Extended ECG Improves Classification of Paroxysmal and Persistent Atrial Fibrillation Based on P- and f-Waves

Matthias Daniel Zink*, Rita Laureanti, Ben J M Hermans, Laurent Pison, Sander Verheule, Suzanne Philippens, Nikki Pluymaekers, Mindy Vroomen, Astrid Hermans, Arne van Hunnik, Harry J G M Crijns, Kevin Vernooy, Dominik Linz, Luca Mainardi, Angelo Auricchio, Stef Zeemering, Ulrich Schotten

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Background: The standard 12-lead ECG has been shown to be of value in characterizing atrial conduction properties. The added value of extended ECG recordings (longer recordings from more sites) has not been systematically explored yet.

Objective: The aim of this study is to employ an extended ECG to identify characteristics of atrial electrical activity related to paroxysmal vs. persistent atrial fibrillation (AF).

Methods: In 247 participants scheduled for AF ablation, an extended ECG was recorded (12 standard plus 3 additional leads, 5 min recording, no filtering). For patients presenting in sinus rhythm (SR), the signal-averaged P-wave and the spatiotemporal P-wave variability was analyzed. For patients presenting in AF, f-wave properties in the QRST (the amplitude complex of the ventricular electrical activity: Q-, R-, S-, and T-wave)-canceled ECG were determined.

Results: Significant differences between paroxysmal (N = 152) and persistent patients with AF (N = 95) were found in several P-wave and f-wave parameters, including parameters that can only be calculated from an extended ECG. Furthermore, a moderate, but significant correlation was found between echocardiographic parameters and P-wave and f-wave parameters. There was a moderate correlation of left atrial (LA) diameter with P-wave energy duration (r = 0.317, p < 0.001) and f-wave amplitude in lead A3 (r = -0.389, p = 0.002). The AF-type classification performance significantly improved when parameters calculated from the extended ECG were taken into account [area under the curve (AUC) = 0.58, interquartile range (IQR) 0.50-0.64 for standard ECG parameters only vs. AUC = 0.76, IQR 0.70-0.80 for extended ECG parameters, p < 0.001].

Conclusion: The P- and f-wave analysis of extended ECG configurations identified specific ECG features allowing improved classification of paroxysmal vs. persistent AF. The extended ECG significantly improved AF-type classification in our analyzed data as compared to a standard 10-s 12-lead ECG. Whether this can result in a better clinical AF type classification warrants further prospective study.

Original languageEnglish
Article number779826
Number of pages12
JournalFrontiers in physiology
Publication statusPublished - 4 Mar 2022


  • P-wave
  • P-wave variability
  • QRST-canceled ECG
  • RISK
  • atrial fibrillation
  • f-wave
  • paroxysmal
  • persistent
  • signal-averaged P-wave

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