Among 7,083 adults free of baseline cardiovascular disease, electrocardiographic markers of atrial cardiomyopathy (AtCM) — defined by prolonged P-wave duration ≥120 ms, abnormal P-wave axis, or deep terminal negativity in V1 — significantly stratified CVD mortality risk when layered onto cardiometabolic risk factor (CMRF) burden. Participants carrying both AtCM and two or more CMRFs (hypertension, diabetes, obesity) faced a hazard ratio of 2.25 (95% CI 1.75–2.87) for CVD death compared to those with neither. Individual CMRFs combined with AtCM similarly elevated risk, with diabetes plus AtCM reaching HR 2.08.
The practical implication is notable: a standard 12-lead ECG — already ubiquitous in clinical care — could be mined for atrial structural disease markers to identify high-risk individuals who might otherwise appear only moderately at-risk based on CMRF count alone. Atrial cardiomyopathy has gained traction as a stroke and arrhythmia precursor distinct from atrial fibrillation, and this analysis extends its relevance to all-cause CVD mortality. However, several limitations temper enthusiasm. The cohort is observational, mortality follow-up ended in 2006, and confounding by unmeasured variables remains possible. The mean age of 58 limits generalizability to younger populations. Crucially, this is a preprint posted on medRxiv and has not yet been peer-reviewed — findings should be treated as preliminary. If validated, ECG-based AtCM screening could represent a scalable, low-cost layer in cardiovascular risk stratification for metabolically burdened patients.