Etiology distribution of patients with atrial fibrilation by echocardiography: results from a prospective study in 3755 adults Enes Abdovic Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina

Purpose Atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia 1 It is a disease of the elderly and it is common in patients with structural heart disease 1 Hypertension (HA), diabetes mellitus, myocardial infarction, heart failure (with impaired or preserved left ventricular systolic function), and valvular heart disease are recognized predisposing factors to AF 2,3,4 Objectives: To evaluate predisposing factors for development of AF in our hospital settings 1 Go AS, et al. JAMA 2001;285:2370–75. 2 Aidietis A, et al. Curr Pharm Des 2007;13:2545–55. 3 Grigioni F, et al. J Am Coll Cardiol 2002;40:84–92. 4 Olsson LG, et al. J Am Coll Cardiol 2006;47:1997–2004. Purpose

From June 2000 to February 2013, 3755 consecutive patients with AF were studied during echocardiographic check-up According to transthoracic echo, patients were divided in groups based on dominative underlying heart diseases Electrocardiographically documented AF was subdivided in two groups: transitory and chronic – Transitory AF fulfilled criteria for paroxysmal or persistent AF 1 – Chronic AF were cases of long-standing persistent or permanent AF 1 Binary logistic regression was used to investigate relationship of gender, age, hypertension, diabetes and underlying heart diseases with the type of AF Camm AJ, et al. Eur Heart J 2010;31:2369–2429. Methods

Results The median age was 72 years, age range between 16 and 96 years There were 51.4% of females. Chronic AF was observed in 68.3% pts. Lone AF was diagnosed in only 25 patients, mostly in younger males (median age 48 years, range 29–59, men 80%)

HHD=hypertensive heart disease; DCM=dilated cardiomyopathy; CAD=coronary artery disease; VHD=valvular heart disease; Lone=lone AF; HF=heart failure; AF=atrial fibrillation. Etiological distribution AF by echocardiography (3755 pts)

HHDDCMCADVHDLoneOTHERTOTAL N o of pts (%) 1511 (40.2)935 (24.9)522 (13.9)416 (11.1)25 (0.7)346 (9.2) 3755 (100) Females (%) 850 (56.3)394 (42.1)224 (42.9) 251 ( 60.3 ) 5 (20.0)207 (59.8) 1931 (51.4) Age, median (yrs) Age, range (yrs) BMI [kg/m 2 ] ±5 Transitory AF (%) 543 (35.9)200 (21.4)220 (42.2)84 (20.2) 18 ( 72.0 ) 126 (36.4) 1191 (31.7) Hypertension (%) 1511 ( 100 )624 ( 66.7 )348 ( 66.7 ) 198 (47.6)0172 (49.7) 2832 (75.4) Diabetes (%) 300 (19.9)168 (18.0) 158 ( 30.3 ) 37 (8.9)041 (11.9) 706 (18.8) Thyreoid disease (%) 0 (0)51 (5.5)27 (5.2)18 (4.3)0 181 ( 52.3 )240 (6.4) No=number; pts=patients; AF=atrial fibrillation; BMI=body mass index; HHD=hypertensive heart disease; DCM=dilated cardiomyopathy; CAD=coronary artery disease; VHD=valvular heart disease; Lone=lone AF. Comorbidities associated with AF

HHDDCMCADVHDLoneOTHERTOTAL N o of pts (%) 1511 (40.2)935 (24.9)522 (13.9)416 (11.1)25 (0.7)346 (9.2) 3755 (100) Females (%) 850 (56.3)394 (42.1)224 (42.9) 251 ( 60.3 ) 5 (20.0)207 (59.8) 1931 (51.4) Age, median (yrs) Age, range (yrs) BMI [kg/m 2 ] ±5 Transitory AF (%) 543 (35.9)200 (21.4)220 (42.2)84 (20.2) 18 ( 72.0 ) 126 (36.4) 1191 (31.7) Hypertension (%) 1511 ( 100 )624 ( 66.7 )348 ( 66.7 ) 198 (47.6)0172 (49.7) 2832 (75.4) LBBB(%) 95 (24.7) 209 ( 54.4 ) 36 (9.4)19 (5.0)025 (6.5) 384 (10.2) Galstones (%) 263 ( 45.7 ) 131 (22.8)84 (14.6)51 (8.9)045 (7.8) 575 (15.3) No=number; pts=patients; AF=atrial fibrillation; BMI=body mass index; HHD=hypertensive heart disease; DCM=dilated cardiomyopathy; CAD=coronary artery disease; VHD=valvular heart disease; Lone=lone AF. Comorbidities associated with AF

