Non-invasive markers of atrial cardiomyopathy for identifying left-atrial low-voltage areas and predicting post-PVI arrhythmia recurrence

Background/Introduction Atrial cardiomyopathy (AtCM) relates to atrial fibrillation (AF) onset, persistence and recurrence after pulmonary vein isolation (PVI). Electro-anatomical mapping (EAM) quantifies left-atrial low-voltage areas (LVA) but is invasive and resource-intensive. Readily available non-invasive markers could aid risk stratification. Purpose To compare common ECG, echocardiographic and blood-based AtCM markers regarding (i) association with advanced LVA on EAM and (ii) prediction of arrhythmia recurrence after first-time PVI. Methods Consecutive patients with AF undergoing first PVI in sinus rhythm (n=200) were assessed. ECG metrics included conventional and amplified P-wave duration (APWD), P-wave dispersion/axis, P-wave terminal force in V1 and P-wave amplitude in lead I. Echocardiography provided left-atrial volume index (LAVI), left-atrial diameter (LAD) and LV ejection fraction; biomarkers included hs-troponin T and hs-CRP. LVA were defined as bipolar voltage <0.5 mV and staged by affected LA surface (I <5%, II ≥5–<20%, III ≥20–<30%, IV ≥30%). Logistic regression identified markers of advanced LVA (III–IV). Arrhythmia recurrence within 12 months was ascertained by structured follow-up and ambulatory 12-lead ECG. Results LVA stages: I n=93, II n=69, III n=15, IV n=23. Advanced LVA associated with older age and female sex (both p<0.001). Across LVA stages, APWD increased (median 130→163 ms; p<0.001) while P-wave amplitude in lead I decreased (0.09→0.06 mV; p<0.001). LAVI rose (37→48 mL/m²; p=0.002) and LV-EF was lower (62%→57%; p=0.043). In univariable analyses, age, female sex, CHA2DS2-VA, hs-troponin T, APWD, abnormal P-wave axis, larger LAD/LAVI, lower LV-EF and ≥moderate mitral regurgitation associated with advanced LVA. In multivariable modelling, female sex (OR 22.55, 95% CI 3.57–142.63), APWD (OR 2.66, 1.23–5.75) and P-wave amplitude in lead I (OR 0.20, 0.05–0.81) remained independent. APWD ≥145 ms predicted lower recurrence-free survival after PVI (log-rank p=0.0156; median follow-up 277 days). Conclusions Among non-invasive AtCM markers, APWD and P-wave amplitude in lead I independently identify advanced LVA; only APWD also predicts post-PVI arrhythmia recurrence. Routine ECG—particularly APWD—may enable early, non-invasive risk stratification and reduce reliance on invasive mapping.