P-Wave

I posed this question several years ago and tried to locate the post but a search did not go back far enough.

Quick history……

Natale ablation for paroxysmal atrial fibrillation in March 2011 and basically issue free since. If a problem develops will head back to Austin.

I had discussed with Shannon about locating a EP cardiologist here in Houston in order to establish a relationship with a doctor for any questions or issues. He spoke with Natale and referred me to John Seger. In my initial meeting with Seger he stated that based on my EKG I was in atrial fibrillation! I explained that I did not believe that was the case…….prior to my ablation I always knew without a doubt when an event occurred. Real long story short……he re-ran the EKG several times and we got copies of several prior year’s EKGs from my cardiologist. After an extensive review of all the EKGs he said…..this is really interesting, you have a reduced or non-existent p-wave. You are not in arrhythmia. He then complemented Natale’s work.

This experience was a catalyst for me to go back to Austin and see Natale. At the meeting he confirmed my situation. He told me that it would take a highly skilled individual to accurately read my EKG…..less experienced people could mistakenly think I was in arrhythmia.

Now the issue……

I have hereditary hypertension and have been on blood pressure medication since I was 25. As a result, I proactively see my cardiologist about every two years (he wants me to come annually!!). At a recent meeting he scheduled an echocardiogram and during the test the technician told me I was in arryhthmia. I tried to explain the situation. At the appointment with the doctor, we again reviewed the situation with my EKG.

In visits to my family doctor there are no issues as he understands my situation. But for example, a recent visit with a medi-clinic type facility for a flu test resulted in a comment about being in arrhythmia from the nurse practitioner.

I know an ablation is not a cure and I could really be in arrhythmia again. So, do not want to overlook an issue.

Any thoughts or comments about how to handle this situation

Thanks


Steve
Klein, Tx.

I'm surprised you've run into so many people who are willing to diagnose afib based solely on lack of a visible P wave. Feel your pulse. Is it a steady, regular rhythm? If so, you are NOT in afib and those professionals should know that. The hallmark of afib is an irregularly irregular heartbeat. Without that, it is not afib. Period.

My P waves are undetectable by a Kardia (or probably any consumer device) and on a 12-lead they're very small. But my pulse is regular as a rock, so I know with certainty I'm in NSR. Everyone who looks at my ECGs notes the diminutive P waves, but none of them have mistaken it for afib.

Get a note from Natale with an attached sample ekg, explaining why you're not in afib, even though it may look like it. This will save you a lot of aggravation debating those lower down on the ekg reading chain. Of course, if things change and they sometimes do, get follow up confirmations from Natale or another competent ep that you haven't reverted back to afib.

Jim

This is where being symptomatic when in AF has one of those rare advantages over being largely or fully asymptomatic. I know when I'm in arrhythmia. It's like sandpaper being dragged over my wrists...it can't be ignored or mistaken. I think the idea of having a plasticized card or something official from an EP like Natale could be presented to anyone who feels that they can't provide a service because they think you're in AF might be a good one.

What's the difference between irregular heart rate and heart rate variability?

A couple of years ago I was in a GP's office and she told me that i was in AF taking my pulse. I think it was 80 0r so but certainly under 100.
I said that it wasn't, so she put me on a 12 lead EKG straight away. She measured the R to R and insisted that i was in AF. I told here that it shows a clear P wave and that means my HR is just irregular.
She prescribed beta blockers and anticoagulation straight away. Later that day i got a call from her telling me that their specialist looked at my EKG and it wasn't AF - no need to take the drugs.
Anyway, the irregular heart rate settled and it became more regular again after my cold/flu settled down.

Heart rate variability is a change in the rate of heart rhythm over time. Irregular heartbeat is an arrhythmia, meaning that, whether the heart needs to beat quickly or slowly, when it does beat it's sequencing is 'off'. Rate and rhythm are two different concepts.

Heart rate variability depends on mood, health, and other factors, not least of which would be physical exertion. So, heart rate variability is both normal and necessary. When a person is at rest, calm, not anxious, and the rate is distinctly variable, it's a sign of something going on.

