Cerebral Embolism Beyond Atrial Fibrillation: Interatrial Block

Helena Martínez-Sellés, Ana Ayesta, Manuel Martínez-Sellés

DOI: https://doi.org/10.7175/cmi.v14i1.1462


This paper is devoted to conditions that imply a risk for cerebral embolism beyond atrial fibrillation (AF). We focus on advanced interatrial block (IAB) and its relationship with stroke in elderly patients with no documented arrhythmias. Advanced IAB is manifested in the surface electrocardiogram (ECG) as a P-wave duration >120 ms plus biphasic morphology (positive and negative deflection) in leads II, III, and aVF. Several data suggest that AF is not necessarily the leading cause of stroke, but rather a risk factor. In fact, a high stroke risk has been described even in the absence of AF in patients with high CHA2DS2VASc-score (Congestive Heart failure, hypertension, Age ≥75 years [doubled], Diabetes, Stroke [doubled], Vascular disease, Age 65-74 years, Sex category [female sex]). Moreover, excessive atrial ectopy and short atrial runs also increase stroke risk. Some of the previously mentioned stroke risk factors in patients without documented arrhythmias might be combined to determine thrombotic risk. That risk is particularly high in elderly patients with advanced IAB, structural heart disease, CHA2DS2-VASc score ≥3, and frequent ambient atrial arrhythmias. Systematic screening for advanced IAB in elderly patients can be performed with a simple surface ECG. Advanced IAB is a risk marker of stroke.


Stroke; Anticoagulation; Atrial Fibrillation; Risk Factor; ECG; Interatrial Block

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  • Bachmann G. The significance of splitting of the P-wave in the ECG. Ann Intern Med 1941; 14: 1702-9; https://doi.org/10.7326/0003-4819-14-9-1702
  • Goyal S, Spodick D. Electromechanical dysfunction of the left atrium associated with interatrial block. Am Heart J 2001; 142: 823-7; https://doi.org/10.1067/mhj.2001.118110
  • Tischer Ts, Schneider R, Lauschke J, et al. Prevalence of atrial fibrillation in patients with high CHADS2- and CHA2DS2VASc-scores: anticoagulate or monitor high-risk patients? Pacing Clin Electrophysiol 2014; 37: 1651-7; https://doi.org/10.1111/pace.12470
  • Zuo ML, Liu S, Chan KH, et al. The CHADS2 and CHA 2DS 2-VASc scores predict new occurrence of atrial fibrillation and ischemic stroke. J Interv Card Electrophysiol 2013; 37: 47-54; https://doi.org/10.1007/s10840-012-9776-0
  • Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37: 2893-962; https://doi.org/10.1093/eurheartj/ehw210
  • Martínez-Sellés M, Baranchuk A, Elosua R, et al. Rationale and design of the BAYES (Interatrial Block and Yearly Events) registry. Clin Cardiol 2017; 40: 196-9; https://doi.org/10.1002/clc.22647
  • Bayés de Luna A. Bloqueo a nivel auricular. Rev Esp Cardiol 1979; 32: 5-10.
