Cardiac electrophysiological characteristics of silent paroxysmal atrial fibrillation: What causes asymptomaticity?
Action Potentials
Aged
Asymptomatic Diseases
Atrial Fibrillation
/ diagnosis
Catheter Ablation
Electrocardiography, Ambulatory
Electrophysiologic Techniques, Cardiac
Female
Heart Conduction System
/ physiopathology
Heart Rate
Humans
Male
Middle Aged
Predictive Value of Tests
Prospective Studies
Recurrence
Refractory Period, Electrophysiological
Risk Factors
Time Factors
Treatment Outcome
asymptomaticity
atrial ectopy
atrioventricular conductivity
inducibility
silent paroxysmal atrial fibrillation
Journal
Journal of cardiovascular electrophysiology
ISSN: 1540-8167
Titre abrégé: J Cardiovasc Electrophysiol
Pays: United States
ID NLM: 9010756
Informations de publication
Date de publication:
12 2019
12 2019
Historique:
received:
04
09
2019
revised:
29
09
2019
accepted:
30
09
2019
pubmed:
8
10
2019
medline:
21
10
2020
entrez:
8
10
2019
Statut:
ppublish
Résumé
A diagnosis of silent paroxysmal atrial fibrillation (AF) is highly challenging due to its asymptomatic and intermittent nature. The goal of the present study was to clarify its asymptomaticity with the use of a comprehensive electrophysiological approach. We prospectively compared (a) 24-hour Holter monitoring data, (b) invasive cardiac electrophysiological properties, (c) AF inducibility, and (d) outcome of radiofrequency catheter ablation between patients with symptomatic paroxysmal AF and those with silent paroxysmal AF, defined as transient asymptomatic AF detected by chance. Patients with silent paroxysmal AF (N = 57) were more likely than patients with symptomatic paroxysmal AF (N = 282) to be male (75.4% vs 56.7%; P = .009), and to have a previous stroke (17.5% vs 6.7%; P = .008), more prolonged atrio-His interval (114.9 ± 29.1 vs 105.5 ± 24.1 ms; P = .01), longer atrioventricular nodal effective refractory period (352.3 ± 103 vs 318.2 ± 77.2 ms; P = .007), slower Wenckebach cycle length (488.5 ± 83.9 vs 443.3 ± 74.9 ms; P < .001), and lower maximum heart rate during AF (128.7 ± 31.9 vs 143.9 ± 29.6 beats/min; P = .02). Atrial ectopy (median [interquartile range], 385 [88, 2430] vs 207 [73.8, 870.8] beats/24 h; P = .02) and pharmacological AF induction (66.7% vs 43.2%; P = .02) were more common in silent paroxysmal AF patients. There was no difference in the 1-year freedom from AF following the ablation between the two patient groups. The more attenuated atrioventricular conduction properties in silent paroxysmal AF patients may explain their asymptomatic nature, and their higher likelihood of atrial arrhythmias may increase the chance to detect AF episodes. Whether or not they benefit from catheter ablation is uncertain.
Sections du résumé
BACKGROUND
A diagnosis of silent paroxysmal atrial fibrillation (AF) is highly challenging due to its asymptomatic and intermittent nature. The goal of the present study was to clarify its asymptomaticity with the use of a comprehensive electrophysiological approach.
METHODS
We prospectively compared (a) 24-hour Holter monitoring data, (b) invasive cardiac electrophysiological properties, (c) AF inducibility, and (d) outcome of radiofrequency catheter ablation between patients with symptomatic paroxysmal AF and those with silent paroxysmal AF, defined as transient asymptomatic AF detected by chance.
