Atrial fibrillation progression and management: A 5-year prospective follow-up study

doi:10.1016/j.hrthm.2008.08.011

Heart Rhythm

Volume 5, Issue 11, November 2008, Pages 1501-1507

https://doi.org/10.1016/j.hrthm.2008.08.011 Get rights and content

Background

Few data on atrial fibrillation (AF) progression from the first paroxysmal episode are available.

Objective

The purpose of this study was to assess the progression of AF not due to potentially reversible causes in patients treated according to current guidelines recommendations that also include catheter ablation.

Methods

Among 402 screened patients with first AF, 106 patients (mean age 57.5 years) were selected and followed for 5 years. Of these patients, 54 had lone AF and 52 had comorbidities.

Results

Fifty patients (61.1% with lone AF) had no further recurrence after 5 years. The remaining 56 patients within 19 months after the first episode developed recurrent paroxysmal AF requiring long-term antiarrhythmic drug therapy, which was continued in 45 patients and was stopped because of intolerance/failure in 11 patients who underwent catheter ablation. AF became persistent in 24 of the 45 patients on antiarrhythmic drug therapy and then permanent in 16, of whom 6 had refused catheter ablation at the time of persistence. No AF recurrences or AF progression occurred after ablation. Kaplan-Meier curves demonstrated that patients with comorbidities were more likely to progress than were those with lone AF (P <.001) and that patients who underwent catheter ablation were at lower risk for progression to permanent AF than were those on antiarrhythmic drug therapy (P = .029). Age, diabetes, and heart failure (P <.001) predict final progression to permanent AF.

Conclusion

Patients with first AF and comorbidities are at higher risk for rapid progression to permanent AF, and age, diabetes, and heart failure are independent predictors. Catheter ablation rather than antiarrhythmic drug therapy is beneficial in eliminating recurrences delaying arrhythmia progression.

Introduction

At present, no prospective data on atrial fibrillation (AF) progression and management according to recent AF guideline recommendations are available.1, 2 Published data on AF progression mainly derive from retrospective analyses3, 4, 5, 6 or survey data registries.⁷ To date, no prospective information that includes a potential influence of catheter ablation is available. Accordingly, the purpose of this prospective study was to report additional data on AF progression and management, which includes catheter ablation as an alternative to conventional antiarrhythmic drug therapy.

Section snippets

Study population

All consecutive patients admitted to the emergency department with a first episode of paroxysmal AF were recruited for this 5-year prospective follow-up study. Final inclusion required ECG confirmation of the arrhythmia and verification of the episode as the first recognized AF event for the individual without previous antiarrhythmic drug therapy. Patients with arrhythmia due to potentially reversible causes, such as acute or recent (<6 months) myocardial infarction, recent cardiac surgery, New

Study population

Enrollment began between January 2002 and July 2002, and the study ended in July 2007. Among 402 screened patients, 244 had potentially reversible causes and were excluded from the study. Of the 158 eligible patients, 52 declined to enter the study, and the remaining 106 patients completed the study protocol (Figure 1). Baseline clinical characteristics of the 106 patients and of those who progressed are given in Table 1. Heart failure was present in 12.2% of subjects with preserved left

Discussion

According to current guidelines for classification and management, AF is characterized by different clinical forms depending on its clinical presentation and course, in all probability reflecting different stages with multiple mechanisms.1, 2 Frequently, a first episode is due to a reversible cause, and in most cases after treatment of the underlying disease AF will not recur and no therapy is required.1, 2 However, in other patients, the first episode may not be due to a reversible cause, and

Conclusion

This prospective study provides new insights into AF progression and shows that over 5-year follow-up, patients with lone AF are less likely to progress from the first detected episode to permanent AF. Age, diabetes mellitus, and heart failure predict final progression, which indicates a significant role of underlying heart disease in modulating such progression. Catheter ablation may be of benefit in preventing AF recurrences and delaying final AF progression, but larger randomized studies are