  • Bayés de Luna A, Platonov P, Cosio FG, et al. Interatrial blocks. A separate entity from left atrial enlargement: a consensus report. J Electrocardiol 2012; 45: 445-51; https://doi.org/10.1016/j.jelectrocard.2012.06.029
  • Spodick DH, Ariyarajah V. Interatrial block: a prevalent, widely neglected and portentous abnormality. J Electrocardiol 2008; 41: 61; https://doi.org/10.1016/j.jelectrocard.2007.02.006
  • Magnani JW, Gorodeski EZ, Johnson VM, et al. P wave duration is associated with cardiovascular and all-cause mortality outcomes: the National Health and Nutrition Examination Survey. Heart Rhythm 2011; 8: 93; https://doi.org/10.1016/j.hrthm.2010.09.020
  • Bayés de Luna A, Fort de Ribot R, Trilla E, et al. Electrocardiographic and vectorcardiographic study of interatrial conduction disturbances with left atrial retrograde activation. J Electrocardiol 1985; 18: 1; https://doi.org/10.1016/S0022-0736(85)80029-7
  • Bayés de Luna A, Guindo J, Viñolas X, et al. Third-degree inter-atrial block and supraventricular tachyarrhythmias. Europace 1999; 1: 43; https://doi.org/10.1053/eupc.1998.0006
  • Bayés de Luna A, Baranchuk A, Niño Pulido C, et al. Second-degree interatrial block: Brief review and concept. Ann Noninvasive Electrocardiol 2018; 23: e12583; https://doi.org/10.1111/anec.12583
  • Bayés de Luna A, Escobar-Robledo LA, Aristizabal D, et al. Atypical advanced interatrial blocks: Definition and electrocardiographic recognition. J Electrocardiol 2018; 51: 1091-3; https://doi.org/10.1016/j.jelectrocard.2018.09.004
  • Martínez-Sellés M, Massó-van Roessel A, Álvarez-García J, et al. Interatrial block and atrial arrhythmias in centenarians: Prevalence, associations, and clinical implications. Heart Rhythm 2016; 13: 645-51; https://doi.org/10.1016/j.hrthm.2015.10.034
  • Hernandez-Betancor I, Izquierdo-Gomez MM, Garcia-Niebla J,et al. Bayes Syndrome and imaging techniques. Curr Cardiol Rev 2017; 13: 263-73; https://doi.org/10.2174/1573403X13666170713122600
  • Bayés de Luna A, Baranchuk A, Escobar Robledo LA, et al. Diagnosis of interatrial block. J Geriatr Cardiol 2017; 14: 161-5; https://doi.org/10.11909/j.issn.1671-5411.2017.03.007.
  • Istolahti T, Eranti A, Huhtala H, et al. The prevalence and prognostic significance of interatrial block in the general population. Ann Med 2020; 20: 1-23; https://doi.org/10.1080/07853890.2020.1731759
  • O’Neal WT, Kamel H, Zhang ZM, et al. Advanced interatrial block and ischemic stroke: The Atherosclerosis Risk in Communities Study. Neurology 2016; 87: 352-6; https://doi.org/10.1212/WNL.0000000000002888
  • Martínez-Sellés M. Prevalence and incidence of interatrial block in global population and in different clinical situations. J Geriatr Cardiol 2017; 14: 158-60; https://doi.org/10.11909/j.issn.1671-5411.2017.03.006.
  • Goyal S, Spodick D. Electromechanical dysfunction of the left atrium associated with interatrial block. Am Heart J 2001; 142: 823-7; https://doi.org/10.1067/mhj.2001.118110
  • Johner N, Mehdi N, Shah DC. Intra- and interatrial conduction abnormalities: hemodynamic and arrythmic significance. J Interv Card Electrophysiol 2018; 52: 293-302; https://doi.org/10.1007/s10840-018-0413-4
  • LaCalzada-Almeida J, Izquierdo-Gómez MM, Belleyo-Belkasem C, et al. Interatrial block and atrial remodeling assessed using speckle tracking echocardiography. BMC Cardiovasc Disord 2018; 18: 38; https://doi.org/10.1186/s12872-018-0776-6
  • Benito EM, De Luna AB, Baranchuk A, et al. Extensive atrial fibrosis assessed by late gadolinium enhancement cardiovascular magnetic resonance associated with advanced interatrial block electrocardiogram pattern. Europace 2017; 19: 377; https://doi.org/10.1093/europace/euw294
