Etiology distribution of patients with atrial fibrilation by echocardiography: results from a prospective study in 3755 adults

Enes Abdovic Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina

Purpose• Atrial fibrillation (AF) is the most prevalent sustained

cardiac arrhythmia 1

• It is a disease of the elderly and it is common in patients with structural heart disease1

• Hypertension (HA), diabetes mellitus, myocardial infarction, heart failure (with impaired or preserved left ventricular systolic function), and valvular heart disease are recognized predisposing factors to AF2,3,4

• Objectives: To evaluate predisposing factors for development of AF in our hospital settings

1Go AS, et al. JAMA 2001;285:2370–75.2Aidietis A, et al. Curr Pharm Des 2007;13:2545–55.3Grigioni F, et al. J Am Coll Cardiol 2002;40:84–92.

4Olsson LG, et al. J Am Coll Cardiol 2006;47:1997–2004.

Purpose

• From June 2000 to February 2013, 3755 consecutive patients with AF were studied during echocardiographic check-up

• According to transthoracic echo, patients were divided in groups based on dominative underlying heart diseases

• Electrocardiographically documented AF was subdivided in two groups: transitory and chronic– Transitory AF fulfilled criteria for paroxysmal or persistent AF1

– Chronic AF were cases of long-standing persistent or permanent AF1

• Binary logistic regression was used to investigate relationship of gender, age, hypertension, diabetes and underlying heart diseases with the type of AF

Camm AJ, et al. Eur Heart J 2010;31:2369–2429.

MethodsMethods

Results

• The median age was 72 years, age range between 16 and 96 years

• There were 51.4% of females. • Chronic AF was observed in 68.3% pts. • Lone AF was diagnosed in only 25 patients,

mostly in younger males (median age 48 years, range 29–59, men 80%)

HHD=hypertensive heart disease; DCM=dilated cardiomyopathy; CAD=coronary artery disease; VHD=valvular heart disease; Lone=lone AF; HF=heart failure; AF=atrial fibrillation.

Etiological distribution AF by echocardiography (3755 pts)

HHD DCM CAD VHD Lone OTHER TOTAL

No of pts (%) 1511 (40.2) 935 (24.9) 522 (13.9) 416 (11.1) 25 (0.7) 346 (9.2) 3755 (100)

Females (%) 850 (56.3) 394 (42.1) 224 (42.9) 251 (60.3) 5 (20.0) 207 (59.8) 1931 (51.4)

Age, median (yrs) 71 72 72 68 48 69 72

Age, range (yrs) 24-96 32-95 41-96 33-93 29-60 16-92 16-96

BMI [kg/m2] 29.4 26.9 28.4 27 26.4 28.1 28.2±5

Transitory AF (%) 543 (35.9) 200 (21.4) 220 (42.2) 84 (20.2) 18 (72.0) 126 (36.4) 1191 (31.7)

Hypertension (%) 1511 (100) 624 (66.7) 348 (66.7) 198 (47.6) 0 172 (49.7) 2832 (75.4)

Diabetes (%) 300 (19.9) 168 (18.0) 158 (30.3) 37 (8.9) 0 41 (11.9) 706 (18.8)

Thyreoid disease (%) 0 (0) 51 (5.5) 27 (5.2) 18 (4.3) 0 181 (52.3) 240 (6.4)

No=number; pts=patients; AF=atrial fibrillation; BMI=body mass index; HHD=hypertensive heart disease; DCM=dilated cardiomyopathy; CAD=coronary artery disease; VHD=valvular heart disease; Lone=lone AF.

Comorbidities associated with AF

HHD DCM CAD VHD Lone OTHER TOTAL

No of pts (%) 1511 (40.2) 935 (24.9) 522 (13.9) 416 (11.1) 25 (0.7) 346 (9.2) 3755 (100)

Females (%) 850 (56.3) 394 (42.1) 224 (42.9) 251 (60.3) 5 (20.0) 207 (59.8) 1931 (51.4)

Age, median (yrs) 71 72 72 68 48 69 72

Age, range (yrs) 24-96 32-95 41-96 33-93 29-60 16-92 16-96

BMI [kg/m2] 29.4 26.9 28.4 27 26.4 28.1 28.2±5

Transitory AF (%) 543 (35.9) 200 (21.4) 220 (42.2) 84 (20.2) 18 (72.0) 126 (36.4) 1191 (31.7)

Hypertension (%) 1511 (100) 624 (66.7) 348 (66.7) 198 (47.6) 0 172 (49.7) 2832 (75.4)

LBBB(%) 95 (24.7) 209 (54.4) 36 (9.4) 19 (5.0) 0 25 (6.5) 384 (10.2)

Galstones (%) 263 (45.7) 131 (22.8) 84 (14.6) 51 (8.9) 0 45 (7.8) 575 (15.3)

No=number; pts=patients; AF=atrial fibrillation; BMI=body mass index; HHD=hypertensive heart disease; DCM=dilated cardiomyopathy; CAD=coronary artery disease; VHD=valvular heart disease; Lone=lone AF.