When the same circumstances are in place, but the distance/time between the QRS complexes is obvious on an EKG readout, then there is an arrythmia. Or, the P-waves are absent, also an arrhythmia, and in this case it's atrial fibrillation.

Thank you gloaming! In my instance something was not QR but i'm still not clear if it was an AF problem, probably the beginning of going into AF..

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Joe
What's the difference between irregular heart rate and heart rate variability (HRV)?

To give you an order of magnitude, 1 second = 1000 milliseconds (ms). Sixty beats/minutes (BPM) = 1 beat/second. A variance of 100 ms would be 6 BPM. My 30 something daughter has HRV around 120 ms, I have 40-50 ms. In afib, it is not uncommon to have a beats go from 60 BPM to 120. With PAC's, you could have a 60 BPM rate go to 160 BPM for one beat. As you can see the magnitude is hugely different for HRV vs. irregular heart rate. Also, the variability in afib is irregularly irregular.

Thanks for the comments.

At one point I was going to get a Kardia but decided it would indicate I was in arrhythmia when I actually was not. Prior to my ablation there was never a doubt when an event occurred......it would be depilating. My heart rate would be so rapid and erratic that my blood pressure would plummet and I would nearly black out. In fact that is how my AF was originally diagnosed. Was playing in a golf tournament and actually blacked out. My playing partners thought I had a heart attract......$1,000 ambulance ride for a one-mile trip to the hospital.

Since the ablation my heart rate is usually very consistent, but occasionally will experience skipped beats. I am never able to know if that occurs unless I actually take my pulse. I have learned that I have several factors that can cause skipped beats.....medication, age, exercise, height, etc..

Thirteen years post procedure, I am very aware that an ablation is not an indefinite cure. My blood pressure and heart rate have stayed in a fairly consistent range over this time frame, but posed the question about my EKG so that if AF returns I can go see Natale.. Unless the ablation changed how arrhiythmia will affect me......hopefully will be know if it occurs.


Steve. . .

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JAYHAWK
At one point I was going to get a Kardia but decided it would indicate I was in arrhythmia when I actually was not.

Why do you think that?

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GeorgeN

What's the difference between irregular heart rate and heart rate variability (HRV)?


To give you an order of magnitude, 1 second = 1000 milliseconds (ms). Sixty beats/minutes (BPM) = 1 beat/second. A variance of 100 ms would be 6 BPM. My 30 something daughter has HRV around 120 ms, I have 40-50 ms. In afib, it is not uncommon to have a beats go from 60 BPM to 120. With PAC's, you could have a 60 BPM rate go to 160 BPM for one beat. As you can see the magnitude is hugely different for HRV vs. irregular heart rate. Also, the variability in afib is irregularly irregular.

and the 'P' wave?
Assuming that means my GP was right that i was in AF even though i had a good 'P' wave (because it was irregularly irregular in that short EKG)

Was playing in a golf tournament and actually blacked out. My playing partners thought I had a heart attract.
Jayhawk
I have to bring a little humor to this discussion. I was playing golf a few years ago when I first starting getting AFib and did not really understand what was happening to me. On 1 hole on the back 9 I blacked out and fell to my knees with a rapid heart rate. So I sat out one hole and drank a Gatorade. I then felt much better and resumed play on the next par 5 where I hit a drive, 3 hybrid and a 1 putt for an eagle. Playing partner said I should black out more often! Only golfer will get this haha

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Carey


Why do you think that?

I assume that if the normal EKG indicates I am in arrhythmia the Kardia would indicate a false positive as well.


Thanks
Steve

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Carey

My P waves are undetectable by a Kardia (or probably any consumer device) and on a 12-lead they're very small. But my pulse is regular as a rock, so I know with certainty I'm in NSR. Everyone who looks at my ECGs notes the diminutive P waves, but none of them have mistaken it for afib.