  • Larsen BS, Kumarathurai P, Falkenberg J. Excessive atrial ectopy and short atrial runs increase the risk of stroke beyond incident atrial fibrillation. J Am Coll Cardiol 2015; 66: 232-41; https://doi.org/10.1016/j.jacc.2015.05.018
  • Lau KK, Chan PH, Yiu KH, et al. Roles of the CHADS2 and CHA2DS2-VASc scores in post-myocardial infarction patients: Risk of new occurrence of atrial fibrillation and ischemic stroke. Cardiol J 2014; 21: 474-83; https://doi.org/10.5603/CJ.a2014.0034
  • Melgaard L, Gorst-Rasmussen A, Lane DA, et al. Assessment of the CHA2DS2-VASc Score in Predicting Ischemic Stroke, Thromboembolism, and Death in Patients With Heart Failure With and Without Atrial Fibrillation. JAMA 2015; 314: 1030-8; https://doi.org/10.1001/jama.2015.10725
  • James R, Atul V, Halperin JL, et al. Rationale and design of REVEAL AF: a prospective study of previously undiagnosed atrial fibrillation as documented by an insertable cardiac monitor in high-risk patients. Am Heart J 2014; 167: 22; https://doi.org/10.1016/j.ahj.2013.10.007
  • Gladstone D, Spring M, Dorian P, et al. (EMBRACE Investigators and Coordinators). Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med 2014; 370: 2467-77; https://doi.org/10.1056/NEJMoa1311376
  • Sanna T, Diener HC, Passman R, et al. (CRYSTAL AF Investigators). Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014; 370: 2478-86; https://doi.org/10.1056/NEJMoa1313600
  • Benezet-Mazuecos J, Rubio JM, Farré J. Atrial high rate episodes in patients with dual-chamber cardiac implantable electronic devices: unmasking silent atrial fibrillation. PACE 2014; 37: 1080-6; https://doi.org/10.1111/pace.12428
  • Glotzer TV, Daoud EG, Wyse DG, et al. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study. Circ Arrhythm Electrophysiol 2009; 2: 474-80; https://doi.org/10.1161/CIRCEP.109.849638
  • Hohnoloser SH, Capucci A, Fain E, et al. ASSERT Investigators and Committees. Asymptomatic atrial fibrillation and stroke evaluation in pacemaker patients and the atrial fibrillation reduction atrial pacing Trial (ASSERT). Am Heart J 2006; 152: 442-7; https://doi.org/10.1016/j.ahj.2006.02.016
  • Martin DT, Bersohn MM, Waldo AL, et al. IMPACT Investigators. Randomized trial of atrial arrhythmia monitoring to guide anticoagulation in patients with implanted defibrillator and cardiac resynchronization devices. Eur Heart J 2015; 36: 1660-8; https://doi.org/10.1093/eurheartj/ehv115
  • Bacharova L, Wagner GS. The time for naming the interatrial block Syndrome: Bayes Syndrome. J Electrocardiol 2015; 48: 133-4; https://doi.org/10.1016/j.jelectrocard.2014.12.022
  • Kumarathurai P, Mouridsen MR, Mattsson N, et al. Atrial ectopy and N-terminal pro-B-type natriuretic peptide as predictors of atrial fibrillation: a population-based cohort study. Europace 2017; 19: 364-70; https://doi.org/10.1093/europace/euw017
  • O’Neal WT, Kamel H, Kleindorfer D, et al. Premature Atrial Contractions on the Screening Electrocardiogram and Risk of Ischemic Stroke: The Reasons for Geographic and Racial Differences in Stroke Study. Neuroepidemiology 2016; 47: 53-8; https://doi.org/10.1159/000448619
  • Ofoma U, He F, Shaffer ML, et al. Premature cardiac contractions and risk of incident ischemic stroke. J Am Heart Assoc 2012; 1: e002519; https://doi.org/10.1161/JAHA.112.002519
  • García-Niebla J, Lacalzada-Almeida J, Díaz-Muñoz J, et al. Interatrial block and takotsubo syndrome. Europace 2019; 21: 1755; https://doi.org/10.1093/europace/euz241
  • Martín-Demiguel I, Núñez-Gil IJ, Pérez-Castellanos A, et al. Prevalence and Significance of Interatrial Block in Takotsubo Syndrome (from the RETAKO Registry). Am J Cardiol 2019; 123: 2039-43; https://doi.org/10.1016/j.amjcard.2019.03.028
