Diagnosis Of Paroxysmal Atrial Fibrillation Research Articles

Integration of cardiac monitoring with video to enable service transformation

The future of digital care will be significantly enhanced by the integration and interoperation of systems and services. Collaboration between clinicians and service providers will allow combined services to be shaped such that the whole is greater than the sum of the parts. In future services need to enable people to continue with their lives whilst being supported, rapidly and appropriately when required. We present the results of a project to use an innovative cardiac event loop recorder (ELR) and screening service in cooperation with the use of video consultations. The ELR service detects and records abnormal ECG traces. The connected consultant can choose to receive a PDF of any abnormal trace within seconds or have the trace pre-screened by a cardiac physiologist. The consultant can then initiate a video call to the person and discuss the event. The patient might then attend a consultation in person. The goal is to significantly improve the detection of abnormal events and offer immediacy of support and diagnosis i.e. quality improvement by early diagnosis and potential cost saving in the immediate term by reducing surveillance appointments and in the long term by reducing burden of disease e.g. stroke reduction by earlier AF detection This approach facilitates two modes of care delivery that are innovative: The first is the capture of infrequent events. An example case involved a 66-year-old hypertensive female who suffered from 2 years history of palpitations and had been treated for anxiety and ventricular ectopic beats. Physical examination was normal. Echocardiography showed structurally normal heart. Her electrocardiogram showed normal sinus rhythm with normal PR and QT segments Since several 24 hours Holter monitoring episodes had proved to be unsuccessful in the past it was decided to monitor the patient with the smart event ELR. The patient was equipped with a one-channel smart ELR that was used over a period of 2 weeks of continuous monitoring. The recorder was programmed to automatically send both manually triggered cardiac events as well as automatically triggered events for atrial fibrillation (AF). For the latter, the automatic AF detection algorithm had been activated. All events were automatically transferred using GPRS (tele-ECG option) and in virtually real time. International Digital Health and Care Congress, The King’s Fund, London, September 10-12 2014. International Journal of Integrated Care – Volume 14, 01 November – URN:NBN:NL:UI:10-1-116508– http://www.ijic.org/ Over the course of the next days the recorder sent in ECGs, which showed clear evidence of paroxysmal atrial fibrillation (PAF) as a cause of her intermittent palpitation. During these episodes, she felt unwell with erratic heart rate and light-headedness. The episodes lasted between 30 seconds and up to 2 minutes, confirming the diagnosis of PAF. For patients with long-term conditions that include cardiovascular disease the approach offers a pro-active and supportive way to manage people in their own homes. Both approaches address several of the NHS Outcomes Framework domains, specifically: • reducing premature mortality. • ensuring people feel supported to manage their condition. • reducing the amount of time spent in hospital. • improving people’s experience of outpatient care. • improving hospital’s responsiveness to patient’s needs. During the presentation there will be a live demonstration of the cardiac monitoring and the video service.

Clinically important atrial arrhythmia and stroke risk: a UK-wide online survey among stroke physicians and cardiologists.

A recording of ≥30 s is required for diagnosis of paroxysmal atrial fibrillation (AF) when using ambulatory electrocardiography (ECG) monitoring. It is unclear if shorter runs of atrial arrhythmia are relevant with regard to stroke risk. To assess current management of patients with atrial arrhythmia of <30 s duration detected on ambulatory ECG. Online survey. An online survey was sent to cardiologists and stroke physicians in the UK, via their national societies. A total of 205 clinicians responded to the survey (130 stroke physicians, 64 cardiologists, 11 other). Regarding diagnosis of AF, 87% of responders would accept a single 12-lead ECG. In contrast, only 45% would accept a single episode lasting <30 s detected on ambulatory monitoring. There was more agreement with regard to the decision to anticoagulate. When asked whether they would anticoagulate eight hypothetical patients with non-diagnostic paroxysms of AF, there was a mean agreement of responses of 78.6%, with up to 94.1% agreement for high-risk patients. There was a trend suggesting that stroke physicians were more likely to accept an atrial arrhythmia of <30 s as 'AF' than cardiology specialists [OR 1.63 (95% CI 0.88-3.01), P = 0.12]. There is a lack of consensus on the diagnosis and management of patients with brief runs of atrial arrhythmia detected on ambulatory ECG. Further research is needed to clarify the risk of stroke in this unique population of patients.