Carey, when I do a Kardia reading and see my heart rate and normal sinus rhythm, I have not been paying attention to how the tracing looks. Now that I am seeing the posts about the “P” waves I started looking at this and like yours, it seems my P waves are small or undetectable. As you had suggested previously, I do take my pulse and it is normal.
I don’t know what this looks like on an EKG and I never asked. Could you explain a little why diminutive p waves happen.

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JAYHAWK
I assume that if the normal EKG indicates I am in arrhythmia the Kardia would indicate a false positive as well.

I missed the part where a 12-lead said you were in an arrhythmia. What did it actually say? And did a cardiologist agree with that assessment? Doctors who know their way around an ECG ignore those diagnostics they spit out. An ECG on me will always declare that I've had a previous MI, which is always wrong and no doctor has ever even mentioned it.

That said, the only times I've seen a Kardia issue false positives is in the presence of a lot of ectopy, which in all fairness isn't surprising since a lot of ectopy can fool trained humans too.

If you really want the most accurate, reliable afib detector there is, learn to take a pulse and identify a regular vs. irregular heartbeat. If your pulse is irregular and random with no discernable rhythm to it, you're in afib. Nothing else produces an irregularly irregular pulse.

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Pixie
Could you explain a little why diminutive p waves happen.

A previous ablation would be the most common reason, and in my case that's exactly why. Your atria typically don't contract as forcefully after an ablation, and that produces smaller P waves. It can also simply be because you're using a Kardia or wearable device. Things that measure from your hand or arm have a hard time detecting P waves because they're naturally much lower voltage than the ventricular waves (QRS and T), so measuring from the hand instead of the chest means they're often totally undetectable because of the distance from the heart. This is why not seeing P waves on a Kardia, Apple Watch, etc. means almost nothing. Not seeing them on a 12-lead is much more meaningful.

I often see people say absence of P waves is diagnostic for afib, and that is not true. Afib is diagnosed by an irregularly irregular heart beat and missing P waves. But the P waves are kind of a distraction. If your pulse is irregularly irregular, that's diagnostic for afib. It's impossible to be in afib and have a regular heart beat, P waves or not.

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Carey

A previous ablation would be the most common reason, and in my case that's exactly why. Your atria typically don't contract as forcefully after an ablation, and that produces smaller P waves. It can also simply be because you're using a Kardia or wearable device. Things that measure from your hand or arm have a hard time detecting P waves because they're naturally much lower voltage than the ventricular waves (QRS and T), so measuring from the hand instead of the chest means they're often totally undetectable because of the distance from the heart. This is why not seeing P waves on a Kardia, Apple Watch, etc. means almost nothing. Not seeing them on a 12-lead is much more meaningful.

I often see people say absence of P waves is diagnostic for afib, and that is not true. Afib is diagnosed by an irregularly irregular heart beat and missing P waves. But the P waves are kind of a distraction. If your pulse is irregularly irregular, that's diagnostic for afib. It's impossible to be in afib and have a regular heart beat, P waves or not.

Thanks, Carey. I no longer send Kardia readings to TCAI, but when I did, no one commented about this nor was it mentioned when I had EKGs in the office or used the 7 day Vital Connect monitors. Now that I know more, I will ask about this after my next heart monitor.

The P wave is the precursor to atrial contraction. No p, no contraction. At least, not the normal sinus rhythm kind of contraction. The P wave signifies the depolarization of the atrial tissue, which is the first stage of contraction. The re-polarization is not shown on an EKG because where it happens is also where the QRS complex is depicted, meaning the P wave is masked by the more dramatic squiggles of the QRS.

In AF, the P wave is supplanted by chaotic re-entrant foci providing an entry to make contact with endothelial tissue lining both the pulmonary veins and beyond into the wider atrium. The electrical impulses come at varying times, making the atrium beat erratically, and not in time with what would normally be the sequential depolarization and re-polarization of the atrium via the normal sino-atrial node route.

[www.ncbi.nlm.nih.gov]

Thanks, gloaming, for this information. Sometimes all of this seems above my pay grade!!