Chest
Volume 141, Issue 2, February 2012, Pages 339-347
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Original Research
Cardiovascular Disease
A 12-Year Follow-up Study of Patients With Newly Diagnosed Lone Atrial Fibrillation: Implications of Arrhythmia Progression on Prognosis: The Belgrade Atrial Fibrillation Study

https://doi.org/10.1378/chest.11-0340Get rights and content

Background

Lone atrial fibrillation (AF) has been suggested to have a favorable long-term prognosis. Significant interest has been directed at factors predicting arrhythmia progression, and the HATCH score (hypertension, age ≥ 75 years, transient ischemic attack or stroke [2 points], COPD, and heart failure [2 points]) recently has been proposed as a predictive score for AF progression. We investigated long-term outcomes in a large cohort of newly diagnosed lone AF and whether progression from paroxysmal to permanent AF confers an adverse impact on outcomes, including stroke and thromboembolism.

Methods

The study was an observational cohort of 346 patients with newly diagnosed lone AF with a mean follow-up of 12.1 ± 7.3 years.

Results

Baseline paroxysmal AF was confirmed in 242 patients, and of these, 65 (26.9%) subsequently experienced progression to permanent AF. Older age and development of congestive heart failure during follow-up were the multivariate predictors of AF progression (both P < .01), which was documented in 19.8% of patients with a HATCH score of 0 vs 63.2% with a score of 2 (P < .001), although the predictive validity of the HATCH score per se was modest (C statistic, 0.6). The annual rate of thromboembolism and heart failure during follow-up were low (0.4% each), and five patients (1.4%) died. AF progression, development of cardiac diseases, and older age were multivariate predictors of adverse outcomes, including thromboembolism (all P < .05). Baseline CHADS2 (congestive heart failure, hypertension, age ≥ 75, diabetes mellitus, prior stroke or transient ischemic attack) score was not predictive for thromboembolism (C statistic, 0.50; 95% CI, 0.31-0.69).

Conclusions

This 12-year follow-up study provides confirmatory evidence of a generally favorable prognosis of lone AF, but adverse outcomes (including stroke and thromboembolism) are significantly influenced by age and the (new) development of underlying heart disease. Arrhythmia progression in lone AF is a marker of increased risk for adverse cardiovascular events.

Section snippets

Materials and Methods

We conducted an observational, longitudinal cohort study of patients with newly diagnosed lone AF in the Belgrade Atrial Fibrillation Study, which was a prospectively completed registry of patients with AF seen in the Clinical Center of Serbia between 1992 and 2007. This is the main cardiology center for specialist arrhythmia services serving the population of Belgrade. All patients gave informed consent. The study complies with the Declaration of Helsinki. The institutional review board stated

Results

Of 1,086 patients with newly diagnosed AF, 346 (31.9%) met inclusion criteria for lone AF. Table 1 shows baseline characteristics and differences among clinical types of AF. Mean total follow-up was 12.1 ± 7.3 years (median, 10.0 years; range, 5–40 years). Mean prospective follow-up was 6.3 ± 4.6 years (median, 5 years; range, 1–16 years). Approximately one-third of patients developed cardiovascular risk factors during follow-up, most frequently hypertension (25%). The rate of development of

Discussion

To our knowledge, the present study examines one of the largest prospective cohorts of newly diagnosed lone AF. After a median 10-year follow-up, our results confirm previous findings of a generally favorable long-term prognosis of lone AF in terms of mortality, thromboembolism, and CHF, with a similar rate of progression to permanent AF as in other lone AF studies.5, 10, 11, 12, 13, 17 Moreover, the present study has documented significant negative implications of progression to permanent AF

Conclusions

The present study provides convincing evidence of a generally favorable prognosis of patients with lone AF. However, long-term outcome in such patients is significantly influenced by aging and the development of underlying heart disease. Because there is no cure for aging per se, thorough screening, prevention, and treatment of associated comorbidities should be among the most important issues in the management of patients with lone AF. Moreover, progression to permanent AF despite active

Acknowledgments

Author contributions: Dr Potpara had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Potpara: contributed to the hypothesis, data collection and analyses, data interpretation, and drafting of the manuscript.

Dr Stankovic: contributed to the data interpretation and drafting of the manuscript.

Dr Beleslin: contributed to the data interpretation and drafting of the manuscript.

Dr Polovina: contributed to the

References (36)

  • GYH Lip et al.

    Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor based approach: the Euro Heart Survey on Atrial Fibrillation

    Chest

    (2010)
  • TP Van Staa et al.

    A comparison of risk stratification schemes for stroke in 79884 atrial fibrillation patients in general practice

    J Thromb Haemost

    (2011)
  • T Watson et al.

    Mechanisms of thrombogenesis in atrial fibrillation: Virchow's triad revisited

    Lancet

    (2009)
  • MK Ryder et al.

    Epidemiology and significance of atrial fibrillation

    Am J Cardiol

    (1999)
  • DM Lloyd-Jones et al.

    Lifetime risk for development of atrial fibrillation: the Framingham Heart Study

    Circulation

    (2004)
  • V Fuster et al.

    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)

    Circulation

    (2006)
  • SL Kopecky et al.

    The natural history of lone atrial fibrillation. A population-based study over three decades

    N Engl J Med

    (1987)
  • EJ Benjamin et al.

    Impact of atrial fibrillation on the risk of death: the Framingham Heart Study

    Circulation

    (1998)
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    Funding/Support: The authors have reported to CHEST that no funding was received for this study.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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