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Original research
Association of inverted T wave during atrial fibrillation rhythm with subsequent cardiac events
  1. Tetsuma Kawaji1,2,
  2. Hisashi Ogawa3,
  3. Yasuhiro Hamatani3,
  4. Masashi Kato1,
  5. Takafumi Yokomatsu1,
  6. Shinji Miki1,
  7. Mitsuru Abe3,
  8. Masaharu Akao3
  9. The Fushimi AF Registry investigators
  1. 1 Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
  2. 2 Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
  3. 3 Department of Cardiovascular Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
  1. Correspondence to Dr Masaharu Akao, Department of Cardiovascular Medicine, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan; akao{at}


Objective The clinical significance of ECG abnormalities during atrial fibrillation (AF) rhythm is poorly understood. The aim of the current study was to explore the impact of inverted T wave on cardiac prognosis in patients with AF.

Methods The current study enrolled 2709 patients with AF whose baseline ECG was available from a Japanese community-based prospective survey, the Fushimi AF Registry, and the impact of inverted T wave in baseline ECG at AF rhythm on the composite of cardiac death, myocardial infarction and hospitalisation due to heart failure was examined.

Results Intraventricular conduction delay, ST segment depression and inverted T wave were observed in 15.8%, 24.7% and 41.4% of baseline ECG with a mean heart rate of 94.7 beats per minute. The median follow-up duration was 5.0 years. The incidence rate of the composite cardiac endpoint was significantly higher in patients with inverted T wave than those without (5.8% vs 3.3% per patient-year, log-rank p<0.01). The higher risk associated with inverted T wave was consistent even for individual components of the composite cardiac endpoint. By multivariable analysis, inverted T wave was an independent predictor of the composite cardiac endpoint (HR 1.53, 95% CI 1.26 to 1.85, p<0.01). Inverted T wave was detected in 15.7% at anterior leads, 19.8% at inferior leads and 26.6% at lateral leads. The location of inverted T wave was not associated with risk of composite cardiac endpoint.

Conclusions Inverted T wave was commonly observed in patients with AF and its presence during AF rhythm was associated with subsequent cardiac events.

  • atrial fibrillation
  • electrocardiography
  • heart failure

Data availability statement

No data are available. Deidentified participant data will not be shared.

Statistics from

Data availability statement

No data are available. Deidentified participant data will not be shared.

