroxysmal atrial fibrillation prone to frequent recurrences based upon abnormalities in the P-wave SAECG [8-10]. The use of the SAECG in other settings is discussed separately. (See "Clinical applications of the signal-averaged electrocardiogram: Overview" and "Use of the signal-averaged electrocardiogram in nonischemic heart disease and cardiac transplantation" and "Use of the signal-averaged electrocardiogram in ischemic heart disease".)
PREDICTING THE EFFICACY OF ANTIARRHYTHMIC DRUGS
Although anti-arrhythmic drug efficacy is typically assessed by absence of recurrent arrhythmias, the SAECG offers an a priori method to assess drug efficacy. Several studies have tested the hypothesis that abnormalities on the SAECG evolve with the arrhythmogenic substrate, and thus diminish with successful antiarrhythmic therapy, in parallel with reduced risk for ventricular arrhythmias. As expected, changes in the SAECG correlate poorly with the clinical efficacy of anti-arrhythmic drugs that have not been shown to abolish late potentials . (See "Pharmacologic therapy in survivors of sudden cardiac arrest".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Bayés de Luna A, Coumel P, Leclercq JF. Ambulatory sudden cardiac death: mechanisms of production of fatal arrhythmia on the basis of data from 157 cases. Am Heart J 1989; 117:151.
- Zheng ZJ, Croft JB, Giles WH, Mensah GA. Sudden cardiac death in the United States, 1989 to 1998. Circulation 2001; 104:2158.
- El-Sherif N, Scherlag BJ, Lazzara R, Hope RR. Re-entrant ventricular arrhythmias in the late myocardial infarction period. 1. Conduction characteristics in the infarction zone. Circulation 1977; 55:686.
- Pogwizd SM, Hoyt RH, Saffitz JE, et al. Reentrant and focal mechanisms underlying ventricular tachycardia in the human heart. Circulation 1992; 86:1872.
- Jamil-Copley S, Vergara P, Carbucicchio C, et al. Application of ripple mapping to visualize slow conduction channels within the infarct-related left ventricular scar. Circ Arrhythm Electrophysiol 2015; 8:76.
- Jaïs P, Maury P, Khairy P, et al. Elimination of local abnormal ventricular activities: a new end point for substrate modification in patients with scar-related ventricular tachycardia. Circulation 2012; 125:2184.
- Signal-averaged electrocardiography. J Am Coll Cardiol 1996; 27:238.
- Freedman RA, Steinberg JS. Selective prolongation of QRS late potentials by sodium channel blocking antiarrhythmic drugs: relation to slowing of ventricular tachycardia. Electrophysiologic Study Versus Electrocardiographic Monitoring Trial (ESVEM) Investigators. J Am Coll Cardiol 1991; 17:1017.
- Denniss AR, Johnson DC, Richards DA, et al. Effect of excision of ventricular myocardium on delayed potentials detected by the signal-averaged electrocardiogram in patients with ventricular tachycardia. Am J Cardiol 1987; 59:591.
- Ehlert FA, Steinberg JS. The P wave signal-averaged ECG. J Electrocardiol 1995; 28 Suppl:33.
- Denniss AR, Ross DL, Richards DA, et al. Effect of antiarrhythmic therapy on delayed potentials detected by the signal-averaged electrocardiogram in patients with ventricular tachycardia after acute myocardial infarction. Am J Cardiol 1986; 58:261.
- Hopson JR, Kienzle MG, Aschoff AM, Shirkey DR. Noninvasive prediction of efficacy of type IA antiarrhythmic drugs by the signal-averaged electrocardiogram in patients with coronary artery disease and sustained ventricular tachycardia. Am J Cardiol 1993; 72:288.
- Kulakowski P, Bashir Y, Heald S, et al. Effects of procainamide on the signal-averaged electrocardiogram in relation to the results of programmed ventricular stimulation in patients with sustained monomorphic ventricular tachycardia. J Am Coll Cardiol 1993; 21:1428.
- Greenspon AJ, Kidwell GA, DeCaro M, Hessen S. The effects of type I antiarrhythmic drugs on the signal-averaged electrocardiogram in patients with malignant ventricular arrhythmias. Pacing Clin Electrophysiol 1992; 15:1445.
- Takanaka C, Nonokawa M, Machii T, et al. Mexiletine and propafenone: a comparative study of monotherapy, low, and full dose combination therapy. Pacing Clin Electrophysiol 1992; 15:2130.
- Lombardi F, Finocchiaro ML, Dalla Vecchia L, et al. Effects of mexiletine, propafenone and flecainide on signal-averaged electrocardiogram. Eur Heart J 1992; 13:517.