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This study aimed to evaluate the progression of electrophysiological phenomena in a cohort of patients with paroxysmal atrial fibrillation (PAF) and persistent atrial fibrillation (PsAF).
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A progressive decrease of mean conduction velocity was recorded across the groups (111.6 ± 55.5 cm/s control subjects, 97.1 ± 56.3 cm/s PAF, and 84.7 ± 55.7 cm/s PsAF). The number and density of slow conduction corridors increase in parallel with the progression of AF (8.6 ± 2.2 control subjects, 13.3 ± 3.2 PAF, and 20.5 ± 4.5 PsAF). In PsAF the atrial substrate is characterized by a higher curvature of wave-front propagation (0.86 ± 0.71 1/s PsAF vs 0.74 ± 0.63 1/s PAF; P = 0.003) and higher number of pivot points (25.1 ± 13.8 PsAF vs 9.5 ± 6.7 PAF; P < 0.0001). Slow conductions: corridors were mostly associated with pivot sites tending to cluster around pulmonary veins antra.
The electrical remodeling hinges mainly on corridors of slow conduction and higher curvature of wave-front propagation. Pivot points associated to SC corridors may be the major determinants for functional localized re-entrant circuits creating the substrate for maintenance of AF.
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In patients with diabetes, myocardial fibrosis may contribute to the pathogenesis of heart failure and arrhythmogenesis, increasing ventricular stiffness and delaying conduction. Diabetic myocardial fibrosis involves effects of hyperglycemia, lipotoxicity and insulin resistance on cardiac fibroblasts, directly resulting in increased matrix secretion, and activation of paracrine signaling in cardiomyocytes, immune and vascular cells, that release fibroblast-activating mediators. Neurohumoral pathways, cytokines, growth factors, oxidative stress, advanced glycation end-products (AGEs), and matricellular proteins have been implicated in diabetic fibrosis; however, the molecular links between the metabolic perturbations and activation of a fibrogenic program remain poorly understood. Although existing therapies using glucose- and lipid-lowering agents and neurohumoral inhibition may act in part by attenuating myocardial collagen deposition, specific therapies targeting the fibrotic response are lacking. This review manuscript discusses the clinical significance, molecular mechanisms and cell biology of diabetic cardiac fibrosis and proposes therapeutic targets that may attenuate the fibrotic response, preventing heart failure progression.
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2021, Journal of the American College of Cardiology
Atrial fibrillation (AF), the most common sustained arrhythmia observed in clinical practice, is a chronic and progressive disorder characterized by exacerbations and remissions. Guidelines recommend antiarrhythmic drugs as the initial therapy for the maintenance of sinus rhythm; however, antiarrhythmic drugs have modest efficacy to maintain sinus rhythm and can be associated with significant adverse effects. An initial treatment strategy of cryoballoon catheter ablation in patients with treatment-naïve AF has been shown to significantly improve arrhythmia outcomes (freedom from any, or symptomatic atrial tachyarrhythmia), produce clinically meaningful improvements in patient-reported outcomes (symptoms and quality of life), and significantly reduce subsequent health care resource use (hospitalization), and it does not increase the risk of serious or any adverse events compared with initial antiarrhythmic drug therapy. These findings are relevant to inform patients, providers, and health care systems regarding the initial choice of rhythm-control therapy in patients with treatment-naïve AF.
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There is a lack of data on atrial fibrillation (AF) progression after AF screening.
We studied the hypothesis that progression of AF subtype after AF screening was similar to the progression noted in clinical AF cases. We also studied predictors for AF progression and AF symptoms during 5-year follow-up.
All participants from the STROKESTOP study with screening-detected AF were included in this prospective cohort study (n = 218). Deceased patients, patients with dementia and/or patients receiving institutional care were excluded (n = 31). Patients were interviewed at their visit regarding symptoms, treatment with oral anticoagulation and clinical events during follow-up and instructed to record ECG using a handheld ECG recording twice daily for two weeks.
A total of 187 patients were invited for follow-up and 120 (64%) participated. The mean age was 81.0 ± 0.6 years and 56 (47%) of the participants were women. The mean follow-up time was 5.3 ± 0.4 years. Among the participants with 5-year follow-up data available, 18% (22/120) were diagnosed with permanent AF at study entry, compared to 49/120 (41%) after five years (p < 0.001). Among patients with paroxysmal AF at study entry, 33/98 (34%) had progressed to permanent AF after five years. Among participants approximately half remained asymptomatic, whereas 48% reported predominantly mild symptoms. None of the components of CHA₂DS₂-VASc were significantly predictive of AF progression.
The progression for screening-detected AF is like that of clinically detected AF. Half of the patients with screening-detected AF report symptoms over time, and symptoms were generally mild.
Catheter ablation of atrial fibrillation in patients with diabetes mellitus
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Diabetes mellitus (DM) is an independent risk factor for atrial fibrillation (AF). Few studies have compared clinical outcomes after catheter ablation between patients with and those without DM.
The purpose of this study was to compare AF ablation outcomes in patients with and those without DM.
We performed a retrospective analysis of 351 consecutive patients who underwent first-time AF ablation. Clinical outcomes included freedom from recurrent atrial arrhythmia, symptom burden (Mayo AF Symptom Inventory score), cardiovascular and all-cause hospitalizations, and periprocedural complications.
Patients with DM (n = 65) were older, had a higher body mass index, more persistent AF, more hypertension, and larger left atrial diameter (P <.05 for all). Median (Q1, Q3) total radiofrequency duration [64.0 (43.6, 81.4) minutes vs 54.3 (39.2, 76.4) minutes; P = .132] and periprocedural complications (P = .868) did not differ between patients with and those without DM. After a median follow-up of 29.5 months, arrhythmia recurrence was significantly higher in the DM group compared to the no-DM group after adjustment for baseline differences (adjusted hazard ratio [HR] 2.24; 95% confidence [CI] 1.42–3.55; P = .001). There was a nonsignificant trend toward higher AF recurrence with worse glycemic levels (HR 1.29; 95% CI 0.99–1.69; P = .064).
Although safety outcomes associated with AF ablation were similar between patients with and those without DM, arrhythmia-free survival was significantly lower among patients with DM. Poor glycemic control seems to an important risk factor for AF recurrence.

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Original-clinicalAtrial fibrillation progression and management: A 5-year prospective follow-up study

Background

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Study population

Study population

Discussion

Conclusion

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

Circulation

Follow-up of atrial fibrillation: the initial experience of the Canadian Registry of atrial fibrillation

Eur Heart J

Long-term progression and outcomes with aging in patients with lone atrial fibrillationA 30-year follow-up study

Circulation

Original-clinical
Atrial fibrillation progression and management: A 5-year prospective follow-up study