Abstract 16646 : The Left Atrium Emptying Fraction Improves Diagnosis of Paroxysmal Atrial Fibrillation after Cryptogenic Ischemic Stroke: Results from The SURPRISE Study

Tor Biering- Sorensen, 2013 Finalist and Presenting Author

N-Terminal Pro-Brain Natriuretic Peptide Shows Diagnostic Accuracy for Detecting Atrial Fibrillation in Cryptogenic Stroke Patients

Diagnosing paroxysmal atrial fibrillation in patients with stroke can be difficult. We aimed to determine if N-terminal pro-brain natriuretic peptide can help identify paroxysmal atrial fibrillation in cryptogenic stroke. Among 264 ischemic stroke patients, serum levels of N-terminal pro-brain natriuretic peptide were measured within 72 h of stroke onset. In cryptogenic stroke patients, 24-h Holter monitoring was used to look for paroxysmal atrial fibrillation within the first week and also three- and six-months after admission. First, patients with a defined etiology were used to construct a receiver operating characteristic curve for the diagnosis of atrial fibrillation. From this curve, the sensitivity and specificity of preestablished cutoff points for the diagnosis of atrial fibrillation were calculated. A logistic regression was performed to assess the independent relationship of the logarithm of N-terminal pro-brain natriuretic peptide levels with atrial fibrillation. The cutoff points were then evaluated in patients with cryptogenic stroke. One hundred eighty-four patients had a specific stroke etiology. Fifty-five patients had atrial fibrillation. Using multivariate analysis, the logarithm of N-terminal pro-brain natriuretic peptide levels was independently associated with atrial fibrillation. The area under the receiver operating characteristic curve of N-terminal pro-brain natriuretic peptide for the diagnosis of atrial fibrillation was 0.91 (95% confidence interval 0.87-0.95). The cutoff point of 265.5 pg/ml had a sensitivity of 100% and specificity of 70.5% for the diagnosis of atrial fibrillation. The cutoff point of 912 pg/ml had a sensitivity of 81.8% and a specificity of 87.5%. Eighty patients had a cryptogenic stroke. In 17, paroxysmal atrial fibrillation was found during follow-up. In these patients, the area under the curve for the diagnosis of paroxysmal atrial fibrillation was 0.83. The cutoff point of 265.5 had a sensitivity of 88.2% and a specificity of 61.9%. The cutoff point of 912 pg/ml had a sensitivity of 47.1% and a specificity of 88.9%. N-terminal pro-brain natriuretic peptide has good accuracy in predicting the presence of paroxysmal atrial fibrillation in patients with cryptogenic stroke and can help to identify these patients.

Age-dependent yield of screening for undetected atrial fibrillation in stroke patients: the Find-AF study

Diagnosis of paroxysmal atrial fibrillation (AF) in stroke patients is challenging, but highly clinically relevant. The percentage of stroke patients with permanent AF increases with age, but limited data are available for the age-dependent yield of paroxysmal AF by Holter monitoring. Patients with acute cerebral ischemia were included into the prospective observational Find-AF study. Patients free from AF at presentation received 7 day Holter monitoring. We calculated the percentage of otherwise undetected paroxysmal AF and the number needed to screen for age groups under 60 years, and in 5 year clusters from the age of 60 up to 85 and older. 272 patients were included, 43 (15.8 %) had AF at admission, 33 patients with paroxysmal AF were identified by 7 day Holter (n = 29) or medical history (n = 4).The yield of 7 day Holter ECG clearly increased with older age (p = 0.004): <60 years: 5 %, 60–64 years: 5 %, 65–69 years: 7 %, 70–74 years: 11 %, 75–79 years: 13 %, 80–84 years: 25 %, ≥85 years: 39 %. The number needed to screen (NNS) to find one patient with paroxysmal AF decreased with age: ≤60 years: 18, 60–64 years: 20, 65–69 years: 14, 70–74 years: 9, 75–79 years: 8, 80–84 years: 4, ≥85 years: 3, respectively. In patients <65 years, all AF cases were detected by Holter ECG. The percentage of paroxysmal AF in stroke patients increases with age. The 7 day Holter ECG is most efficient in elderly patients.