- Kulakowski P, Gibson S, Ward J, Camm AJ. Flecainide-related alterations in the signal-averaged electrocardiogram: similarity between patients with or without ventricular tachycardia. Eur Heart J 1992; 13:808.
- Denniss AR, Richards DA, Cody DV, et al. Prognostic significance of ventricular tachycardia and fibrillation induced at programmed stimulation and delayed potentials detected on the signal-averaged electrocardiograms of survivors of acute myocardial infarction. Circulation 1986; 74:731.
- Kulakowski P, Bashir Y, Heald S, et al. Prediction of antiarrhythmic efficacy of class I and III agents in patients with ventricular tachycardia by signal-averaged ECG analysis. Pacing Clin Electrophysiol 1992; 15:2116.
- Borbola J, Denes P. Oral amiodarone loading therapy. I. The effect on serial signal-averaged electrocardiographic recordings and the QTc in patients with ventricular tachyarrhythmias. Am Heart J 1988; 115:1202.
- Goedel-Meinen L, Hofmann M, Schmidt G, et al. Amiodarone--efficacy and late potentials during long-term therapy. Int J Clin Pharmacol Ther Toxicol 1990; 28:449.
- Freedman RA, Karagounis LA, Steinberg JS. Effects of sotalol on the signal-averaged electrocardiogram in patients with sustained ventricular tachycardia: relation to suppression of inducibility and changes in tachycardia cycle length. J Am Coll Cardiol 1992; 20:1213.
- Waldo AL, Camm AJ, deRuyter H, et al. Effect of d-sotalol on mortality in patients with left ventricular dysfunction after recent and remote myocardial infarction. The SWORD Investigators. Survival With Oral d-Sotalol. Lancet 1996; 348:7.
- Cain ME, Ambos HD, Witkowski FX, Sobel BE. Fast-Fourier transform analysis of signal-averaged electrocardiograms for identification of patients prone to sustained ventricular tachycardia. Circulation 1984; 69:711.
- Wolzt M, Schmetterer L, Kastner J, et al. Short-term drug effects on the signal-averaged electrocardiogram in healthy men: assessment of intra- and interindividual variability of spectral temporal mapping and time-domain analysis. J Pharmacol Exp Ther 1995; 275:1375.
- Cain, ME, Ambos, et al. Therapeutic implications of spectral alterations in ECGs induced by antiarrhythmic drugs (abstract). Circulation 1990; 82:III354.
- Fetsch, T, et al. Is the efficacy of sotalol treatment predictable by the analysis of spectral turbulences from the signal-averaged ECG? (abstract). Circulation 1993; 88(Suppl) I:I.
- Anderson KP, Bigger JT Jr, Freedman RA. Electrocardiographic predictors in the ESVEM trial: unsustained ventricular tachycardia, heart period variability, and the signal-averaged electrocardiogram. Prog Cardiovasc Dis 1996; 38:463.
- Marcus NH, Falcone RA, Harken AH, et al. Body surface late potentials: effects of endocardial resection in patients with ventricular tachycardia. Circulation 1984; 70:632.
- Dailey SM, Kay GN, Epstein AE, Plumb VJ. Modification of late potentials by intracoronary ethanol infusion. Pacing Clin Electrophysiol 1992; 15:1646.
- Reddy VY, Reynolds MR, Neuzil P, et al. Prophylactic catheter ablation for the prevention of defibrillator therapy. N Engl J Med 2007; 357:2657.
- Oginosawa Y, Nogami A, Soejima K, et al. Effect of cardiac resynchronization therapy in isolated ventricular noncompaction in adults: follow-up of four cases. J Cardiovasc Electrophysiol 2008; 19:935.
- Santangeli P, Di Biase L, Horton R, et al. Ablation of atrial fibrillation under therapeutic warfarin reduces periprocedural complications: evidence from a meta-analysis. Circ Arrhythm Electrophysiol 2012; 5:302.
- Zorzi A, Migliore F, Elmaghawry M, et al. Electrocardiographic predictors of electroanatomic scar size in arrhythmogenic right ventricular cardiomyopathy: implications for arrhythmic risk stratification. J Cardiovasc Electrophysiol 2013; 24:1321.
- Breithardt G, Borggrefe M, Karbenn U, Schwarzmaier J. Effects of pharmacological and non-pharmacological interventions on ventricular late potentials. Eur Heart J 1987; 8 Suppl A:97.
- Guidera SA, Steinberg JS. The signal-averaged P wave duration: a rapid and noninvasive marker of risk of atrial fibrillation. J Am Coll Cardiol 1993; 21:1645.
