Atrial fibrillation natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]
Overview
The natural tendency of atrial fibrillation is to become a chronic condition. Based on epidemiological studies atrial fibrillation starts as the paroxysmal form and then evolves to the permanent form eventually in some cases. Numerous complications in association to atrial fibrillation (such as impaired cardiac output, stroke, heart failure and Cognitive disturbances) have been recognized. Although after introduction of anticoagulant treatment rate of stroke and consequently risk of death have been decreased. In a study done on Swedish patients with atrial fibrillation risk of stroke is 25 per 1,000 person/year in patients treated with anticoagulants, compared to 45 per 1,000 person/year risk of stroke in AF patients who didn't received anticoagulant therapy. The occurrence of atrial fibrillation in the setting of ST elevation MI is associated with a poor prognosis including a 40% rise in the risk of mortality in meta-analyses.
Natural History
- Atrial fibrillation may become continuous (persistent or permanent AF) or alternating between periods of a normal heart rhythm (paroxysmal AF). Paroxysmal atrial fibrillation formed during an extreme vagotonia is the only known exception.[1][2]
- The natural tendency of atrial fibrillation is to become a chronic condition. Chronic atrial fibrillation leads to a small increase in the risk of death.[2][3]
- Based on epidemiological studies atrial fibrillation starts as the paroxysmal form and then evolves to the permanent form eventually in some cases.[1][4][5]
- Based on some studies atrial fibrillations responsive to various treatments often progress to a resistant form which can not be switched to sinus rhythm.[1]
Complications
The following are complications of atrial fibrillation:[6][7][8][2][9][4][10][11][12][13]
- Reduced mechanical pumping action of the atrium:
- Due to the lack of coordination of atrial activation, there is a decline in the mechanical pumping action of the atrium. The decline in mechanical function of the atrium may or may not lead to inadequate filling of the ventricles depending upon the importance of the atrial kick or atrial contribution to ventricular filling in a given patient.
- In patients with a stiff left ventricle (such as patients with hypertension), the atrial kick may be critical to achieve adequate ventricular filling.
- Heart failure:
- Risk of heart failure increases in patients with atrial fibrillation, compared to normal population. Based on a study women with AF have 11-fold increase in risk of heart failure, compared to women without atrial fibrillation. In contrast risk of heart failure in male patients with atrial fibrillation increases 3-fold, compared to men without AF.[14][15]
- Worsening the signs and symptoms of congestive heart failure usually occurs in patients with previous history of congestive heart failure (particularly among patients with valvular heart disease).
- Due to the reduced atrial kick needed to fill the left ventricle.
- Stroke
- Patients with atrial fibrillation usually have a significantly increased risk of stroke (up to 5-7 times that of the general population).[15]
- Stroke risk increases during AF because blood may pool and form clots in the poorly contracting atrium and especially in the left atrial appendage (LAA).
- One in every 6 strokes occurs in atrial fibrillation patients.
- The level of increased risk of stroke depends on the number of additional risk factors (such as [[hypertension, old age, heart failure, diabetes and history of previous stroke).
- Studies have been demonstrated the role of warfarin treatment in preventing 60% of strokes cases due to atrial fibrillation. In contrast anti platelet treatment only reduces this risk by 20%.
- The following are related factors to high mortality rate in stroke due to atrial fibrillation:[15][16][17]
- Thromboembolic nature of the stroke
- Presence of other cardiovascular disease
- Involvement of anterior circulation or multiple foci du to the stroke
- Presence or development of pro-inflammatory and hypercoagulable states
- The following table is a summary of stroke risk in different population: [18][19]
| Region | Year | Risk of Stroke |
|---|---|---|
| The United States | 1992 | 48 per 1,000 person |
| The United States | 2007 | 17 per 1,000 person |
| Sweden | 2012 | 25 per 1,000 person |
| France | 2013 | 10 per 1,000 person |
- Cognitive disturbances:[20][21]
- Cognitive disturbances such as vascular dementia and subtypes of alzheimer's disease are also related to AF, with or without stroke.