Comorbidities associated with AF

HHD=hypertensive heart disease; DCM=dilated cardiomyopathy; CAD=coronary artery disease; VHD=valvular heart disease; Lone=lone AF; HF=heart failure; AF=atrial fibrillation.

AF and HA pts (2854=76%)

HHD=hypertensive heart disease; DCM=dilated cardiomyopathy; CAD=coronary artery disease; VHD=valvular heart disease; Lone=lone AF; HF=heart failure; AF=atrial fibrillation.

AF and HF pts (1832=49%)

AF, type Chronic AF Transitory AF Total

No pts (%) 2564 (68.3) 1191 (31.7) 3755 (100%)

Females (%) 1306 (50.9) 625 (52.5) 1931 (51.4)

Age,means&SD,yrs (range) 70±10 (16-96) 68±11 (24-94) 71±10 (16-96)

BMI [kg/m2] 28.4 27.9 28.2

Hypertension (%) 1891 (73.8) 941 (79.0) 2832 (75.4)

Diabetes (%) 430 (16.8) 191 (16.0) 706 (18.8)

Coronary artery dysease (%) 594 (23.2) 347 (29.1) 941 (25.1)

Gallstones (%) 366 (14.3) 203 (17.1) 569 (15.3)

LBBB (%) 259 (10.1) 124 (10.4) 383 (10.2)

Stroke/TIA (%) 241 (9.4) 67 (5.6) 308 (8.2)

Thyroid dysfunction (%) 156 (6.1) 84 (7.1) 240 (6.4)

No=number; pts=patients; AF=atrial fibrillation; SD=standard deviation, yrs=years, BMI=body mass index; LBBB=left bundle branch block; TIA=transitory ischemic attack.

Characteristics of patients with chronic vs. transitory AF

Results (2)

• Hypertensive heart disease (HHD) was the most common underlying heart disease (40.2%) followed by dilated cardiomyopathy (DCM), 24.9%, coronary artery disease (CAD), 13.9% and valvular heart disease (VHD), 11.1%.

• Thyroid gland disease was found in 240:6.3% of patients of which 52.9% was hypothyroidism (127 vs 113)

Results (2)

Results (2)

• Hypertension, diabetes and thyroid gland disease were found in 75.4%, 18.8% and 6.3% patients, respectively, mostly in females:

• (HA: 1556pts/2832=55.0%) • (DM: 453pts/706=64.2%)• (Thy.gl.disease: 193pts/240=80.4%)

Results (3)

Risk of chronic atrial fibrillation (binary logistic regression model)HHD, hypertensive heart disease; DCM, dilated cardiomyopathy; CHD, coronary artery disease; VHD, valvular heart disease; Lone, lone atrial fibrillation; BMI, body mass index; HA, hypertension; DM, diabetes mellitus; TH, diseases of thyroid gland; IVB, intraventricular block.

Pts with/without Paroxismal AF Aged ≥65yrs and/or with LAE ≥ 25 and/or with IAB

Group 1N=3985

2N=1783

3N=396

4N=400

5N=472

6N=403

7N=172

8N=154

Age≥65 - + - - + + - +

IAB - - + - + - + +

LAE - - - + - + + +

AF/NO 2883 1619 359 354 392 368 89 143

AF/YES 129 136 30 35 61 59 40 54

AF(%) 3.2 7.6 7.6 8.8 12.9 14.7 23.3 35.1

CHA2DS2-VASc score ≥ 2 = 86.5% HHD DCM CAD VHD Other Age Female

(%)Total3777

0 - - 11 36 40 53 ± 9 - 106

1 158 41 52 92 57 58 ± 9 72 (17.8) 405

2 342 119 108 90 97 66 ± 9 256 (33.8) 757

3 457 242 146 110 78 72 ± 7 518 (50.2) 1033

4 365 282 106 54 55 75 ± 6 600 (69.6) 862

5 153 158 72 25 16 75 ± 6 337 (79.5) 424

6 40 72 27 8 3 77 ± 5 119 (79.3) 150

7 8 17 3 - - 77 ± 3 27 (96.4) 28

8 - 4 5 1 - 77 ± 3 10 (100.0) 10

9 - 2 - - - 80 ± 0 2 (100.0) 2

Conclusion

• Hypertension was by far the most prevalent associated medical condition in patients with AF

• AF without underlying heart disease was present in only 0.7%, mostly in younger patients, males, with transitory AF

• Almost 1/2 of pts with AF had HF and 59.2% had diastolic HF.

• Chronic AF was predominant in groups with advanced cardiac remodeling such as DCM and VHD, mostly in elderly

Conclusion

Conclusion

• Optimal treatement of HA as well as DM

• to prevent CAD and HF and • to eliminate or at least postpone AF,

the most common sustained cardiac arrhythmia

Take Home Message