RESULTS
Patients with silent paroxysmal AF (N = 57) were more likely than patients with symptomatic paroxysmal AF (N = 282) to be male (75.4% vs 56.7%; P = .009), and to have a previous stroke (17.5% vs 6.7%; P = .008), more prolonged atrio-His interval (114.9 ± 29.1 vs 105.5 ± 24.1 ms; P = .01), longer atrioventricular nodal effective refractory period (352.3 ± 103 vs 318.2 ± 77.2 ms; P = .007), slower Wenckebach cycle length (488.5 ± 83.9 vs 443.3 ± 74.9 ms; P < .001), and lower maximum heart rate during AF (128.7 ± 31.9 vs 143.9 ± 29.6 beats/min; P = .02). Atrial ectopy (median [interquartile range], 385 [88, 2430] vs 207 [73.8, 870.8] beats/24 h; P = .02) and pharmacological AF induction (66.7% vs 43.2%; P = .02) were more common in silent paroxysmal AF patients. There was no difference in the 1-year freedom from AF following the ablation between the two patient groups.
CONCLUSIONS
The more attenuated atrioventricular conduction properties in silent paroxysmal AF patients may explain their asymptomatic nature, and their higher likelihood of atrial arrhythmias may increase the chance to detect AF episodes. Whether or not they benefit from catheter ablation is uncertain.
Types de publication
Comparative Study
Journal Article
Observational Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
2716-2723Commentaires et corrections
Type : ErratumIn
Informations de copyright
© 2019 Wiley Periodicals, Inc.
Références
Gladstone DJ, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med. 2014;370:2467-2477.
Boriani G, Laroche C, Diemberger I, et al. Asymptomatic atrial fibrillation: clinical correlates, management, and outcomes in the EORP-AF Pilot General Registry. Am J Med. 2015;128:509-518.e2.
Esato M, Chun YH, An Y, et al. Clinical impact of asymptomatic presentation status in patients with paroxysmal and sustained atrial fibrillation. Chest. 2017;152:1266-1275.
Dorian P, Guerra PG, Kerr CR, et al. Validation of a new simple scale to measure symptoms in atrial fibrillation: the Canadian Cardiovascular Society Severity in Atrial Fibrillation scale. Circ Arrhythm Electrophysiol. 2009;2:218-224.
Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017;14:e275-e444.
Binici Z, Intzilakis T, Nielsen OW, Køber L, Sajadieh A. Excessive supraventricular ectopic activity and increased risk of atrial fibrillation and stroke. Circulation. 2010;121:1904-1911.
Sairaku A, Nakano Y, Suenari K, et al. Electrical remodeling of the atrioventricular node caused by persistent atrial fibrillation in humans. J Cardiovasc Electrophysiol. 2016;27:918-922.
American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (ACC/AHA/HRS Writing Committee to Develop Data Standards on Electrophysiology), Buxton AE, Calkins H, et al. ACC/AHA/HRS 2006 key data elements and definitions for electrophysiological studies and procedures: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (ACC/AHA/HRS Writing Committee to Develop Data Standards on Electrophysiology). Circulation. 2006;114:2534-2570.
Ellenbogen KA, Dias VC, Plumb VJ, Heywood JT, Mirvis DM. A placebo-controlled trial of continuous intravenous diltiazem infusion for 24-hour heart rate control during atrial fibrillation and atrial flutter: a multicenter study. J Am Coll Cardiol. 1991;18:891-897.
Childers R. The AV node: normal and abnormal physiology. Prog Cardiovasc Dis. 1977;19:361-384.
Narula OS. Atrioventricular conduction defects in patients with sinus bradycardia: analysis by His bundle recordings. Circulation. 1971;44:1096-1110.
James TN. Structure and function of the sinus node, AV node and His bundle of the human heart: part I-structure. Prog Cardiovasc Dis. 2002;45:235-267.
Walters TE, Nisbet A, Morris GM, et al. Progression of atrial remodeling in patients with high-burden atrial fibrillation: implications for early ablative intervention. Heart Rhythm. 2016;13:331-339.
Botto GL, Padeletti L, Santini M, et al. Presence and duration of atrial fibrillation detected by continuous monitoring: crucial implications for the risk of thromboembolic events. J Cardiovasc Electrophysiol. 2009;20:241-248.
Kalman JM, Sanders P, Rosso R, Calkins H. Should we perform catheter ablation for asymptomatic atrial fibrillation? Circulation. 2017;136:490-499.
Packer DL, Mark DB, Robb RA, et al. Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: the CABANA randomized clinical trial. JAMA. 2019;321:1261-1274.