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Iden L, Richardt G, Weinert R, Groschke S, Toelg R, Borlich M. Typical atrial flutter but not fibrillation predicts coronary artery disease in formerly healthy patients. Europace 2021; 23:1227-1236. [PMID: 33611584 DOI: 10.1093/europace/euab002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 01/06/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS Long-term mortality after ablation of typical atrial flutter has been found to be increased two-fold in comparison to atrial fibrillation ablations through a period of 5 years with unclear mechanism. METHODS AND RESULTS We analysed 189 consecutive patients who underwent ablation for typical atrial flutter (AFL), in which the incidence of AF was the first manifestation of cardiac disease. According to the clinical standards of our centre, the routine recommendation was to evaluate for coronary artery disease (CAD) by invasive angiogram or computed tomography scan. We compared the AFL patients to 141 patients with paroxysmal atrial fibrillation (AFIB) without known structural heart disease who underwent ablation in the same period and who had routine coronary angiograms performed. Out of 189 patients who presented with AFL, coronary status was available in 152 patients (80.4%). Both groups were balanced for mean age (64.9 years in AFL vs. 63.2 years in AFIB; P = 0.15), body mass index (BMI; 28.8 vs. 28.5 kg/m2; P = 0.15), CHA2DS2-VASc-Score (2.20 vs. 2.04; P = 0.35), smoking status (22.2% smokers vs. 28.4%; P = 0.23), and renal function (GFR >60 mL/min in 96.7% of all patients vs. 95.7%; P = 0.76). There were significantly lower values for left ventricular ejection fraction (52.5% vs. 59.7%; P < 0.001), female sex (17.0% vs. 47.5%; P < 0.001), hyperlipidaemia (37.9% vs. 58.9%; P < 0.001), and family history of cardiovascular disease (CVD) (15.0 vs. 31.9%; P = 0.001) in the AFL vs. AFIB cohorts. Coronary artery disease with stenoses >50% was found in 26.3% of all patients with available coronary status in AFL and in 7.0% in AFIB (P < 0.001). Coronary artery disease with stenoses >75% in 16.4% in AFL whereas only in 1.4% in AFIB (P < 0.001). Multivessel disease was detected in 10.5% in AFL and 0.7% in AFIB (P < 0.001). After correction for age, left ventricular ejection fraction, BMI, CHA2DS2-VASc-Score and its individual components, smoking status, hyperlipidaemia, and family history of CVD, there was a more than five-fold increase in the likelihood of CAD with stenosis >50% in AFL as compared to AFIB [odds ratio (OR 5.26)]. A multivariate analysis was performed in the AFL group. Patients with clinically relevant stenoses (>75%) were older (70.6 years vs. 63.8 years; P = 0.001), had a higher number of risk factors (3.08 vs. 2.24; P ≤ 0.0016) and a higher CHA2DS2-VASc-Score (3.20 vs. 2.00; P < 0.0001). With logistic regression, significant CAD could be predicted by higher values for CHA2DS2-VASc-Score with an exponential rise to a pretest-probability of 42.1% at a value of 4 points. CONCLUSION These data suggest that typical atrial flutter constitutes a manifestation of previously asymptomatic CAD. Due to the inclusion criteria, CAD has to be considered silent and chronic in most of the patients. Therefore, the presence of typical atrial flutter in formerly healthy patients should raise suspicion of otherwise silent CAD and initiate further investigations and risk stratification with particular emphasis on the individual CHA2DS2-VASc-Scores.
