Prevalence and determinants of atrial fibrillation progression in paroxysmal atrial fibrillation

Abstract

ObjectiveAtrial fibrillation (AF) often progresses from paroxysmal AF (PAF) to more permanent forms. To improve personalised medicine, we aim to develop a new AF progression risk prediction model in patients with PAF.MethodsIn this interim-analysis of the Reappraisal of AF: Interaction Between HyperCoagulability, Electrical Remodelling, and Vascular Destabilisation in the Progression of AF study, patients with PAF undergoing extensive phenotyping at baseline and continuous rhythm monitoring during follow-up of ≥1 year were analysed. AF progression was defined as (1) progression to persistent or permanent AF or (2) progression of PAF with >3% burden increase. Multivariable analysis was done to identify predictors of AF progression.ResultsMean age was 65 (58–71) years, 179 (43%) were female. Follow-up was 2.2 (1.6–2.8) years, 51 of 417 patients (5.5%/year) showed AF progression. Multivariable analysis identified, PR interval, impaired left atrial function, mitral valve regurgitation and waist circumference to be associated with AF progression. Adding blood biomarkers improved the model (C-statistic from 0.709 to 0.830) and showed male sex, lower levels of factor XIIa:C1-esterase inhibitor and tissue factor pathway inhibitor, and higher levels of N-terminal pro-brain natriuretic peptide, proprotein convertase subtilisin/kexin type 9 and peptidoglycan recognition protein 1 were associated with AF progression.ConclusionIn patients with PAF, AF progression occurred in 5.5%/year. Predictors for progression included markers for atrial remodelling, sex, mitral valve regurgitation, waist circumference and biomarkers associated with coagulation, inflammation, cardiomyocyte stretch and atherosclerosis. These prediction models may help to determine risk of AF progression and treatment targets, but validation is needed.Trial registration numberNCT02726698.

Contributing factors to personalised medicine in atrial fibrillation

“…Whilst in those patients who had optimal risk factor control and achieved >10% weight loss, 88% of patients who were initially in persistent AF reversed to either paroxysmal AF or even no AF 6. These findings are in line with those from Nguyen et al 2 and underscore the importance of risk factor management in reducing the underlying substrate which, if untreated, contributes to the onset and worsening of AF.…”

“…Nguyen and colleagues2 outline the development of a prediction model for AF progression and further explore the associated contribution of underlying pathophysiological mechanisms. They performed an interim analysis of the Reappraisal of AF: Interaction between Hypercoagulability, Electrical Remodelling, and Vascular Destabilisation in the Progression of AF (RACE V Study), which aims to investigate the association of clinical factors and biomarkers related to the progression of AF in patients diagnosed with self-terminating (paroxysmal) AF.…”

“…Progression of AF occurred in 5.5% of these patients per year. Moreover, the analysis demonstrated multiple predictors for AF progression, including markers for atrial remodelling, sex, mitral valve regurgitation, waist circumference and several biomarkers 2. Based on these findings, the authors developed a point score providing a 2-year risk estimation for AF, which may assist in the personalised AF treatment in clinical practice.…”

“…While the findings of EAST-AFNET4 have advanced our understanding of the importance or early rhythm control, it has also further highlighted the need for management of reversible comorbidities to prevent progression of the AF disease process. In this regard, the implementation of prediction models, such as that designed in the current study, could facilitate the personalisation of management to the individual with AF 2…”

New concepts in atrial fibrillation pathophysiology

“…The identification of AF triggers originating from the myocardial sleeves of the pulmonary veins by Haïssaguerre and colleagues represents the basis of isolation of the pulmonary veins as the cornerstone of modern catheter ablation procedures for AF [2]. However, AF has been identified as a progressive disease (AF progression occurs in 5.5%/year) [3], which may limit the effect of rhythm control strategies in a significant proportion of patients. This progression in AF can be partially explained by different non-treated risk factors contributing to an adverse atrial remodeling process [4].…”