Association between Paroxysmal Atrial Fibrillation and the Left Atrial Appendage Ejection Fraction during Sinus Rhythm in the Acute Stage of Stroke: A Transesophageal Echocardiographic Study

This study aimed to investigate whether left atrial appendage (LAA) dysfunction evaluated by transesophageal echocardiography (TEE) during sinus rhythm is predictable of paroxysmal atrial fibrillation (PAF) as an embolic source in the acute stage of stroke. We measured and analyzed LAA flow velocity (LAA-FV) and LAA ejection fraction (LAA-EF) in 300 acute ischemic stroke patients by TEE. We divided the acute ischemic stroke patients into 3 groups. The atrial fibrillation (AF) group (n=58) comprised patients whose TEE was performed during AF rhythm. The PAF group (n=42) comprised patients with a history of AF but with normal sinus rhythm when TEE was performed. The normal sinus (sinus) group (n=200) did not have any history of AF. We found that mean LAA-FV and LAA-EF values in the PAF group were significantly lower than those in the sinus group (P<.001). The diagnostic accuracy of LAA-FV for the diagnosis of PAF calculated as the area under receiver operating characteristic curves was low (.582, 95% confidence interval [CI]=.498-.665) but that of LAA-EF was modest (.721, 95% CI=.653-.789), with an optimal cutoff point of 49.1%. LAA dysfunction as determined by TEE (LAA-EF<49.1%) in the acute stage of stroke is predictive of PAF with moderate accuracy. Long-term electrocardiographic monitoring is recommended for cryptogenic stroke patients with LAA dysfunction.

The search for paroxysmal atrial fibrillation in cryptogenic stroke

Atrial fibrillation (AF), a well-established cause of ischemic stroke, is found in up to 25% of first strokes.(1,2) Most patients with stroke from AF will benefit from anticoagulation for secondary stroke prevention, so finding AF as a cause of ischemic stroke is critical. Many patients with AF have paroxysmal AF (PAF), in which periods of normal sinus rhythm alternate with sometimes brief episodes of AF. Conventional monitoring for AF in the hospital or for a small number of days as an outpatient may therefore miss the diagnosis of PAF. Although most of the data to support anticoagulation for stroke patients with AF come from patients with continuous AF, PAF has a similar risk of stroke when compared to continuous AF(3,4) and there appears to be a similar benefit of anticoagulation in reducing the risk of stroke in patients with PAF.(3.)

Abstract 32: N-terminal Probrain Natriuretic Peptide Shows Diagnostic Accuracy For Atrial Fibrillation

Introduction: The diagnosis of paroxysmal atrial fibrillation (pAF) in patients with stroke is of paramount importance and has therapeutic implications. However identifying pAF can be difficult. N-terminal probrain natriuretic peptide (NT-proBNP),a peptide produced by the heart, may be useful to identify pAF in patients with cryptogenic stroke. Hypothesis: Cut-off points of serum NT-proBNP at the time of stroke onset can help identify pAF in cryptogenic stroke patients. Methods: Among 263 ischemic stroke patients admitted to a stroke unit NT-proBNP serum levels were measured within 72 hours of stroke onset. Etiological evaluation included: TTE, ECG and 24-Holter. Etiology was classified using TOAST criteria. In patients with cryptogenic stroke, 24-Holter was done to look for pAF within the first week, three and six months after admission. First, patients with a defined etiology were used to construct a Receive Operating Characteristic (ROC) curve for the diagnosis of AF. From this curve, the sensitivity and specificity of pre-established cut-off points was calculated. A logistic regression was done to assess the independent relationship of lnNT-proBNP with AF controlling for confounders. In a second phase the cut-off points previously established were evaluated, in patients with cryptogenic stroke, for the diagnosis of pAF. Results: In 179 patients a stroke etiology could be established. Fifty five patients had the diagnosis of cardioembolic stroke related to AF. Using multivariate analysis the lnNT-proBNP was independently associated to AF (OR - 2.7, 95% CI 1.5-4.8; p=0.01). The Area Under the Curve (AUC) of the ROC curve of lnNT-proBNP for the diagnosis of AF was excellent - 0.91, 95% CI (0.87-0.95). The previously defined cut-off of 265.5 pg/ml had a sensitivity of 100% and specificity of 72.6%. The cut-off point of 912 pg/ml had a specificity of 87.9%. 83 patients had a cryptogenic stroke. In 16 (19%) pAF was found during follow-up. The cut-off point of 265.5 pg/ml had a sensitivity of 93.8% and a specificity of 58.8% for the diagnosis of pAF. The cut-off point of 912 pg/mL had a specificity of 88.2%. Conclusion: NT-proBNP had good accuracy to predict pAF in patients with cryptogenic stroke and can help evaluate these patients.