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Affiliation(s)
- Leon Iden
- Department of Cardiology, Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein, 23795, Germany
| | - Gert Richardt
- Department of Cardiology, Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein, 23795, Germany
| | - Rolf Weinert
- Department of Cardiology, Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein, 23795, Germany
| | - Susann Groschke
- Department of Cardiology, Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein, 23795, Germany
| | - Ralph Toelg
- Department of Cardiology, Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein, 23795, Germany
| | - Martin Borlich
- Department of Cardiology, Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein, 23795, Germany
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Two in one is better than one plus one: comparison of adverse events between combining electrophysiological examination and coronary angiography versus performing them consecutively. J Interv Card Electrophysiol 2017; 50:203-209. [PMID: 29177982 DOI: 10.1007/s10840-017-0298-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 11/16/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE In some patients, both an electrophysiological examination (EPS) and a coronary angiography (CA) are necessary. It might be preferable to choose a combined approach of EPS and CA versus performing them consecutively. The purpose of this study is to evaluate the type and rate of adverse events between both approaches. METHODS Patients were eligible if they underwent a CA and an EPS in a combined approach or in a time interval of at most 2 months. In all patients, clinical adverse events were recorded. RESULTS A total of 1184 patients were included. CA and EPS were performed in a combined procedure (comb) in 492 patients, whereas they were performed consecutively in 692 patients (cons). The acute major complication rate was 0.67%, showing no differences between both groups. In the comb 6.9% and in the cons 6.6% of vascular complications were observed (p = 0.20). The rates of AV fistula and hematoma needing transfusion showed a significantly higher rate in the cons group (p = 0.018 and p = 0.045, respectively). In a multivariate logistic regression analysis, age was a significant predictor for groin complications. After propensity matching, AV fistula occurred significantly more often in the cons group (p = 0.002). CONCLUSION Overall, serious adverse events were rare and there were no differences between the combined approach of EPS and CA and the consecutive approach; however, the occurrence of AV fistula and groin hematoma needing transfusion occurred significantly less in the combined procedure group. Therefore, a combined approach is preferable to a consecutive one.
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Rahman F, Wang N, Yin X, Ellinor PT, Lubitz SA, LeLorier PA, McManus DD, Sullivan LM, Seshadri S, Vasan RS, Benjamin EJ, Magnani JW. Atrial flutter: Clinical risk factors and adverse outcomes in the Framingham Heart Study. Heart Rhythm 2016; 13:233-40. [PMID: 26226213 PMCID: PMC4698205 DOI: 10.1016/j.hrthm.2015.07.031] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Few epidemiologic cohort studies have evaluated atrial flutter (flutter) as an arrhythmia distinct from atrial fibrillation (AF). OBJECTIVE The purpose of this study was to examine the clinical correlates of flutter and its associated outcomes to distinguish them from those associated with AF in the Framingham Heart Study. METHODS We reviewed and adjudicated electrocardiograms (ECGs) previously classified as flutter or AF/flutter and another 100 ECGs randomly selected from AF cases. We examined the clinical correlates of flutter by matching up to 5 AF and 5 referents to each flutter case using a nested case referent design. We determined the 10-year outcomes associated with flutter with Cox models. RESULTS During mean follow-up of 33.0 ± 12.2 years, 112 participants (mean age 72 ± 10 years, 30% women) developed flutter. In multivariable analyses, smoking (odds ratio [OR] 2.84, 95% confidence interval [CI] 1.54-5.23), increased PR interval (OR 1.28 per SD, 95% CI 1.03-1.60), myocardial infarction (OR 2.25, 95% CI 1.05-4.80) and heart failure (OR 5.22, 95% CI 1.26-21.64) were associated with incident flutter. In age- and sex-adjusted models, flutter (vs referents) was associated with 10-year increased risk of AF (hazard ratio [HR] 5.01, 95% CI 3.14-7.99), myocardial infarction (HR 3.05, 95% CI 1.42-6.59), heart failure (HR 4.14, 95% CI 1.90-8.99), stroke (HR 2.17, 95% CI 1.13-4.17), and mortality (HR 2.00, 95% CI 1.44-2.79). CONCLUSION We identified the clinical correlates associated with flutter and observed that flutter was associated with multiple adverse outcomes.
