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Background  Whether PR prolongation independently predicts new-onset ischemic events of myocardial infarction and stroke was unclear. Underlying pathophysiological mechanisms of PR prolongation leading to adverse cardiovascular events were poorly understood. We investigated the role of PR prolongation in pathophysiologically-related adverse cardiovascular events and underlying mechanisms.    Methods  We prospectively investigated 597 high-risk cardiovascular outpatients (mean age 66 ± 11 yrs.; male 67%; coronary disease 55%, stroke 22%, diabetes 52%) for new-onset ischemic stroke, myocardial infarction (MI), congestive heart failure (CHF), and cardiovascular death. Vascular phenotype was determined by carotid intima-media thickness (IMT).    Results  PR prolongation >200 ms was present in 79 patients (13%) at baseline. PR prolongation >200 ms was associated with significantly higher mean carotid IMT (1.05 ± 0.37 mm vs 0.94 ± 0.28 mm,  P = 0.010 ). After mean study period of 63 ± 11 months, increased PR interval significantly predicted new-onset ischemic stroke ( P = 0.006 ), CHF ( P = 0.040 ), cardiovascular death ( P < 0.001 ), and combined cardiovascular endpoints ( P < 0.001 ) at cut-off >200 ms. Using multivariable Cox regression, PR prolongation >200 ms independently predicted new-onset ischemic stroke (HR 8.6, 95% CI: 1.9–37.8,  P = 0.005 ), cardiovascular death (HR 14.1, 95% CI: 3.8–51.4,  P < 0.001 ) and combined cardiovascular endpoints (HR 2.4, 95% CI: 1.30–4.43,  P = 0.005 ). PR interval predicts new-onset MI at the exploratory cut-off >162 ms (C-statistic 0.70,  P = 0.001;  HR: 8.0, 95% CI: 1.65–38.85,  P = 0.010 ).    Conclusions  PR prolongation strongly predicts new-onset ischemic stroke, MI, cardiovascular death, and combined cardiovascular endpoint including CHF in coronary patients or risk equivalent. Adverse vascular function may implicate an intermediate pathophysiological phenotype or mediating mechanism.    Electronic supplementary material  The online version of this article (doi:10.1186/s12872-017-0667-2) contains supplementary material, which is available to authorized users.

PR interval prolongation in coronary patients or risk equivalent: excess risk of ischemic stroke and vascular pathophysiological insights