- Cardiomyopathy
- If left untreated, the chronic tachycardia associated with atrial fibrillation may result in a tachycardia mediated cardiomyopathy.
- Death
Prognosis
- After introduction of anticoagulant treatment rate of stroke and consequently risk of death have been decreased.[18]
- Based on numerous studies the improved prognosis of atrial fibrillation has been demonstrated after anticoagulant treatment.
- In a study done on Swedish patients with atrial fibrillation risk of stroke is 25 per 1,000 person/year in patients treated with anticoagulants, compared to 45 per 1,000 person/year risk of stroke in AF patients who didn't received anticoagulant therapy.[18]
- Stroke itself increases the chance of serious disabilities and death in patient with atrial fibrillation, compared to stroke in patients without atrial fibrillation.[15]
- The rate of ischemic stroke among nonrheumatic atrial fibrillation patients averages over 5% per year, a rate that is between 2 and 7 times that of non-AF patients.
- The CHADS Score can estimate this rate with greater certainty:
- The rate of brain ischemia in conjunction with nonvalvular atrial fibrillation exceeds 7% per year.
- Patients with both rheumatic heart disease and atrial fibrillation have an 17-fold risk increase when compared to age-matched controls and an attributable risk of 5 times greater than those with nonrheumatic atrial fibrillation.
- Mortality rate is higher (69%) in patients with atrial fibrillation within 30 days after non cardiac surgery, compared to non atrial fibrillation patients.[15][22]
Atrial Fibrillation in the Setting of STEMI
- The occurrence of atrial fibrillation in the setting of ST elevation MI is associated with a poor prognosis including a 40% rise in the risk of mortality in meta-analyses. [23]
- Based on another study presence of atrial fibrillation increases the mortality rate in MI patients by 4-fold.[24]
- Highest rate of death in atrial fibrillation in the setting of ST elevation MI occurs when AF develop after 1 month of MI (HR, 2.58; 95% CI, 2.21 to 3.00). On the contrary, lowest rate of death associated to AF development after MI occurs when atrial fibrillation develop within first 2 days of MI (HR, 1.63; 95% CI, 1.37 to 1.93).[15]
- The basis for this increase risk of mortality is not clear. Most likely it reflects the fact that atrial fibrillation is a marker of impaired LV function, but it may also reflect the loss of the atrial kick or the hazard associated with triple therapy with aspirin, clopidogrel, and coumadin.
Post Operative Atrial Fibrillation
- Development of atrial fibrillation after a cardiac surgery is a well known arrhythmic complication.[15][25]
- Chance of post operative atrial fibrillation after CABG is higher in patients younger than 70 years old.
- Previous studies on post operative atrial fibrillation demonstrated a minimal long term prognostic value.
- In contrast to previous studies, a new study with longer follow up period (6 years) reported relation between post operative atrial fibrillation and higher all causes mortality rate.
- Atrial fibrillation after CABG is also associated to postoperative infection and renal insufficiency.
Observational Studies
- The Framingham Heart Study demonstrated a high rate of death in patients with both atrial fibrillation and heart failure compared to each condition alone.[15]
- The Framingham Heart Study also found that the annual risk of stroke attributable to atrial fibrillation increased from 1.5% in those aged 50-59 years to 23.5% for those aged 80-89 years.
- In the Manitoba follow up study, atrial fibrillation doubled the risk of stroke independently of other risk factors.
- The relative risk for stroke in the Whitehall study was 6.99%.
- Relative risk in the Regional Heart study was 2.3%.
- In the ALFA study follow up, patients with atrial fibrillation were found to have a 2.4% incidence of thromboembolism with the mean being 8.6 months of follow-up time.[26]
References
- ↑ 1.0 1.1 1.2 Allessie MA, Boyden PA, Camm AJ, Kléber AG, Lab MJ, Legato MJ; et al. (2001). "Pathophysiology and prevention of atrial fibrillation". Circulation. 103 (5): 769–77. doi:10.1161/01.cir.103.5.769. PMID 11156892.