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Affiliation(s)
- Faisal Rahman
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Na Wang
- Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts
| | - Xiaoyan Yin
- Department of Biostatistics, Boston University, Boston, Massachusetts
| | - Patrick T Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Steven A Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Paul A LeLorier
- Department of Medicine, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - David D McManus
- National Heart Lung and Blood Institute and Boston University's Framingham Heart Study, Framingham, Massachusetts; Departments of Medicine and Quantitative Health Sciences, University of Massachusetts, Worcester, Massachusetts; Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts
| | - Lisa M Sullivan
- Department of Biostatistics, Boston University, Boston, Massachusetts
| | - Sudha Seshadri
- Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts; Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Ramachandran S Vasan
- National Heart Lung and Blood Institute and Boston University's Framingham Heart Study, Framingham, Massachusetts; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Emelia J Benjamin
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; National Heart Lung and Blood Institute and Boston University's Framingham Heart Study, Framingham, Massachusetts; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Jared W Magnani
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; National Heart Lung and Blood Institute and Boston University's Framingham Heart Study, Framingham, Massachusetts.
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Weijs B, Pisters R, Haest RJ, Kragten JA, Joosen IA, Versteylen M, Timmermans CC, Pison L, Blaauw Y, Hofstra L, Nieuwlaat R, Wildberger J, Crijns HJ. Patients originally diagnosed with idiopathic atrial fibrillation more often suffer from insidious coronary artery disease compared to healthy sinus rhythm controls. Heart Rhythm 2012; 9:1923-9. [DOI: 10.1016/j.hrthm.2012.08.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Indexed: 12/16/2022]
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Weijs B, de Vos CB, Tieleman RG, Peeters FECM, Limantoro I, Kroon AA, Cheriex EC, Pisters R, Crijns HJGM. The occurrence of cardiovascular disease during 5-year follow-up in patients with idiopathic atrial fibrillation. Europace 2012; 15:18-23. [PMID: 22782972 DOI: 10.1093/europace/eus203] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
AIMS Idiopathic atrial fibrillation (AF) may be an expression of as yet undetected underlying heart disease. We found it useful for clinical practice to study the long-term development of cardiovascular disease (CVD) in patients diagnosed with idiopathic AF. METHODS AND RESULTS Forty-one consecutive idiopathic AF patients (56 ± 10 years, 66% male) were compared with 45 healthy control patients in permanent sinus rhythm. Patients were free of hypertension, antihypertensive and antiarrhythmic drugs, diabetes, congestive heart failure, coronary artery or peripheral vascular disease, previous stroke, thyroid, pulmonary and renal disease, and structural abnormalities on echocardiography. Baseline characteristics and echocardiographic parameters were equal in AF cases and controls. During a mean follow-up of 66 ± 11 months, CVD occurred significantly more often in idiopathic AF patients compared with controls (49 vs. 20%, P= 0.006). Patients with idiopathic AF were significantly younger at the time of their first CV event compared with controls (59 ± 9 vs. 64 ± 5 years, P= 0.027), and had more severe disease. Multivariable Cox regression analysis revealed that age, a history of AF, and echocardiographic left ventricular wall width were significant predictors of CVD development. CONCLUSION Patients originally diagnosed with idiopathic AF develop CVD more often, at younger age, and with a more severe disease profile compared with healthy sinus rhythm control patients. The detection and treatment of CVD in an early stage could improve the prognosis of these patients. At present it seems prudent to regularly check idiopathic AF patients for the insidious development of CVD.
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Affiliation(s)
- B Weijs
- Department of Cardiology, Maastricht University Medical Center & Cardiovascular Research Institute, PO Box 5800, Maastricht 6202 AZ, Groningen, The Netherlands.
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Feld GK. In search of an arrhythmic cause of coronary artery disease: the electrophysiologist's next frontier? Europace 2010; 12:1664-5. [PMID: 20974754 DOI: 10.1093/europace/euq378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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