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  • Collaborators The Fushimi AF RegistryChief investigator: Akao M (National Hospital Organization Kyoto Medical Center). Steering Committee: Esato M (Ijinkai Takeda General Hospital), Abe M (National Hospital Organization Kyoto Medical Center), Tsuji H (Tsuji Clinic), Furuke K (Furuke Clinic). Statistical Analysis: Wada H (National Hospital Organization Kyoto Medical Center). Participating institutions: Department of Cardiology, National Hospital Organization Kyoto Medical Center (Akao M, Abe M, Ogawa H, Masunaga N, Iguchi M, Ishii M, Unoki T, Takabayashi K, Hamatani Y, Yamashita Y, Takagi D, Niki S, Doi K, Ikeda S, Aono, Y, Osakada G, Nakashima Y, Kanasaki M, Nakano T, Funatsu J, Nishio M, Takenaka Y); Department of Arrhythmia, Ijinkai Takeda General Hospital (Chun YH, Esato M, Kida Y, Nishina N); Koujinkai Oshima Hospital (Terada K); Divison of Translational Research, National Hospital Organization Kyoto Medical Center (Hasegawa K, Wada H); Kanai Hospital (Nishio M, Kamiya Y, Abe M, Ishii M); Tsuji clinic (Tsuji H); Furukawa Medical Clinic (Furukawa K); Nishikawa Clinic (Nishikawa M); Taniguchi Clinic (Taniguchi Y); Gushiken Clinic (Gushiken T); Fushimi Shimizu Hospital (Hirata Y); Yoda Clinic (Yoda J); Tasato Clinic (Tasato H); Ogawa Medical Office (Ogawa T); Saiwai Hospital (WakatsukiY, Yahata M, Higashitani N); Itoh Hemodialysis Clinic (Itoh H); Itoh Clinic (Itoh H, Ohmori Y); RyokuhoukaiTsuji Clinic (Tsuji K); Kitamura Clinic (Kitamura S); Izumikawa Clinic (Izumikawa F); Hirota Clinic (HirotaN); Kyomachi-Oota Clinic (Oota K); Kouseikai Rehabilitation Clinic (Kou K); Inariyama Hospital (Tanaka T, Iguchi M); Matsushita Clinic (Matsushita N); Kitani Clinic (Kitani K); Kimura Clinic (Kimura F); Hayashi Clinic (Hayashi S); Handa Clinic (Handa S); Soseikai General Hospital (Hasegawa S, Kono T, Otsuka K, Soyama A, Okamoto J, Nakai Y); Asamoto Clinic (Asamoto H); Sugano Clinic (Tanaka H, Murata T); Kyoto Ohashi General Hospital (Kayawake S, Kinoshita Y); Furuke Clinic (Furuke K); Kanehisa Clinic (Asano N); Tahara Clinic (Tahara K); Matsumoto Medical Office (Matsumoto K); Kuroda Clinic (Kuroda O); OchiaiClinic (Ochiai K, Ochiai J); Fujii Clinic (Fujii M); Kurihara Clinic (Kurihara M); Kuzuyama Clinic (Ito A); Kenkokai Fushimi Clinic (Totsuzaki S); Nakayama Orthopedic Clinic (Nakayama H); Department of Cardiovascular Medicine, Ijinkai Takeda General Hospital (Kawai C, Hashimoto T, Kakio T, Watanabe C, Takeda S, Sasaki Y, Shirasawa K, Beppu K, Inoue T, Shirasaka A, Doi T); Tatsumi Clinic (Ueda T); OishiClinic (Oishi M); Koizumi Clinic (Kasahara A); Kishida Clinic (Kishida S); Shibata Clinic (Shibata M); Shimizu Clinic (Shimizu J); Shirasu Clinic (Shirasu M); Fujinokai Clinic (Tateishi S); Tsukuda Clinic (Tsukuda N); Shinseikai Tsuji Clinic (Tsuji K); Nishi Clinic (Nishi T); Nishimura Clinic (Nishimura S); HabaClinic (Haba T); Higashimae Clinic (Higashimae R); Fujimori Clinic (Fujimori C); Hotta Clinic (Hotta T); Matsui Clinic (Matsui H, Matsui H); Shadan Matsumoto Clinic (Matsumoto H); Maruo Clinic (Maruo N); Misu Clinic (Mikami M); Mekata Clinic (Mekata H); Mori Pediatric Clinic (Mori H); Wakabayashi Clinic (Wakabayashi M); Nakatsugawa Clinic (Sasaki Z); Shiseikai Nishimura Clinic (Nishimura S); Yuge Eye Clinic (Yuge K); Gokita Hospital (Haruta M); Soseikai Clinic (Tsuda E); Toujinkai Hospital (Nishimura M); KounoClinic (Kouno T, Kouno Y); Matsumura Clinic (Matsumura S); Fujita Clinic (Fujita A); Takayasu Clinic (Takayasu F, Takayasu S); Yano Clinic (Yano Y); Niki Clinic (Niki S); Hasegawa Meiando Clinic (Hasegawa S); Watanabe Medical Clinic (Watanabe T). Clinical Research Cordinator: Shinagawa T, Mitamura M, Fukahori M, Kimura M, Fukuyama M, Kamata C.

  • Contributors TK analysed the data and wrote the paper. HO, YH, MAb and MAk contributed to acquisition of data and helped in data analysis and interpretation. HO, YH, MK, TY and SM contributed to statistical analysis. MAk is a principal investigator of the Fushimi AF Registry and the corresponding author of this paper. MAk had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of data analysis.

  • Funding The Fushimi AF Registry is supported by research funding from Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi Sankyo, Novartis Pharma, MSD, Sanofi-Aventis and Takeda Pharmaceutical. This study was partially supported by the Practical Research Project for Life-Style related Diseases including Cardiovascular Diseases and Diabetes Mellitus from the Japan Agency for Medical Research and Development (AMED; 19ek0210082h0003 and 18ek0210056h0003).

  • Disclaimer The sponsors had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review or approval of the manuscript.

  • Competing interests MAk received lecture fees from Pfizer, Bristol-Myers Squibb, Boehringer Ingelheim, Bayer Healthcare and Daiichi Sankyo.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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