Iron deficiency anemia (IDA) is a common global health issue affecting over two billion people and is associated with cardiovascular complications. Electrocardiographic (ECG) abnormalities may reflect cardiac involvement in IDA. The Morphology-Voltage-P wave Duration (MVP) score, which assesses P-wave duration, voltage, and morphology, is linked to atrial fibrillation (AF) risk. This study aimed to investigate the relationship between IDA and MVP score to evaluate its potential in cardiac risk assessment.
A prospective study was conducted between January 1 and June 30, 2024, at a tertiary hospital. It included 241 IDA patients and 204 healthy controls. All participants underwent ECG and echocardiography. MVP scores were calculated, and left atrial (LA) diameter and left ventricular ejection fraction (LVEF) were recorded.
MVP scores were significantly higher in the IDA group compared to controls (p < 0.001). P-wave morphology and voltage were notably altered in IDA patients (p < 0.001). LA diameters were larger, and LVEF values were lower in the IDA group (p < 0.001). MVP scores positively correlated with LA size and negatively with LVEF. Additionally, IDA patients had higher heart rates and lower diastolic blood pressure (p < 0.001).
IDA is associated with increased MVP scores, suggesting possible atrial remodeling and higher AF risk. The MVP score may serve as a non-invasive tool for cardiovascular risk stratification in IDA patients. Further research is needed to assess the impact of IDA treatment on ECG parameters and arrhythmia risk.
We read with interest the article by Ali Amghaiab et al. titled “Decoding South African Flag Sign—When Lead V2 Speaks Volumes” published in JAMA Internal Medicine (Ali Amghaiab et al. 2025). The authors describe a case of suspected ST-segment elevation myocardial infarction (STEMI) based on isolated ST elevation in lead V2, subtle ST elevation in leads I and aVL, and reciprocal changes in lead III, ultimately attributed to occlusion of the first diagonal (D1) branch of the left anterior descending artery.
Although we commend the authors for highlighting this important and often underrecognized electrocardiographic pattern, we respectfully propose an alternative interpretation of the initial ECG. Upon close inspection, lead V2 does not demonstrate classic ST-segment elevation. Instead, it exhibits upsloping ST-segment depression followed by a tall, symmetric T wave, a morphology consistent with the de Winter pattern. Leads I and aVL similarly show hyperacute T waves without definitive ST elevation, suggesting early transmural ischemia rather than established injury current.
The de Winter pattern, originally described in proximal LAD occlusion, is increasingly recognized in isolated D1 occlusion, particularly when the ischemic vector is postero-inferiorly, aligning with the axis of lead V2 (de Winter et al. 2008). This pattern represents a STEMI equivalent, often preceding overt ST elevation, and mandates urgent reperfusion therapy.
This single-lead V2 de Winter pattern is, to my knowledge, previously unreported and may represent the earliest electrocardiographic signature of a proximally arising, anatomically dominant D1 branch. Recognition of isolated de Winter morphology in V2 as a solitary anterior lead sign of D1 occlusion is clinically invaluable, especially in the absence of contiguous lead involvement. It expands the spectrum of occlusion myocardial infarction (OMI) patterns and supports the shift from traditional STEMI versus NSTEMI paradigms toward OMI versus NOMI classification (McLaren et al. 2024).
We congratulate the authors on this insightful case and emphasize that hyperacute T waves and de Winter morphology, even in a single lead, should prompt immediate suspicion of coronary occlusion and urgent angiographic evaluation.
The author takes full responsibility for this article.
The author declares no conflicts of interest.
The long-term prognostic value of resting electrocardiogram (ECG) in the prediction of ischemic heart disease (IHD) incidence and mortality in the asymptomatic middle-aged population is not well characterized. This study was designed to assess the prognostic value of major and minor ischemic changes in ECG as a potential screening tool in healthy adults.
