Effects of sinus rhythm restoration in patients with persistent atrial fibrillation: a clinical, echocardiographic and hormonal study☆
Introduction
Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practise. The prevalence is estimated at 0.4% of the general population and greater than 6% in patients over 80 years [1]. The overall incidence of AF is likely to rise in the next decades as the elderly population is increasing in industrialised countries. AF is an independent predictor of increased mortality and morbidity and is associated with higher risk of thromboembolic events. Loss of atrial systolic function and a fast, irregular, ventricular response result in impairment of hemodynamic function [2]. In several cases the hemodynamic effects can result in heart failure [3]. On the other hand heart failure is an important risk factor for the development of AF and associated with AF has a worse prognosis than heart failure without AF [4].
In clinical practice, AF remains the most difficult arrhythmia to treat. The criteria to select patients for the different therapeutic options are still a matter of debate. However, the symptoms of AF such as palpitations, a reduced exercise tolerance and impact on quality of life provide a clear reason to consider early restoration and maintenance of sinus rhythm.
Electrical remodelling (shortening of atrial refractoriness) develops within the first days of AF [5]. Tachycardia-induced structural and hormonal remodelling takes place over a different time period and probably correlates with the duration of AF. The electrical, mechanical and hormonal remodelling are completely reversible after successful cardioversion of short term persistent AF but after prolonged duration of AF recovery from contractile dysfunction, due to intracellular calcium overload and ‘atrial stunning’, may take several weeks to months and is not well-defined [6], [7], [8].
The purpose of our study was to assess changes in exercise capacity, echocardiographic findings and cardiac hormonal activity reflected by the evolution of atrial natriuretic peptide (ANP) level in patients with non-rheumatic persistent AF, just before and 30 days after cardioversion.
Section snippets
Methodology
We studied 42 patients who had a broad spectrum of underlying cardiac disease (Table 1) and were admitted for cardioversion of AF to normal sinus rhythm. The mean age of the study group was 58±8 years; 29% were women. The mean duration of AF was 7.1±7.1 consecutive months. The time of onset of AF was taken as the onset of symptoms or the first documentation of AF in asymptomatic patients. Twenty six (62%) out of 42 patients were in NYHA I–II classification, 16 (38%) patients were in NYHA III
Results
The mean age of study group was 58±8 years; 29% were women. The mean duration of AF was 7.1±7.1 consecutive months. Twenty six (62%) out of 42 patients were in NYHA I–II classification, 16 (38%) patients were in NYHA III classification.
Thirty days after cardioversion only two (5%) patients were in the third functional class according to the NYHA classification. Thirty-five out of the 42 patients were successfully cardioverted to sinus rhythm. Thirty days after cardioversion, 29 patients
Discussion
The major consequences of AF may be subdivided as electrophysiological, hemodynamic, hormonal and thromboembolic. The impact of AF on both exercise and cardiac resting output has been examined in a number of studies [11], [12]. The loss of atrial systolic function results in a reduction in stroke volume, leading to lower cardiac output and increased atrial stasis. The contribution of atrial systolic function (‘atrial kick’) is particularly important with increasing age, due to progressive
Conclusions and clinical implications
Our data confirm that successful cardioversion of persistent AF improves hemodynamic measures of cardiac performance, increases exercise capacity, leads to normalisation of plasma ANP levels and prevents heart cavity enlargement. Restoration of sinus rhythm should be considered in previously non-cardioverted patients, under 60, with persistent AF.
Acknowledgements
We would like to thank Fergus Mahon and Marek Strzelecki for their help.
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Abbreviated data from the manuscript have been presented in poster form during The 7th Annual Meeting of the Working Group on Heart Failure Update 2002 of the ESC, Oslo (P264) and XXIV ESC Congress 2002, Berlin (P1540).