Practice Update: Cardiology

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PAC or PVC on 12-Lead ECG
May Predict Risk of Atrial
Fibrillation, Heart Failure,
or Death
Journal of the American Heart Association
Take-home message
• The authors of this retrospective study aimed to determine if premature atrial
contractions or premature ventricular contractions on a 12-lead ECG predicted
long-term cardiovascular outcomes and death. They used data from the Cardi-
ovascular Health Study (CHS), which included 5577 participants observed for a
median of 12 years. A baseline 12-lead ECG with premature atrial contraction was
associated with an increased risk of atrial fibrillation (HR, 1.6; P < .001) and death (HR,
1.3; P = .008). Likewise, premature ventricular contraction on the baseline 12-lead
ECG was associated with an increased risk of heart failure (HR, 1.3; P = .021) and
death (HR, 1.2; P = .044).
• This study demonstrated that premature atrial contraction and premature ventricular
contractions on 12-lead ECG are predictive of long-term cardiac complications
and death.
Abstract
BACKGROUND Atrial fibrillation and heart failure
are 2 of the most common diseases, yet ready
means to identify individuals at risk are lacking.
The 12-lead ECG is one of the most accessible
tests in medicine. Our objective was to deter-
mine whether a premature atrial contraction
observed on a standard 12-lead ECG would pre-
dict atrial fibrillation and mortality and whether a
premature ventricular contraction would predict
heart failure and mortality.
METHODS AND RESULTSWe utilized the CHS (Car-
diovascular Health) Study, which followed 5577
participants for a median of 12 years, as the pri-
mary cohort. The ARIC (Atherosclerosis Risk
in Communities Study), the replication cohort,
captured data from 15 792 participants over
a median of 22 years. In the CHS, multivaria-
ble analyses revealed that a baseline 12-lead
ECG premature atrial contraction predicted a
60% increased risk of atrial fibrillation (hazard
ratio, 1.6; 95% CI, 1.3-2.0; P<0.001) and a pre-
mature ventricular contraction predicted a 30%
increased risk of heart failure (hazard ratio, 1.3;
95% CI, 1.0-1.6; P=0.021). In the negative control
analyses, neither predicted incident myocardial
infarction. A premature atrial contraction was
associated with a 30% increased risk of death
(hazard ratio, 1.3; 95% CI, 1.1-1.5; P=0.008) and a
premature ventricular contraction was associ-
ated with a 20% increased risk of death (hazard
ratio, 1.2; 95% CI, 1.0-1.3; P=0.044). Similarly sta-
tistically significant results for each analysis were
also observed in ARIC.
CONCLUSIONS Based on a single standard ECG,
a premature atrial contraction predicted inci-
dent atrial fibrillation and death and a premature
ventricular contraction predicted incident heart
failure and death, suggesting that this commonly
used test may predict future disease.
Ectopy on a single 12-lead ECG, incident car-
diac myopathy, and death in the community. J
Am Heart Assoc 2017 Aug 03;6(8)e006028, KT
Nguyen, E Vittinghoff, TA Dewland, et al.
COMMENT
By Samuel J Asirvatham MD, FACC, FHRS
and Danesh Kella MBBS
You Can’t Have Two
Without Ever Having
One…
Introduction
The 12-lead electrocardiogram, although
a commonly performed test, is a momen-
tary snapshot attempting to capture a
high frame rate video sequence repre-
senting heart health over an extended
period of time. In this context, the unique
findings first reported by Nguyen et al are
eye-catching and of potentially significant
clinical and population-wide relevance.
The authors report that, from a single
12-lead electrocardiogram, one pre-
mature atrial contraction (PAC) predicts
incident atrial fibrillation (AF) and death,
and one premature ventricular contrac-
tion (PVC) predicts incident heart failure
and death.
Utility and Impact
Ascertainment bias is a major limita-
tion of most attempts that correlate an
unanticipated finding from a test with
outcomes that are intimately linked with
the indication for which a test is typically
ordered. For example, just the fact that
ARRHYTHMIAS/HEART RHYTHM DISORDERS 24
PRACTICEUPDATE CARDIOLOGY