- Fukunami M, Yamada T, Ohmori M, et al. Detection of patients at risk for paroxysmal atrial fibrillation during sinus rhythm by P wave-triggered signal-averaged electrocardiogram. Circulation 1991; 83:162.
- Chang, AC, Winkler, et al. P wave signal-averaging identifies hypertrophic cardiomyopathy patients with paroxysmal atrial fibrillation [abstract]. J Am Coll Cardiol 1990; 15:191A.
- Stafford PJ, Turner I, Vincent R. Quantitative analysis of signal-averaged P waves in idiopathic paroxysmal atrial fibrillation. Am J Cardiol 1991; 68:751.
- Roberts-Thomson KC, Stevenson IH, Kistler PM, et al. Anatomically determined functional conduction delay in the posterior left atrium relationship to structural heart disease. J Am Coll Cardiol 2008; 51:856.
- Lalani GG, Schricker A, Gibson M, et al. Atrial conduction slows immediately before the onset of human atrial fibrillation: a bi-atrial contact mapping study of transitions to atrial fibrillation. J Am Coll Cardiol 2012; 59:595.
- Yamada T, Fukunami M, Ohmori M, et al. Characteristics of frequency content of atrial signal-averaged electrocardiograms during sinus rhythm in patients with paroxysmal atrial fibrillation. J Am Coll Cardiol 1992; 19:559.
- Abe Y, Fukunami M, Yamada T, et al. Prediction of transition to chronic atrial fibrillation in patients with paroxysmal atrial fibrillation by signal-averaged electrocardiography: a prospective study. Circulation 1997; 96:2612.
- Iwakura, K, Abe, et al. Relationship between frequency and duration of paroxysmal atrial fibrillation attacks and atrial late potentials (abstract). Circulation 1992; 86(Suppl I):I131.
- Klein M, Evans SJ, Blumberg S, et al. Use of P-wave-triggered, P-wave signal-averaged electrocardiogram to predict atrial fibrillation after coronary artery bypass surgery. Am Heart J 1995; 129:895.
- Zaman AG, Archbold RA, Helft G, et al. Atrial fibrillation after coronary artery bypass surgery: a model for preoperative risk stratification. Circulation 2000; 101:1403.
- Stafford PJ, Kolvekar S, Cooper J, et al. Signal averaged P wave compared with standard electrocardiography or echocardiography for prediction of atrial fibrillation after coronary bypass grafting. Heart 1997; 77:417.
- Cecchi F, Montereggi A, Olivotto I, et al. Risk for atrial fibrillation in patients with hypertrophic cardiomyopathy assessed by signal averaged P wave duration. Heart 1997; 78:44.
- Holmqvist F, Platonov PG, McNitt S, et al. Abnormal P-wave morphology is a predictor of atrial fibrillation development and cardiac death in MADIT II patients. Ann Noninvasive Electrocardiol 2010; 15:63.
- Holmqvist F, Platonov PG, Carlson J, et al. Altered interatrial conduction detected in MADIT II patients bound to develop atrial fibrillation. Ann Noninvasive Electrocardiol 2009; 14:268.
- Raitt MH, Ingram KD, Thurman SM. Signal-averaged P wave duration predicts early recurrence of atrial fibrillation after cardioversion. Pacing Clin Electrophysiol 2000; 23:259.
- Yoshida T, Ikeda H, Hiraki T, et al. Detection of concealed left sided accessory atrioventricular pathway by P wave signal averaged electrocardiogram. J Am Coll Cardiol 1999; 33:55.
- Stafford PJ, Cooper J, Fothergill J, et al. Reproducibility of the signal averaged P wave: time and frequency domain analysis. Heart 1997; 77:412.
- Cheema AN, Ahmed MW, Kadish AH, Goldberger JJ. Effects of autonomic stimulation and blockade on signal-averaged P wave duration. J Am Coll Cardiol 1995; 26:497.
- Stafford PJ, Cooper J, Garratt CJ. Improved recovery of high frequency P wave energy by selective P wave averaging. Pacing Clin Electrophysiol 1996; 19:1225.
- PREDICTING THE EFFICACY OF ANTIARRHYTHMIC DRUGS
- Summary for predicting drug efficacy
- DETERMINING THE SUCCESS OF ANATOMICAL ARRHYTHMIA THERAPY
- Summary for predicting efficacy of ablation
- P-WAVE SAECG AND ATRIAL FIBRILLATION
- Paroxysmal AF
- Transition to chronic AF
- Development of AF
- Recurrence of AF after cardioversion
- Detection of accessory pathway
- Summary for predicting AF
- SUMMARY AND RECOMMENDATIONS