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

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

• 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

Padfield et al. Heart Rhythm 2017;14:801-7

Predictors of AF progression and the HATCH

score

De Vos J Am Coll Cardiol 2010;55:725–31

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

Predictors of AF progression and the

HATCH score

De Vos J Am Coll Cardiol 2010;55:725–31

Progression to Persistent Form in Asymtomatic Paroxysmal AF

Senoo et al. Circ J 2014; 78: 1121-6

Potpara et al. CHEST 2012; 141:339-47

Potpara et al. CHEST 2012; 141(2):339–347

Predictors of TE Events and CHF during Follow-up:

Nielsen et al. Heart Rhythm 2015;12:1887–95

Inohara T, et al. Heart 2018;0:1-8

B-type natriuretic peptide, disease progression and clinical outcomes in atrial fibrillation

Buttner et al. Heart Rhythm 2018;15:1132-7

Role of NT-proANP & NT-proBNP in AF progression

LVA: Low Voltage Area

p =NS

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

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

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

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

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

Incidence of CIED–Detected Atrial High-Rate

Episodes in population with CIED

Freedman B et al. Circulation. 2017;135:1851-67

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

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

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

• 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

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:

Detecting atrial fibrillation by pulse palpation

Cooke G et al. J Fam Pract. 2006;55:130–134

“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

AF detection in smartphone era

Wareable sensors Single lead strip

portable devices

Sensitivity and Specificity of Different Methods of

Screening for Atrial Fibrillation

Freedman B et al. Circulation. 2017;135:1851-67

• 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:

AF progression occurred in 18.6% of patients at 12 months

Zhang et al. Am J Cardiol 2013

A Systematic Review on the Progression of

Paroxysmal to Persistent AF

Proietti et al J Am Coll Cardiol EP 2015;1:105–15

AF progression and spectrum of AF

management

Kotecha et al Europace 2018;20: 395-407