- ↑ 2.0 2.1 2.2 Benjamin EJ, Wolf PA, D'Agostino RB, Silbershatz H, Kannel WB, Levy D (1998). "Impact of atrial fibrillation on the risk of death: the Framingham Heart Study". Circulation. 98 (10): 946–52. PMID 9737513.
- ↑ Wattigney WA, Mensah GA, Croft JB (2002). "Increased atrial fibrillation mortality: United States, 1980-1998". Am. J. Epidemiol. 155 (9): 819–26. doi:10.1093/aje/155.9.819. PMID 11978585.
- ↑ 4.0 4.1 Nieuwlaat R, Prins MH, Le Heuzey JY, Vardas PE, Aliot E, Santini M; et al. (2008). "Prognosis, disease progression, and treatment of atrial fibrillation patients during 1 year: follow-up of the Euro Heart Survey on atrial fibrillation". Eur Heart J. 29 (9): 1181–9. doi:10.1093/eurheartj/ehn139. PMID 18397874.
- ↑ de Vos CB, Pisters R, Nieuwlaat R, Prins MH, Tieleman RG, Coelen RJ; et al. (2010). "Progression from paroxysmal to persistent atrial fibrillation clinical correlates and prognosis". J Am Coll Cardiol. 55 (8): 725–31. doi:10.1016/j.jacc.2009.11.040. PMID 20170808.
- ↑ Fuster V, Rydén LE, Asinger RW; et al. (2001). "ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology". Eur. Heart J. 22 (20): 1852–923. doi:10.1053/euhj.2001.2983. PMID 11601835. Unknown parameter
|month=ignored (help) - ↑ Jahangir A, Lee V, Friedman PA, Trusty JM, Hodge DO, Kopecky SL, Packer DL, Hammill SC, Shen WK, Gersh BJ (2007). "Long-term progression and outcomes with aging in patients with lone atrial fibrillation: a 30-year follow-up study". Circulation. 115 (24): 3050–6. doi:10.1161/CIRCULATIONAHA.106.644484. PMID 17548732.
- ↑ Wolf PA, Dawber TR, Thomas HE, Kannel WB (1978). "Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham study". Neurology. 28 (10): 973–7. PMID 570666.
- ↑ Wattigney WA, Mensah GA, Croft JB (2002). "Increased atrial fibrillation mortality: United States, 1980-1998". Am. J. Epidemiol. 155 (9): 819–26. doi:10.1093/aje/155.9.819. PMID 11978585.
- ↑ Anter E, Jessup M, Callans DJ (2009). "Atrial fibrillation and heart failure: treatment considerations for a dual epidemic". Circulation. 119 (18): 2516–25. doi:10.1161/CIRCULATIONAHA.108.821306. PMID 19433768.
- ↑ Hart RG, Pearce LA, Aguilar MI (2007). "Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation". Ann Intern Med. 146 (12): 857–67. doi:10.7326/0003-4819-146-12-200706190-00007. PMID 17577005.
- ↑ Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ (2001). "Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation". JAMA. 285 (22): 2864–70. doi:10.1001/jama.285.22.2864. PMID 11401607.
- ↑ Mountantonakis SE, Grau-Sepulveda MV, Bhatt DL, Hernandez AF, Peterson ED, Fonarow GC (2012). "Presence of atrial fibrillation is independently associated with adverse outcomes in patients hospitalized with heart failure: an analysis of get with the guidelines-heart failure". Circ Heart Fail. 5 (2): 191–201. doi:10.1161/CIRCHEARTFAILURE.111.965681. PMID 22361078.