Effect of Anxiety and Depression on the Recurrence of Paroxysmal Atrial Fibrillation After Circumferential Pulmonary Vein Ablation

Effect of Anxiety and Depression on the Recurrence of Paroxysmal Atrial Fibrillation. Whether circumferential pulmonary vein ablation (CPVA) can alleviate anxiety and depression symptoms is unknown and the effect of anxiety and depression on the recurrence of atrial fibrillation (AF) after CPVA is not clear. Two hundred and ten patients with a diagnosis of paroxysmal AF were admitted in the study. Ninety-eight patients (CPVA group) and 102 patients (medicine group) were treated with CPVA and antiarrhythmic drugs, respectively. All patients were followed up for 1 year. Zung Self-Rating Anxiety Scale (SAS), Zung Self-Rating Depression Scale (SDS), and Short-Form life survey-36 items (SF-36) were assessed before and after follow-up. In CPVA group, the scores of SAS and SDS decreased (41.69 ± 8.32 vs 37.66 ± 4.82, P < 0.001 and 45.01 ± 9.71 vs 40.05 ± 8.56, P < 0.001, respectively) and SF-36 score improved (565.29 ± 143.37 vs 606.84 ± 102.84, P = 0.021) after follow-up. Compared with the data in recurrent patients, the SAS and SDS scores were significantly lower in nonrecurrent patients at baseline (44.68 ± 8.40 vs 38.10 ± 7.55, P < 0.001 and 51.75 ± 9.41 vs 43.96 ± 8.95, P < 0.001, respectively). The results of multivariate logistic regression analysis showed normalized scores of SAS (OR = 3.20, 95% CI [3.05, 3.48], P = 0.023) and SDS (OR = 3.26, 95% CI [3.12, 3.49], P = 0.023) were the independent risk factor of AF recurrence after CPVA. CPVA can ameliorate anxiety and depression, which may contribute to improvement of quality of life in patients with paroxysmal AF. Anxiety and depression increase the recurrence risk of AF after CPVA.

Detection of Paroxysmal Atrial Fibrillation by 30-Day Event Monitoring in Cryptogenic Ischemic Stroke

Patients with cryptogenic ischemic stroke may have undetected paroxysmal atrial fibrillation (PAF). We established the Stroke and Monitoring for PAF in Real Time (SMART) Registry to determine the yield of 30-day outpatient PAF monitoring in cryptogenic ischemic stroke. The SMART Registry was a 3-year, prospective multicenter registry of 239 patients with cryptogenic ischemic stroke undergoing 30-day outpatient autotriggered PAF detection in Kaiser Permanente Northern California. In intention-to-monitor analysis, PAF was detected in 29 of 239 patients (12.1%; 95% CI, 8.6%-16.9%). After retrospective chart review was performed, a new diagnosis of PAF was confirmed in 26 of 236 patients (11.0%; 95% CI, 7.6%-15.7%). The majority of detected PAF events were asymptomatic; only 6 of 98 recorded PAF events (6.1%) were patient-triggered or associated with symptoms. -Approximately 1 in every 9 patients with cryptogenic ischemic stroke was found to have new PAF within 30 days. Routine monitoring in this population should be strongly considered.