A total of 9035 middle-aged subjects with available ECGs were recruited. ECG ischemia was classified using the Minnesota Coding system. All the participants were followed up regarding the occurrence of IHD over 10 years. A cardiologist confirmed IHD, and additional tests were performed if indicated. Multiple logistic regression was applied to estimate the odds of ischemic changes in ECG to predict the occurrence of IHD. A p-value less than 0.05 was considered significant.
Among 9035 participants, 1225 (13.6%) had major ischemic changes and 1088 (12.0%) had minor ischemic changes. After a 10-year follow-up, 747 (8.3%) were confirmed with IHD (124 had died and 623 survived). IHD was more prevalent among men, older people, smokers, and retired subjects (p < 0.001). Both major and minor ischemic changes were significantly higher in participants with IHD (p = 0.001), while only major ischemic changes were associated with IHD-cause mortality (p = 0.004). These relationships remained significant after adjustment for confounding factors.
Both minor and major isolated abnormalities in ECG are associated with an increased risk of long-term IHD incidence in the middle-aged population, while only combined major ischemia increases the odds of death caused by IHD.
This letter critically appraises the recent study by Long et al. investigating the role of transesophageal echocardiography (TEE) in guiding and evaluating left atrial appendage occlusion (LAAO) among patients with non-organic heart disease. While the authors demonstrate the procedural utility of TEE, its limitations, including invasiveness, patient tolerance, and lack of long-term data, remain notable. Current literature highlights the growing role of intracardiac echocardiography (ICE) and computed tomography (CT) as alternative or complementary modalities. Larger multicenter studies integrating these approaches are warranted to optimize procedural outcomes and patient safety in atrial fibrillation–related stroke prevention.
To investigate two conditions that have been poorly investigated in the medical literature before in the context of atrial fibrillation: the coexistence and association of right or left bundle branch block and axis deviation in patients with permanent atrial fibrillation compared to the control group of healthy subjects with sinus rhythm.
We conducted an analytic, retrospective observational study performed at Ziv Medical Center, Safed, Israel, collecting data from medical history records of all patients that have been diagnosed with permanent atrial fibrillation versus healthy controlled patients with normal sinus rhythm. We analyzed their ECGs in order to assess the presence of any bundle branch block and/or axis deviation.
Subjects with atrial fibrillation have significant correlation with left bundle branch block. Subjects with sinus rhythm have significant correlation to left axis deviation. Young subjects (below the age 73.5 y/o) with atrial fibrillation show significantly higher correlation with left bundle branch block and older subjects (above the age 73.5 y/o) with sinus rhythm show significantly higher correlation to left axis deviation.
There is a correlation between atrial fibrillation and left bundle branch block. The presence of left bundle branch block could be a risk factor for atrial fibrillation and the presence of left axis deviation could be a protective factor. There is no difference between female and male patients. There is a difference in the age group; young subjects with atrial fibrillation have a significant correlation with left bundle branch block, which may demonstrate a poor prognosis for patients with atrial fibrillation.
This letter provides a critical appraisal of the study by Wei et al. on clinical and electrocardiographic predictors of left circumflex artery occlusion in NSTEMI patients. While the authors identified STV5 + STV6 ≥ 2.5 mm and T-wave imbalance as potential markers, concerns remain regarding the single-center, retrospective design, limited sensitivity of ECG findings, and the lack of significant differences in clinical outcomes. Prior meta-analyses suggest a higher risk in patients with occluded culprit arteries, highlighting inconsistencies with the present study. Future research should employ multicenter prospective designs and advanced diagnostic modalities, including posterior ECG leads and artificial intelligence–based analysis, to improve detection and risk stratification of culprit LCX occlusion in NSTEMI.
