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Extended Electrocardiographic Poincare Analysis (EPA) for Better Identification of Patients with Paroxysmal Atrial Fibrillation

Thomas Duning, P. Kirchhof, H. Wersching, T. Hepp, R. Reinhardt, H. Heuer, E. B. Ringelstein and S. Knecht

Background: Atrial fibrillation (AF) – be it permanent or paroxysmal – is the most frequent and most effectively treatable cause of stroke. However, when paroxysmal, even electrocardiography for 24 hours (24h-ECG) misses AF in more than 50% of cases. We assessed whether extended Poincaré analysis of ECG R-R intervals (EPA) can help to identify electrocardiographic remodeling suggestive of paroxysmal AF (PAF).

Methods: Twenty-nine patients with previously diagnosed PAF were re-assessed by 24h-ECG using conventional analysis and EPA based on a previously trained algorithm considering among other ratios of R-R interval duration, number of premature atrial complexes, approximate entropy, and standard deviation of Poincaré plots-axes. 24h-ECG from 21 healthy subjects without a history of AF served as negative, and 9 patients with permanent AF as positive controls.

Results: PAF during 24h-ECG was detected in 4 out of 29 (14%) patients with a history of PAF by conventional analysis. EPA classified ECGs of these and 22 additional patients with a history of PAF, i.e. a total 90%, as suggestive of PAF. All patients with permanent AF were identified by both tools. EPA additionally classified the ECG in 4 out of 21 control subjects as suggestive of PAF.

Conclusions: Extended Poincaré analysis in patients with a history of PAF is more sensitive to electrocardiographic abnormalities than is conventional 24h- ECG analysis. These findings warrant prospective studies of EPA in patients with a high likelihood of PAF, i.e. with stroke of undetermined origin.