Epicardial Adipose Tissue and Neural Mechanisms of Atrial Fibrillation

In this issue of Circulation: Arrhythmia and Electrophysiology , Nagashima et al1 reported that there is higher epicardial adipose tissue (EAT) volume and greater serum inflammatory biomarker levels in patients with persistent atrial fibrillation (PerAF) than in patients with paroxysmal atrial fibrillation (PAF). Furthermore, they noted that high dominant frequency (DF) sites are located adjacent to EAT sites. The authors proposed 2 possible explanations for these findings. One is that EAT secretes proinflammatory cytokines that alter local atrial and pulmonary vein (PV) electrophysiology and facilitates the development of atrial fibrillation (AF). The second is that EAT contains abundant ganglionated plexi. Activation of the autonomic nerves in the ganglionated plexi facilitates the maintenance of AF. The results of the present study extended their previous observation on EAT2 by providing new data on the correlation between high DF sites and EAT sites. These novel observations provide new insights into the anatomic and physiological differences between PAF and PerAF. Article see p 676 After the initial diagnosis of PAF, there is a slow (5%–10% per year) but steady progression to chronic (permanent or persistent) AF.3 Baseline echocardiographic variables, age, cardiomyopathy, and heart rate are independently associated with progression to chronic AF. On the other hand, PerAF is also frequently the initial diagnosis without preceding PAF episodes. How often PerAF and permanent forms of AF are preceded by recurrent PAF remains unclear. Improving the understanding of PAF to PerAF progression may help secondary prevention efforts to reduce the complications associated with AF. Wijffels et al4 performed intermittent rapid atrial pacing in goats to study the progression of PAF to PerAF. They found that when AF is maintained artificially, the duration of the paroxysms progressively increases, becoming sustained after 1 to 3 weeks of AF. The transition from PAF to PerAF …

Esophageal Long-Term ECG Reveals Paroxysmal Atrial Fibrillation

A 79-year-old man was referred for coronary angiography because of atypical chest pain. The patient's medical history included a myocardial infarction 5 years previously and well-controlled arterial hypertension. Three months before this admission he reported atypical chest pain, sometimes associated with palpitations lasting seconds up to a few minutes. Hence, he underwent ambulant 24-hour ECG, which revealed frequent atrial premature beats but no other arrhythmia. On admission, the patient was in sinus rhythm. Echocardiography showed normal ventricular function without structural heart disease. After successful percutaneous transluminal coronary angioplasty, the patient was included in a study …

Natriuretic Peptides for the Detection of Paroxysmal Atrial Fibrillation in Patients with Cerebral Ischemia – the Find-AF Study

Background and PurposeDiagnosis of paroxysmal atrial fibrillation (AF) can be challenging, but it is highly relevant in patients presenting with sinus rhythm and acute cerebral ischemia. We aimed to evaluate prospectively whether natriuretic peptide levels and kinetics identify patients with paroxysmal AF.MethodsPatients with acute cerebral ischemia were included into the prospective observational Find-AF study. N-terminal pro brain-type natriuretic peptide (NT-proBNP), brain-type natriuretic peptide (BNP) and N-terminal pro atrial-type natriuretic peptide (NT-proANP) plasma levels were measured on admission, after 6 and 24 hours. Patients free from AF at presentation received 7 day Holter monitoring. We prospectively hypothesized that patients presenting in sinus rhythm with NT-proBNP>median were more likely to have paroxysmal AF than patients with NT-proBNP<median.Results281 patients were included, of whom 237 (84.3%) presented in sinus rhythm. 220 patients naïve to AF with an evaluable prolonged Holter ECG were analysed. In patients with NT-proBNP>median (239 pg/ml), 17.9% had paroxysmal AF in contrast to 7.4% with NT-proBNP<239 pg/ml (p = 0.025). The ratio of early (0 h) to late (24 h) plasma levels of NT-proBNP showed no difference between both groups. For the detection of paroxysmal atrial fibrillation, BNP, NT-proBNP and NT-proANP at admission had an area under the curve in ROC analysis of 0.747 (0.663–0.831), 0.638 (0.531–0.744) and 0.663 (0.566–0.761), respectively. In multivariate analysis, BNP was the only biomarker to be independently predictive for paroxysmal atrial fibrillation.ConclusionsBNP is independently predictive of paroxysmal AF detected by prolonged ECG monitoring in patients with cerebral ischemia and may be used to effectively select patients for prolonged Holter monitoring.

Abstract 3735: Utility A Second 24-hours Holter Monitoring For The Diagnosis Of Paroxismal Atrial Fibrillation After An Acute Stroke