Interatrial block (IAB) is a conduction disorder linked to atrial fibrillation (AF) and ischemic stroke. Intermittent IAB, often triggered by premature atrial complexes (PACs), may precede AF and increase thromboembolic risk. We present a case of embolic stroke of undetermined source (ESUS) with intermittent partial IAB detected on ECG. Serial ECGs and Holter monitoring were analyzed. Intermittent partial IAB with dynamic P-wave changes was observed. No AF or alternative embolic source was identified. Intermittent IAB may indicate atrial vulnerability in ESUS. Recognizing subtle ECG changes could aid risk stratification and stroke prevention.
To evaluate and compare the predictive performance of Padua and Caprini scores for venous thromboembolism (VTE) risk assessment in individuals aged ≥ 90 years.
A cross-sectional study was conducted among 511 nonagenarians in Rugao, China. Participants underwent comprehensive clinical assessments including both Padua and Caprini risk scoring. VTE events were monitored through the follow-up period. The predictive efficacy of both scoring systems was analyzed using receiver operating characteristic (ROC) curves, and risk factors were evaluated through multivariate logistic regression.
During follow-up, 31 participants (6.07%) developed VTE. The VTE group demonstrated significantly higher mean Padua scores (4.97 ± 2.21 vs. 4.11 ± 2.45, p = 0.0463), Caprini scores (6.39 ± 2.42 vs. 5.02 ± 2.39, p = 0.0044), and D-dimer levels (median 2.79 vs. 1.31 mg/L, p = 0.0133) compared to the non-VTE group. Both scoring systems showed moderate predictive capability, with the Padua score achieving an area under the curve (AUC) of 0.625 (95% CI: 0.533–0.717) and the Caprini score showing an AUC of 0.679 (95% CI: 0.590–0.768). Optimal cutoff values were 3.5 points for the Padua score (sensitivity 80.65%, specificity 50.42%) and 4.5 points for the Caprini score (sensitivity 77.42%, specificity 51.46%). Multivariate analysis identified atrial fibrillation (OR 4.130, 95% CI: 1.667–9.673, p = 0.001) and elevated Caprini score (OR 1.310, 95% CI: 1.073–1.582, p = 0.006) as significant independent risk factors for VTE. Interestingly, hypertension showed an unexpected protective association with VTE risk (OR 0.400, 95% CI: 0.162–0.907, p = 0.035).
While both Padua and Caprini scores demonstrate moderate predictive value for VTE risk in nonagenarians, their accuracy suggests the need for age-specific refinement.
Electrical cardioversion (ECV) remains a treatment option for atrial fibrillation (AF). The study aimed to find predictors of SR maintenance after ECV using spectral and vector cardiographic (VCG) analysis of ECGs.
Consecutive patients with AF referred for elective ECV were prospectively enrolled. A digital ECG recording was obtained before the ECV and was analyzed using spectral and VCG analysis. AF activity was analyzed using spectral analysis to determine the dominant frequency (DF), RI (regularity index), and OI (organizational index). QRS complexes were analyzed using vectorcardiography to determine the dXmean, dYmean, and dZmean (derivation of VCG signals). We used Lasso Logistic Regression (LLR) in five-fold cross-validation for feature selection and to build combined predictive models of SR maintenance. For model training and evaluation, data were split in a 60%–40% ratio for training and testing, respectively.
A total of 80 patients were enrolled (age 70.2 ± 10.6 years, 49 (61%) were men, BMI 29.7 kg/m2). At the 3-month follow-up, AF recurrence was present in 36 patients (45%). The best single VCG parameter to predict SR maintenance was dZMean (OR 0.18, 95% CI 0.06–0.51, p < 0.001). VCG-domain parameters combined into the LLR model showed an area under the curve (AUC) of 0.78. From the spectral analysis domain, the best predictor was DF (OR 3.54, 95% CI 1.28–10.25), p = 0.006; spectral features led to an AUC of 0.76 when combined in the LLR model. Clinical features did not form a model since no features passed feature selection. Combining VCG and spectral analysis features led to an LLR model with an AUC of 0.79.
The combination of spectral analysis of AF activity and VCG analysis of ventricular activity provided more accurate predictive information than either analysis alone.
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