HHD=hypertensive heart disease; DCM=dilated cardiomyopathy; CAD=coronary artery disease; VHD=valvular heart disease; Lone=lone AF; HF=heart failure; AF=atrial fibrillation. AF and HA pts (2854=76%)

HHD=hypertensive heart disease; DCM=dilated cardiomyopathy; CAD=coronary artery disease; VHD=valvular heart disease; Lone=lone AF; HF=heart failure; AF=atrial fibrillation. AF and HF pts (1832=49%)

AF, typeChronic AFTransitory AFTotal No pts (%) 2564 ( 68.3 )1191 ( 31.7 ) 3755 (100%) Females (%) 1306 (50.9)625 (52.5) 1931 ( 51.4 ) Age,means&SD,yrs (range) 70±10 (16-96)68±11 (24-94)71±10 (16-96) BMI [kg/m 2 ] Hypertension (%) 1891 (73.8)941 (79.0) 2832 ( 75.4 ) Diabetes (%) 430 (16.8)191 (16.0) 706 ( 18.8 ) Coronary artery dysease (%) 594 (23.2)347 (29.1) 941 ( 25.1 ) Gallstones (%) 366 (14.3)203 (17.1) 569 ( 15.3 ) LBBB (%) 259 (10.1)124 (10.4) 383 ( 10.2 ) Stroke/TIA (%) 241 (9.4)67 (5.6) 308 ( 8.2 ) Thyroid dysfunction (%) 156 (6.1)84 (7.1) 240 ( 6.4 ) No=number; pts=patients; AF=atrial fibrillation; SD=standard deviation, yrs=years, BMI=body mass index; LBBB=left bundle branch block; TIA=transitory ischemic attack. Characteristics of patients with chronic vs. transitory AF

Results (2) Hypertensive heart disease (HHD) was the most common underlying heart disease (40.2%) followed by dilated cardiomyopathy (DCM), 24.9%, coronary artery disease (CAD), 13.9% and valvular heart disease (VHD), 11.1%. Thyroid gland disease was found in 240:6.3% of patients of which 52.9% was hypothyroidism (127 vs 113) Results (2)

Hypertension, diabetes and thyroid gland disease were found in 75.4%, 18.8% and 6.3% patients, respectively, mostly in females: (HA: 1556pts/2832=55.0%) (DM: 453pts/706=64.2%) (Thy.gl.disease: 193pts/240=80.4%) Results (3)

Risk of chronic atrial fibrillation (binary logistic regression model) HHD, hypertensive heart disease; DCM, dilated cardiomyopathy; CHD, coronary artery disease; VHD, valvular heart disease; Lone, lone atrial fibrillation; BMI, body mass index; HA, hypertension; DM, diabetes mellitus; TH, diseases of thyroid gland; IVB, intraventricular block.

Pts with/without Paroxismal AF Aged ≥65yrs and/or with LAE ≥ 25 and/or with IAB Group1 N= N= N=396 4 N=400 5 N=472 6 N=403 7 N=172 8 N=154 Age≥ IAB LAE AF/NO AF/YES AF(%)

CHA 2 DS 2 -VASc score ≥ 2 = 86.5% HHDDCMCADVHDOtherAgeFemale (%) Total ± ± 972 (17.8) ± 9256 (33.8) ± 7518 (50.2) ± 6600 (69.6) ± 6337 (79.5) ± 5119 (79.3) ± 327 (96.4) ± 310 (100.0) ± 02 (100.0)2

Conclusion Hypertension was by far the most prevalent associated medical condition in patients with AF AF without underlying heart disease was present in only 0.7%, mostly in younger patients, males, with transitory AF Almost 1/2 of pts with AF had HF and 59.2% had diastolic HF. Chronic AF was predominant in groups with advanced cardiac remodeling such as DCM and VHD, mostly in elderly Conclusion

Optimal treatement of HA as well as DM to prevent CAD and HF and to eliminate or at least postpone AF, the most common sustained cardiac arrhythmia Take Home Message