OBJETIVE: to assess the utility of a second 24-hours Holter monitoring for the diagnosis of paroxysmal atrial fibrillation (PAF) in patients with suspected cardioembolic ischemic stroke. METHODS: prospective study of ischemic stroke patients (brain infarction/TIA) treated in a Stroke Center (June 2010-February 2011). A first 24-hours Holter monitoring was performed if PAF was suspected and, if it was negative, a second 24-hours Holter monitoring was performed. Variables analyzed: demographic data, vascular risk factors, stroke severity and etiological subtype, presence of carotid plaques by duplex ultrasound, enlarged left atrial by transthoracic/transesophageal echocardiography and presence of chronic/acute brain infarctions by neuroimaging (CT/MRI). RESULTS: 219 patients included, mean age 69.8 (SD 13.5) years, 55.3% male. 17.8% have previous atrial fibrillation (AF). In 14 (6.4%) patients AF was diagnosed by ECG on admission or by serial ECG in the Stroke Unit. 24-hours Holter was performed in 101 patients to assess the presence of PAF, 85 cases during hospitalization and 16 at the outpatient clinic. This 24-hours Holter diagnosed PAF in 28.7% (29/101) of patients. A second 24-hours Holter was performed at the outpatient clinic in 21 cryptogenic brain ischemia patients. The mean time from the first to the second Holter was 143.3 (SD 72.2) days. This second 24-hours Holter detected PAF in 2 (9.5%) patients. CONCLUSION: a second 24-hours Holter monitoring at the outpatient clinic could detect PAF in almost 10% of cryptogenic ischemic stroke patients.

ORAL PRESENTATION

ORAL PRESENTATION

Paroxysmal atrial fibrillation in cryptogenic stroke.

Introduction:Paroxysmal atrial fibrillation (PAF) is perhaps the most underdiagnosed mechanism of apparent cryptogenic stroke (CS). Various studies have shown that increasing the duration of monitoring can increase the diagnosis of PAF in CS.Methods:We compared demographic and risk factors for ischemic stroke across different TOAST (Trial of ORG 10172 in Acute Stroke Treatment) stroke subtypes to look for clinical differences between other subtypes and CS and subsequently performed periodic Holter monitoring and imaging studies in apparent CS patients.Results:Of the 298 patients with ischemic stroke, 17% had CS. Periodic holter monitoring enabled diagnosis of PAF in 29% of patients. Five of 51 patients with CS had recurrent ischemic stroke and all 5 were demonstrated as PAF on repeated Holter monitoring.Conclusions:Long-term periodic rhythm monitoring in patients with apparent CS showed PAF in a significant percentage of CS patients, which altered subsequent treatment.

Impact of reduced left atrial functions on diagnosis of paroxysmal atrial fibrillation: Results from analysis of time-left atrial volume curve determined by two-dimensional speckle tracking

Atrial fibrillation is commonly associated with impaired reservoir and booster functions of the left atrium (LA). Recent advances in two-dimensional speckle tracking technique (2DST) enabled automatic analysis of the time-LA volume curve representing these functions. Our objective was to evaluate LA function in patients with or without paroxysmal atrial fibrillation (PAF) using 2DST. We studied 111 patients (68 men, age 62 ± 16 years) with (n = 53) or without (n = 58) PAF. After constructing time-LA volume curves from the apical four and two chamber views (iE33, Philips with QLAB 6.0, Philips Medical Systems, Bothell, WA, USA), maximal LA volume (LAVmax), preatrial contraction LA volume (LAVpreA), and minimum LA volume (LAVmin) were obtained. Then, LA reservoir volume (ARV=LAVmax-LAVmin) and active emptying volume (AEV=LAVpreA-LAVmin) were calculated to determine ARV/LAVmax as reservoir function and AEV/LAVpreA as booster pump function. PAF was associated with greater LAVmax than that in controls (80 ± 21 ml versus 65 ± 16 ml, p < 0.001) and with reduced reservoir and booster functions (ARV/LAVmax 46 ± 9% versus 52 ± 7%; AEV/LAVpreA 29 ± 10% versus 36 ± 6%, p < 0.001). Multivariate logistic analysis demonstrated that ARV/LAVmax and AEV/LAVpreA were closely associated with the existence of PAF. These results demonstrate that the present 2DST enables determining LA reservoir and booster functions, providing insights into the diagnosis of PAF.