  • Bruña V, Velásquez-Rodríguez J, Valero-Masa MJ, et al. Prognostic of interatrial block after an acute ST-segment elevation myocardial infarction. Cardiology 2019; 142: 109-15; https://doi.org/10.1159/000499501
  • Bernal E, Bayés-Genís A, Ariza-Solé A, et al. Interatrial block, frailty and prognosis in elderly patients with myocardial infarction. J Electrocardiol 2018; 51: 1-7; https://doi.org/10.1016/j.jelectrocard.2017.08.026
  • Alexander B, Haseeb S, van Rooy H, et al. Reduced P-wave voltage in lead I is associated with development of atrial fibrillation in patients with coronary artery disease. J Atr Fibrillation 2017; 10: 1657; https://doi.org/10.4022/jafib.1657
  • Escobar-Robledo LA, Bayés-de-Luna A, Lupón J, et al. Advanced interatrial block predicts new-onset atrial fibrillation and ischemic stroke in patients with heart failure: The “Bayes’ Syndrome-HF” study. Int J Cardiol 2018; 271: 174-80; https://doi.org/10.1016/j.ijcard.2018.05.050
  • Martínez-Sellés M, Escobar-Robledo LA, Bernal E, et al. Rational and design of the Baseline Interatrial block and Transcatheter aortic valve implantation (BIT) registry. J Electrocardiol 2019; 57: 100-3; https://doi.org/10.1016/j.jelectrocard.2019.09.016
  • Diener HC, Hart RG, Koudstaal PJ, et al. Atrial fibrillation and cognitive function: JACC review topic of the week. J Am Coll Cardiol 2019; 73: 612-9; https://doi.org/10.1016/j.jacc.2018.10.077
  • Conen D, Rodondi N, Müller A, et al; Swiss-AF Study Investigators. Relationships of overt and silent brain lesions with cognitive function in patients with atrial fibrillation. J Am Coll Cardiol 2019; 73: 989-99; https://doi.org/10.1016/j.jacc.2018.12.039
  • Bunch TJ, Galenko O, Graves KG, et al. Atrial fibrillation and dementia: exploring the association, defining risks and improving outcomes. Arrhythm Electrophysiol Rev 2019; 8: 8-12; https://doi.org/10.15420/aer.2018.75.2
  • Bayés de Luna A, Martínez-Sellés M, Bayés-Genís A, et al. Surface ECG interatrial block-guided treatment for stroke prevention: rationale for an attractive hypothesis. BMC Cardiovasc Disord 2017; 17: 211; https://doi.org/10.1186/s12872-017-0650-y
  • Martínez-Sellés M, Fernández Lozano I, Baranchuk A, et al. Should we anticoagulate patients at high risk of atrial fibrillation? Rev Esp Cardiol 2016; 69: 374-6; https://doi.org/10.1016/j.rec.2016.01.008
  • Martínez-Sellés M, García-Izquierdo Jaén E, Fernández Lozano I. Anticoagulation in elderly patients at high risk of atrial fibrillation without documented arrhythmias. J Geriatr Cardiol 2017; 14: 166-8; https://doi.org/10.11909/j.issn.1671-5411.2017.03.004
  • Baranchuk A, Alexander B, Cinier G, et al. Bayés’ syndrome: Time to consider early anticoagulation? North Clin Istanb 2018; 5: 370-8; https://doi.org/10.14744/nci.2017.60251
  • Bayés de Luna A, Martínez-Sellés M, Bayés-Genís A, et al. What every clinician should know about Bayés Syndrome. Rev Esp Cardiol 2020; 73: 758-62; https://doi.org/10.1016/j.rec.2020.04.026
  • Guerra JM, Vilahur G, Bayés de Luna A, et al. Interatrial block can occur in the absence of left atrial enlargement: New experimental model. PACE 2020; 43: 427-9; https://doi.org/10.1111/pace.13895
  • Bayés de Luna A, Martínez-Sellés M, Elosua R, et al. Relation of advanced interatrial block to risk of atrial fibrillation and stroke. Am J Cardiol 2020; 125: 1745-8; https://doi.org/10.1016/j.amjcard.2020.02.034
  • Alexander B, Milden J, Hazim B, et al. New electrocardiographic score for the prediction of atrial fibrillation: The MVP ECG risk score (morphology-voltage-P-wave duration). Ann Noninvasive Electrocardiol 2019; 24: e12669; https://doi.org/10.1111/anec.12669


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