Electrocardiographic deep terminal negativity of the P wave in V₁ and risk of sudden cardiac death: The atherosclerosis risk in communities (aric) study

Background: Identifying individuals at risk for sudden cardiac death (SCD) is of critical importance. Electrocardiographic (ECG) deep terminal negativity of P wave in V₁ (DTNPV1), a marker of left atrial abnormality, has been associated with increased risk of allcause and cardiovascular mortality. We hypothesized that DTNPV1 is associated with increased risk of sudden cardiac death (SCD). Methods and Results: This analysis included 15 375 participants (54.1±5.8 years, 45% men, 73% whites) from the Atherosclerosis Risk in Communities (ARIC) study. DTNPV1 was defined from the resting 12-lead ECG as presence of biphasic P wave (positive/negative) in V₁ with the amplitude of the terminal negative phase > 100 μV, or one small box on ECG scale. After a median of 14 years of follow-up, 311 cases of SCD occurred. In unadjusted Cox regression, DTNPV1 was associated with an 8-fold increased risk of SCD (HR 8.21; [95%CI 5.27 to 12.79]). Stratified by race and study center, and adjusted for age, sex, coronary heart disease (CHD), and ECG risk factors, as well as atrial fibrillation (AF), stroke, CHD, and heart failure (HF) as time-updated variables, the risk of SCD associated with DTNPV1 remained significant (2.49, [1.51-4.10]). DTNPV1 improved reclassification: additional 3.4% of individuals were appropriately reclassified into a higher SCD risk group, as compared with traditional CHD risk factors alone. In fully adjusted models DTNPV1 was associated with increased risk of non-fatal events: AF (5.02[3.23-7.80]), CHD (2.24[1.43-3.53]), HF (1.90[1.19-3.04]), and trended towards increased risk of stroke (1.88[0.99-3.57]). Conclusion: DTNPV1 is predictive of SCD suggesting its potential utility in risk stratification in the general population.