Diagnosis of Paroxysmal Atrial Fibrillation in Patients with Implanted Pacemakers: Relationship to Symptoms and Other Variables

Atrial fibrillation (AF) is not always accompanied by clear-cut symptoms and symptoms suggestive of AF may not correspond to a genuine AF episode. The study prospectively evaluated the burden of asymptomatic AF episodes in pacemaker patients (for sick sinus syndrome) with a history of documented paroxysmal AF. Consecutive patients were enrolled and implanted with dual-chamber pacemakers equipped with diagnostic features for AF monitoring. Each patient was instructed about typical AF symptoms and was asked to keep a detailed log of symptoms. Stored pacemaker data were analyzed using only AF episodes >30 s. The mean follow-up was 16 +/- 6 months and 102 patients were enrolled (73 +/- 7 years, 59 M). Thirteen patients (13%) dropped out with the development of permanent AF and their data were discarded. Twenty-three patients (26%) without device-stored AF episodes all reported at least one annotated AF episode. There were 1,245 device-stored AF episodes in 66 (74%) out of 89 patients. Patients reported 1,141 episodes of AF-related symptoms. Only 240 (21%) corresponded to a genuine device-stored AF event. The sensitivity and positive predictive value of symptoms to detect AF were respectively 19% and 21%. Episode duration, rate increase at the onset of the arrhythmia, heart disease, or antiarrhythmic drug therapy showed no statistically significant differences comparing symptomatic and asymptomatic episodes. Many pacemaker patients with paroxysmal AF can develop AF-like symptoms in the absence of device-stored AF. AF-related symptoms have low sensitivity and low positive predictive value in patients with permanent pacemakers.

Predicting factors for atrial fibrillation acute termination during catheter ablation procedures: Implications for catheter ablation strategy and long-term outcome

Termination of atrial fibrillation (AF) can be achieved by catheter ablation. It has been used as one of the procedural endpoints for AF ablation. The purpose of this study was to investigate the factors that predict AF termination and the association with long-term outcomes. Eighty-five consecutive AF patients (33 paroxysmal, 52 nonparoxysmal) underwent three-dimensional mapping and catheter ablation. A stepwise ablation approach included circumferential pulmonary vein (PV) isolation and left atrial (LA) linear ablation, followed by LA and right atrial (RA) electrogram-based (complex fractionated atrial electrogram) ablation. Clinical and electrophysiologic characteristics were assessed to evaluate the predictors of acute AF termination. In univariate analysis, a diagnosis of paroxysmal AF, shorter AF history, absence of history of heart failure, smaller LA diameter, longer postablation coronary sinus cycle length, lower LA and RA mean dominant frequencies, lower RA max dominant frequency, and higher LA voltage were related to acute termination of AF during ablation. Multivariate analysis showed that smaller LA diameter and lower preablation mean RA dominant frequency were independent predictors of AF termination. Multivariate analysis also showed that larger LA diameter and the presence of RA non-PV ectopy during the index procedure could predict late recurrence during long-term (13 +/- 8 months) follow-up. LA size and RA non-PV drivers are important for acute termination of AF and for long-term success. Careful selection of patients, extensive RA mapping, and LA ablation may enhance long-term ablation efficacy.

Usefulness of P-Wave Dispersion in Standard Twelve-Lead Electrocardiography to Predict Transition from Paroxysmal to Persistent Atrial Fibrillation

A prospective study was conducted to investigate the validity of the hypothesis that P-wave dispersion (Pd) may be a clinically useful predictor of progression from paroxysmal to persistent atrial fibrillation (AF). Two hundred four consecutive patients with a diagnosis of paroxysmal AF were studied. Standard 12-lead electrocardiography and echocardiography were performed on all patients at the time of entry into the study. Pd was measured as the difference between maximum and minimum P-wave duration in any of the 12 leads. Mean follow-up was 66 +/- 8 months. Group I included patients (n = 132) in whom paroxysmal AF did not progress to persistent AF, and group II included those (n = 72) who developed persistent AF. In group II, age, percentage of men, percentage of patients with diabetes mellitus, maximum P-wave duration, Pd, and left atrial dimension were significantly higher than in group I (p <0.05). Multivariate logistic regression analysis using these 6 factors identified age (odds ratio 2.18, 95% confidence interval 1.41 to 3.41, p <0.01) and Pd (odds ratio 1.91, 95% confidence interval 1.51 to 2.44, p <0.01) as independent predictors of a transition to persistent AF. Pd >or=40 ms predicted progression to persistent AF with sensitivity of 71%, specificity of 77%, positive predictive value of 63%, negative predictive value of 83%, and accuracy of 75%. In conclusion, Pd was a clinically useful predictor of progression from paroxysmal to persistent AF.