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1
Dr Sakis Themistoclakis
AF & HF 2019, Bologna
Department of Cardiothoracic, Vascular Medicine & Intensive Care
Ospedale dell’Angelo, Mestre-Venice, Italy
Unit of Electrophysiology and Cardiac Pacing
Easy instrument to diagnose AF progression
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Padfield et al. Heart Rhythm 2017;14:801-7
Within 10 years of
presenting with
paroxysmal AF, 50% of
patients will progress to
persistent AF or be dead
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• Increased filling pressures, often relating to structural heart
disease, cause progressive structural and electrical
remodeling of the atrium over time.
• Increasing development of fibrosis and the associated
heterogeneity in conduction velocity and refractory periods
form the substrate for the maintenance of AF and a
propensity to transition from paroxysmal to persistent AF.
Pathophysiology of AF progression
Padfield et al. Heart Rhythm 2017;14:801-7
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Padfield et al. Heart Rhythm 2017;14:801-7
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Predictors of AF progression and the HATCH
score
De Vos J Am Coll Cardiol 2010;55:725–31
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Predictors of AF progression and the
HATCH score
Predictors Points
Hypertension 1
Age ≧ 75 year 1
TIA or stroke 2
Chronic obstructive pulmonary disease 1
Heart failure 2
De Vos J Am Coll Cardiol 2010;55:725–31
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Predictors of AF progression and the
HATCH score
De Vos J Am Coll Cardiol 2010;55:725–31
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Progression to Persistent Form in Asymtomatic Paroxysmal AF
Senoo et al. Circ J 2014; 78: 1121-6
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Potpara et al. CHEST 2012; 141:339-47
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Potpara et al. CHEST 2012; 141(2):339–347
Predictors of TE Events and CHF during Follow-up:
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Nielsen et al. Heart Rhythm 2015;12:1887–95
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Inohara T, et al. Heart 2018;0:1-8
B-type natriuretic peptide, disease progression and clinical outcomes in atrial fibrillation
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Buttner et al. Heart Rhythm 2018;15:1132-7
Role of NT-proANP & NT-proBNP in AF progression
LVA: Low Voltage Area
p =NS
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Jiang T, et al. Europace 2017, 19.3:392-400
Association of pre-ablation level of potential blood markers with atrial fibrillation recurrence after catheter ablation: a meta-analysis
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Association of pre-ablation level of potential blood markers with atrial fibrillation recurrence after catheter ablation: a meta-analysis
Jiang T, et al. Europace 2017, 19.3:392-400
• ANP was associated with AF recurrence in participants
who had no concomitant structural heart diseases (SHD),
however, not in participants who had SHD.
• C-reactive protein was associated with AF recurrence in
Asian studies, whereas not in European studies.
Before practical application on individuals, we should bear the
conception in mind that the level of blood markers might be
influenced by comorbidities and other clinical factor
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Sakabe et al. Heart 2009;95:988–993
40 pts with paroxysmal atrial fibrillation followed with 2D echocardiography
P-A’ time: time from initiation of the P wave on the ECG until the beginning of the late
diastolic tissue Doppler imaging signal at the mitral annulus
Interatrial dyssynchrony on tissue Doppler imaging predicts progression to chronic AF in pts with non-valvular
paroxysmal AF
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Watanabe, et al. Heart Rhythm 2015; 12:490–497
Mechanical and substrate abnormalities of the left atrium assessed by 3-dimensional speckle-tracking echocardiography and electroanatomic mapping system in patients
with paroxysmal atrial fibrillation
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Evaluation of the left atrial substrate in patients with lone atrial fibrillation using delayed-enhanced MRI: Implications for
disease progression and response to catheter ablation
Mahnkopft et al, Heart Rhythm 2010;7:1475–1481
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Incidence of CIED–Detected Atrial High-Rate
Episodes in population with CIED
Freedman B et al. Circulation. 2017;135:1851-67
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ASSERT Study:
Healey JS et al. N Engl J Med 2012;366:120-9
Risk of Clinical atrial tachyarrhythmias according to
the presence or absence of subclinical episodes
detected by PM/ICD
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ASSERT Study:
Healey JS et al. N Engl J Med 2012;366:120-9
Risk of ischemic stroke or systemic embolism
according to the presence or absence of subclinical
atrial tachyarrhythmias detected by PM/ICD
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Intensity of follow-up strategy & AF
detection rate
Kirchhof et al. Europace. 2016;18(11):1609-
1678
Kircher S et al. Cur Cardiol Rev 2012; 8: 354-
61
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• For a screening program to be efficient, the
screening technique must have a high positive
predictive value using a low-risk tool at low cost.
Screening for Atrial Fibrillation: A Report of the AF-
SCREEN International Collaboration
Freedman B et al. Circulation. 2017;135:1851-67
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SAFE study Screening for Atrial Fibrillation in the Elderly
Fitzmaurice DA et al. Br Med J. 2007;335:383
Active screening for atrial fibrillation detects additional cases over current practice.
Systematic and opportunistic screening detected similar numbers of new cases
Pulse palpation effective as a screening strategy:
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Detecting atrial fibrillation by pulse palpation
Cooke G et al. J Fam Pract. 2006;55:130–134
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“Traditional” AF detection Tools
• Non Invasive Monitoring
• Continuous ECG monitoring/Telemetry
• 24h Holter ECG
• Event Loop Recorder
• Wereable ECG vest
• Invasive Monitoring
• Implantable Loop Recorder
• PM/ICD
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AF detection in smartphone era
Wareable sensors Single lead strip
portable devices
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Sensitivity and Specificity of Different Methods of
Screening for Atrial Fibrillation
Freedman B et al. Circulation. 2017;135:1851-67
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• Mass or opportunistic screening for AF can be accomplished by pulse
palpation; oscillometric (blood pressure) or photoplethysmographic
(smartphone camera) devices; and handheld ECG devices providing a
rhythm strip.
• Because ECG confirmation is mandated by guidelines for the
diagnosis of AF, handheld ECG devices have the advantage of
providing a verifiable ECG trace and would therefore be the
preferred screening tool.
• Prolonged continuous ECG monitoring with external or subcutaneous
recorders will diagnose more paroxysmal AF but requires further
evaluation: cost-effectiveness will be limited by expense and detection
of AF with lower absolute stroke risk.
Screening for Atrial Fibrillation: A Report of the AF-
SCREEN International Collaboration
Freedman B et al. Circulation. 2017;135:1851-67
Key point:
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AF progression occurred in 18.6% of patients at 12 months
Zhang et al. Am J Cardiol 2013
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A Systematic Review on the Progression of
Paroxysmal to Persistent AF
Proietti et al J Am Coll Cardiol EP 2015;1:105–15
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AF progression and spectrum of AF
management
Kotecha et al Europace 2018;20: 395-407