Elsevier

American Heart Journal

Volume 162, Issue 2, August 2011, Pages 382-389
American Heart Journal

Clinical Investigation
Electrophysiology
Clinical characteristics of patients with asymptomatic recurrences of atrial fibrillation in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico–Atrial Fibrillation (GISSI-AF) trial

https://doi.org/10.1016/j.ahj.2011.05.008Get rights and content

Background

Atrial fibrillation (AF) is a common arrhythmia that frequently recurs after restoration of sinus rhythm. In a consistent percentage of cases, AF recurrences are asymptomatic, thus making its clinical management difficult in relation to both therapeutic efficacy and thromboembolic risk.

Methods

The GISSI-AF trial enrolled 1,442 patients in sinus rhythm with previous AF episodes. Patients were randomized to valsartan or placebo and followed for 12 months. To improve the likelihood of detecting arrhythmic recurrences, arrhythmic follow-up was based on both programmed or symptom-related control visits and transtelephonic electrocardiographic transmissions. The present post hoc analysis was performed on 1,638 arrhythmic episodes that occurred in 623 patients.

Results

Asymptomatic AF recurrences were present in 49.5% of patients. In multivariable analysis, asymptomatic AF recurrences were significantly associated with a longer duration of qualifying arrhythmias (odds ratio [95% CI] 1.57 (1.26-1.97), P < .0001). A lower ventricular response (P < .001) and a longer duration of the arrhythmic recurrence (P < .001) characterized asymptomatic episodes. Patients with asymptomatic events were more likely to be in AF at the time of electrocardiographic control at the end of the 12-month follow-up (adjusted odds ratio [95% CI] 4.9 (2.8-8.4), P < .001). Moreover, a higher CHADS2 (Congestive heart failure, history of Hypertension, Age≥75 years, Diabetes mellitus, and past history of Stroke or TIA doubled) score and a more frequent use of amiodarone, calcium-channel blockers, and digitalis characterized patients with asymptomatic, whereas 1C drugs were more often used in subjects with symptomatic recurrences.

Conclusion

Asymptomatic AF recurrences were frequent in the GISSI-AF study population in patients who were more likely to develop persistent-permanent AF and were characterized by an increased thromboembolic risk.

Section snippets

Methods

The rationale, design, and results of GISSI-AF trial have already been published16, 17 (Clinical Trials.gov Identifier: NCT00376272). This trial was a prospective, multicenter, randomized, double-blind, placebo-controlled trial, to assess whether addition of the angiotensin II–receptor blocker valsartan to established therapies could reduce the recurrence of AF in patients with a history of AF associated with cardiovascular diseases.

Patients eligible for inclusion in the study were of both

Clinical characteristics of AF recurrences

Of the 2,149 AF recurrences in GISSI-AF trial,16 we analyzed 1,638 AF episodes that were properly classified as symptomatic (n = 979; 59.8%) or asymptomatic (n = 659; 40.2%). Among this latter group, the diagnosis of asymptomatic recurrence was based on the detection of AF in the weekly programmed electrocardiographic transtelephonic transmission in 466 (70.7%) of 659 episodes.

Mean ventricular response was correlated with symptoms: heart rate was significantly lower in asymptomatic AF

Discussion

Our study, which enrolled a large number of ambulatory patients with paroxysmal and persistent AF and represents common clinical practice, indicates that asymptomatic recurrences are a relevant phenomenon, which involves up to 50% of the study population when arrhythmias detection is based on both transtelephonic electrocardiographic transmissions and programmed controls. The occurrence of this type of events was associated with important clinical implications that could affect patients'

Conclusions

Our results indicate that in ambulatory patients, AF recurrences in the absence of symptoms are a common event. In these patients, a longer duration of both the qualifying arrhythmic event and the arrhythmic recurrence predicts the presence of AF as the dominant rhythm at the end of the 1-year follow-up. We also observed that patients with asymptomatic recurrences had more frequently a CHADS2 score ≥2 than did the symptomatic ones. This finding further supports the recommendation that the

Disclosures

Conflict of interest: There are no conflicts of interest for this post hoc analysis.

References (25)

  • J. Pontopiddan et al.

    Symptomatic and asymptomatic atrial fibrillation after pulmonary vein ablation and the impact on quality of life

    PACE

    (2009)
  • P.E.B. Thomsen et al.

    Long-term recording of cardiac arrhythmias with an implantable cardiac monitor in patients with reduced ejection fraction after acute myocardial infarction. The Cardiac Arrhythmias and Risk Stratification After Acute Myocardial Infarction (CARISMA) Study

    Circulation

    (2010)
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