- ↑ Lloyd-Jones DM, Larson MG, Leip EP, Beiser A, D'Agostino RB, Kannel WB; et al. (2002). "Lifetime risk for developing congestive heart failure: the Framingham Heart Study". Circulation. 106 (24): 3068–72. doi:10.1161/01.cir.0000039105.49749.6f. PMID 12473553.
- ↑ 15.0 15.1 15.2 15.3 15.4 15.5 15.6 15.7 McManus DD, Rienstra M, Benjamin EJ (2012). "An update on the prognosis of patients with atrial fibrillation". Circulation. 126 (10): e143–6. doi:10.1161/CIRCULATIONAHA.112.129759. PMC 3678907. PMID 22949543.
- ↑ Watson T, Shantsila E, Lip GY (2009). "Mechanisms of thrombogenesis in atrial fibrillation: Virchow's triad revisited". Lancet. 373 (9658): 155–66. doi:10.1016/S0140-6736(09)60040-4. PMID 19135613.
- ↑ Li-Saw-Hee FL, Blann AD, Lip GY (2000). "A cross-sectional and diurnal study of thrombogenesis among patients with chronic atrial fibrillation". J Am Coll Cardiol. 35 (7): 1926–31. doi:10.1016/s0735-1097(00)00627-6. PMID 10841245.
- ↑ 18.0 18.1 18.2 Zoni-Berisso M, Lercari F, Carazza T, Domenicucci S (2014). "Epidemiology of atrial fibrillation: European perspective". Clin Epidemiol. 6: 213–20. doi:10.2147/CLEP.S47385. PMC 4064952. PMID 24966695.
- ↑ Friberg L, Rosenqvist M, Lip GY (2012). "Net clinical benefit of warfarin in patients with atrial fibrillation: a report from the Swedish atrial fibrillation cohort study". Circulation. 125 (19): 2298–307. doi:10.1161/CIRCULATIONAHA.111.055079. PMID 22514252.
- ↑ Ott A, Breteler MM, de Bruyne MC, van Harskamp F, Grobbee DE, Hofman A (1997). "Atrial fibrillation and dementia in a population-based study. The Rotterdam Study". Stroke. 28 (2): 316–21. doi:10.1161/01.str.28.2.316. PMID 9040682.
- ↑ Cha MJ, Park HE, Lee MH, Cho Y, Choi EK, Oh S (2014). "Prevalence of and risk factors for silent ischemic stroke in patients with atrial fibrillation as determined by brain magnetic resonance imaging". Am J Cardiol. 113 (4): 655–61. doi:10.1016/j.amjcard.2013.11.011. PMID 24360776.
- ↑ van Diepen S, Bakal JA, McAlister FA, Ezekowitz JA (2011). "Mortality and readmission of patients with heart failure, atrial fibrillation, or coronary artery disease undergoing noncardiac surgery: an analysis of 38 047 patients". Circulation. 124 (3): 289–96. doi:10.1161/CIRCULATIONAHA.110.011130. PMID 21709059.
- ↑ Jabre P, Roger VL, Murad MH, et al. Mortality associated with atrial fibrillation in patients with myocardial infarction: a systematic review and meta-analysis. Circulation. Apr 19 2011;123(15):1587-93.
- ↑ Jabre P, Jouven X, Adnet F, Thabut G, Bielinski SJ, Weston SA; et al. (2011). "Atrial fibrillation and death after myocardial infarction: a community study". Circulation. 123 (19): 2094–100. doi:10.1161/CIRCULATIONAHA.110.990192. PMC 3142914. PMID 21536994. Review in: Ann Intern Med. 2011 Sep 20;155(6):JC3-13
- ↑ Elahi M, Hadjinikolaou L, Galiñanes M (2003). "Incidence and clinical consequences of atrial fibrillation within 1 year of first-time isolated coronary bypass surgery". Circulation. 108 Suppl 1: II207–12. doi:10.1161/01.cir.0000089188.45285.fd. PMID 12970234.
- ↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781