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The response praises the prospective design and echo-based assessment while questioning heterogeneity of the population, the mechanistic validity of pathological P-wave thresholds, and the interpretation of ignoring V1 terminal force. It also highlights cross-sectional limits of echocardiographic markers, load dependence, vendor variability, and low prevalence of advanced interatrial block as a screening tool. A multiparametric, longitudinal strategy with advanced imaging is recommended.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/electrocardiographic-markers-of-atrial-cardiomyopathy-strengths-and-limits-of-p-wave-based-assessment/468433/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/electrocardiographic-markers-of-atrial-cardiomyopathy-strengths-and-limits-of-p-wave-based-assessment/468433.png","ImageObject",300,407,{"name":92,"@type":93},"Rhys","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-07","2026-09-30",true,{"@type":102,"interactionType":103,"userInteractionCount":19},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What main ECG marker does the original authors claim is most reliable for impaired left atrial function?","Question",{"text":112,"@type":113},"The letter states that advanced interatrial block (IAB) is presented as the most reliable electrocardiographic marker of impaired left atrial function.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"Why does the letter question the operational definition of pathological P-wave parameters?",{"text":117,"@type":113},"It argues that the thresholds rely largely on epidemiological associations rather than mechanistic validation against atrial tissue pathology or gold-standard imaging, and may not reflect true biological relevance.",{"name":119,"@type":110,"acceptedAnswer":120},"What limitations are highlighted regarding the evidence base and causal inference?",{"text":121,"@type":113},"The letter notes that cross-sectional echocardiographic markers restrict causal inference and that left atrial strain and PA-TDI are load-dependent and can vary across echocardiographic systems and vendors.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},468433,1790774224,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":19,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":129,"read_time":24,"preview_page_count":4},687207024643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","Annals of Noninvasive Electrocardiology   \n LETTER TO THE EDITOR  OPEN ACCESS   \nElectrocardiographic Markers of Atrial Cardiomyopathy: Strengths and Limits of P-Wave–Based Assessment  \nMehmet Mustafa Yılmaz1  | Mücahit Aker1  | Macit Kalçık2   \n1Department of Cardiology, Hitit University Erol Olçok Education and Research Hospital, Corum, Turkey | 2Department of Cardiology, Faculty of Medicine, Hitit University, Corum, Turkey  \nCorrespondence: Macit Kalçık ([macitkalcik@yahoo.com](macitkalcik@yahoo.com))  \nReceived: 1 January 2026 | Revised: 1 January 2026 | Accepted: 5 January 2026  \nTo the Editor,  \nWe read with interest the article by Kazantzi et al. examining the association between established P-wave parameters and left atrial hemodynamics in the context of atrial cardiomyopathy (ACM) (Kazantzi et al. 2026) . The authors should be acknowledged for addressing a clinically relevant question using a prospective design and comprehensive echocardiographic assessment. Their conclusion that advanced interatrial block (IAB) is the most reliable electrocardiographic marker of impaired left atrial function is clearly presented and supported by internal consistency within the dataset.  \nNevertheless, several methodological aspects warrant closer scrutiny. The study population is heterogeneous, comprising patients with prior atrial fibrillation, embolic stroke of undetermined source, and individuals without manifest cardiovascular disease. While this broad inclusion enhances external validity, it may dilute pathophysiologically specific associations between P-wave indices and atrial remodeling. Current consensus documents emphasize that ACM represents a spectrum with variable electrical, structural, and mechanical manifestations, and pooling such diverse phenotypes may obscure parameter-specific diagnostic performance (Goette et al. 2024) .  \nA further concern relates to the operational definition of pathological P-wave parameters. Thresholds derived from consensus recommendations are largely based on epidemiological associations rather than mechanistic validation against atrial tissue pathology or gold-standard imaging. In particular, the dismissal of P-wave terminal force in lead V1 as a hemodynamic marker may reflect cohort characteristics rather than a true lack of biological relevance, given its previously demonstrated association  \nwith atrial fibrosis and stroke risk in population-based studies (Kamel et al. 2014) .  \nAdditionally, the reliance on cross-sectional echocardiographic markers limits causal inference. Left atrial strain and PA-TDI are sensitive indicators of atrial function, yet they remain loaddependent and subject to inter-vendor variability. Longitudinal assessment or correlation with advanced imaging modalities such as late gadolinium-enhanced cardiac magnetic resonance imaging could have strengthened the argument that advanced IAB truly captures the substrate of atrial cardiomyopathy rather than representing an epiphenomenon of aging and comorbidity burden (Bisbal et al. 2020) .  \nFinally, the clinical implications of prioritizing advanced IABover other P-wave parameters deserve cautious interpretation. While advanced IAB appears strongly associated with impaired atrial hemodynamics, its relatively low prevalence may limit utility as a screening tool. A multiparametric approach integrating electrocardiographic, echocardiographic, and biomarker data may better reflect the complex biology of ACM and align with contemporary views of atrial disease as a continuum rather than a binary entity (Kreimer and Gotzmann 2022) .  \nAuthor Contributions  \nAll of the authors contributed to planning, writing, and revision.  \nFunding  \nThe authors have nothing to report.  \nThis is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.  \n© 2026 The Author(s). Annals of Noninvasive Electrocard","cbCairWJyOL7VrxF","https://ap.wps.com/l/cbCairWJyOL7VrxF","pdf",141852,"English","# To the Editor\n## Study strengths and presented conclusion\n## Methodological concerns\n## Definitions and V1 terminal force\n## Limitations of cross-sectional markers\n## Clinical implications and multiparametric approach\n## Author contributions, funding, and declarations","[{\"question\":\"What main ECG marker does the original authors claim is most reliable for impaired left atrial function?\",\"answer\":\"The letter states that advanced interatrial block (IAB) is presented as the most reliable electrocardiographic marker of impaired left atrial function.\"},{\"question\":\"Why does the letter question the operational definition of pathological P-wave parameters?\",\"answer\":\"It argues that the thresholds rely largely on epidemiological associations rather than mechanistic validation against atrial tissue pathology or gold-standard imaging, and may not reflect true biological relevance.\"},{\"question\":\"What limitations are highlighted regarding the evidence base and causal inference?\",\"answer\":\"The letter notes that cross-sectional echocardiographic markers restrict causal inference and that left atrial strain and PA-TDI are load-dependent and can vary across echocardiographic systems and vendors.\"}]","Electrocardiographic Markers of Atrial Cardiomyopathy - Strengths and Limits of P-Wave-Based Assessment | PDF"]