P‐Wave Morphology: Underlying Mechanisms and Clinical Implications

Increasing awareness of atrial fibrillation (AF) and its impact on public health revives interest in identification of noninvasive markers of predisposition to AF and ECG‐based risk stratification. P‐wave duration is generally accepted as the most reliable noninvasive marker of atrial conduction, and its prolongation has been associated with history of AF. However, patients with paroxysmal AF without structural heart disease may not have any impressive P‐wave prolongation, thus suggesting that global conduction slowing is not an obligatory requirement for development of AF. P‐wave morphology is therefore drawing increasing attention as it reflects the three‐dimensional course of atrial depolarization propagation and detects local conduction disturbances. The factors that determine P‐wave appearance include (1) the origin of the sinus rhythm that defines right atrial depolarization vector, (2) localization of left atrial breakthrough that defines left atrial depolarization vector, and (3) the shape and size of atrial chambers. However, it is often difficult to distinguish whether P‐wave abnormalities are caused by atrial enlargement or interatrial conduction delay. Recent advances in endocardial mapping technologies have linked certain P‐wave morphologies with interatrial conduction patterns and the function of major interatrial conduction routes. The value of P‐wave morphology extends beyond cardiac arrhythmias associated with atrial conduction delay and can be used for prediction of clinical outcome of a wide range of cardiovascular disorders, including ischemic heart disease and congestive heart failure.