Pulmonary arterial hypertension and atrial arrhythmias: incidence, risk factors, and clinical impact

Valentina Mercurio, Grace Peloquin, Khalil I Bourji, Nermin Diab, Takahiro Sato, Blessing Enobun, Traci Housten-Harris, Rachel Damico, Todd M Kolb, Stephen C Mathai, Ryan J Tedford, Carlo G Tocchetti, Paul M Hassoun, Valentina Mercurio, Grace Peloquin, Khalil I Bourji, Nermin Diab, Takahiro Sato, Blessing Enobun, Traci Housten-Harris, Rachel Damico, Todd M Kolb, Stephen C Mathai, Ryan J Tedford, Carlo G Tocchetti, Paul M Hassoun

Abstract

Atrial arrhythmia (AA) occurrence in pulmonary arterial hypertension (PAH) may determine clinical deterioration and affect prognosis. In this study we assessed AA incidence in idiopathic (IPAH) and systemic sclerosis related PAH (SSc-PAH) and evaluated risk factors, management, and impact on mortality. We collected baseline data from consecutive IPAH or SSc-PAH patients prospectively enrolled in the Johns Hopkins Pulmonary Hypertension Registry between January 2000 and July 2016. During follow-up AA onset, treatment, and outcome were recorded. Among 317 patients (201 SSc-PAH, 116 IPAH), 42 developed AA (19 atrial fibrillation, 10 flutter-fibrillation, 9 atrial flutter, and 4 atrial ectopic tachycardia) with a 13.2% cumulative incidence. Most events were associated with hospitalization (90.5%). Electrical or pharmacological cardioversion was attempted in most cases. Patients with AA had higher right atrial pressure, pulmonary wedge pressure ( P < 0.005), NT-proBNP ( P < 0.05), and thyroid disease prevalence ( P < 0.005). Higher mortality was observed in patients with AA, though not statistically significant (LogRank P = 0.323). Similar long-term mortality between IPAH with AA and SSc-PAH without AA was observed (LogRank P = 0.098). SSc-PAH with AA had the worst prognosis. In PAH patients AA occurrence is a matter of significant concern. Therapeutic strategies aimed at restoring sinus rhythm may represent an important goal.

Keywords: atrial arrhythmias; pulmonary arterial hypertension; systemic sclerosis.

Figures

Fig. 1.
Fig. 1.
Kaplan–Meier curves for all-cause mortality among PAH patients according to the occurrence of AA. P value PAH with AA vs. PAH without AA: Log Rank P = 0.323; Breslow P = 0.985; Tarone-Ware P = 0.717. PAH, pulmonary arterial hypertension; AA, atrial arrhythmia.
Fig. 2.
Fig. 2.
Kaplan–Meier curves for all-cause mortality among PAH patients according to the etiology and the occurrence of AA. P value SSc-PAH with AA vs. SSc-PAH without AA: Log Rank P = 0.454; IPAH with AA vs. IPAH without AA: Log Rank P = 0.410; SSc-PAH without AA vs. IPAH without AA: Log Rank P < 0.001; SSc-PAH with AA vs. IPAH with AA: Log Rank P = 0.031; SSc-PAH without AA vs. IPAH with AA: Log Rank P = 0.098; SSc-PAH with AA vs. IPAH without AA: Log Rank P < 0.001. PAH, pulmonary arterial hypertension; AA, atrial arrhythmias; IPAH, idiopathic pulmonary arterial hypertension; SSc-PAH, systemic sclerosis related pulmonary arterial hypertension.

References

    1. Simonneau G, Gatzoulis MA, Adatia I, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol 2013; 62: D34–41.
    1. Medi C, Kalman JM, Ling LH, et al. Atrial electrical and structural remodeling associated with longstanding pulmonary hypertension and right ventricular hypertrophy in humans. J Cardiovasc Electrophysiol 2012; 23: 614–620.
    1. Cannillo M, Grosso Marra W, Gili S, et al. Supraventricular arrhythmias in patients with pulmonary arterial hypertension. Am J Cardiol 2015; 116: 1883–1889.
    1. Wen L, Sun ML, An P, et al. Frequency of supraventricular arrhythmias in patients with idiopathic pulmonary arterial hypertension. Am J Cardiol 2014; 114: 1420–1425.
    1. Tongers J, Schwerdtfeger B, Klein G, et al. Incidence and clinical relevance of supraventricular tachyarrhythmias in pulmonary hypertension. Am Heart J 2007; 153: 127–132.
    1. Ruiz-Cano MJ, Gonzalez-Mansilla A, Escribano P, et al. Clinical implications of supraventricular arrhythmias in patients with severe pulmonary arterial hypertension. Int J Cardiol 2011; 146: 105–106.
    1. Olsson KM, Nickel NP, Tongers J, et al. Atrial flutter and fibrillation in patients with pulmonary hypertension. Int J Cardiol 2013; 167: 2300–2305.
    1. Matthews JC, McLaughlin V. Acute right ventricular failure in the setting of acute pulmonary embolism or chronic pulmonary hypertension: A detailed review of the pathophysiology, diagnosis, and management. Curr Cardiol Rev 2008; 4: 49–59.
    1. Galie N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society Of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J 2016; 37: 67–119.
    1. Park JS, Park MC, Song JJ, et al. Application of the 2013 ACR/EULAR classification criteria for systemic sclerosis to patients with Raynaud’s phenomenon. Arthritis Res Ther 2015; 17: 77.
    1. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002; 166: 111–117.
    1. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline 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 Heart Rhythm Society. Circulation 2014; 130: e199–267.
    1. Malaczynska-Rajpold K, Komosa A, Blaszyk K, et al. The management of supraventricular tachyarrhythmias in patients with pulmonary arterial hypertension. Heart Lung Circ 2016; 25: 442–450.
    1. Bandorski D, Bogossian H, Ecke A, et al. Evaluation of the prognostic value of electrocardiography parameters and heart rhythm in patients with pulmonary hypertension. Cardiol J 2016; 23: 465–472.
    1. Rottlaender D, Motloch LJ, Schmidt D, et al. Clinical impact of atrial fibrillation in patients with pulmonary hypertension. PLoS One 2012; 7: e33902.
    1. Kanmanthareddy A, Reddy YM, Boolani H, et al. Incidence, predictors, and clinical course of atrial tachyarrhythmias in patients with pulmonary hypertension. J Interv Card Electrophysiol 2014; 41: 9–14.
    1. Li JH, Safford RE, Aduen JF, et al. Pulmonary hypertension and thyroid disease. Chest 2007; 132: 793–797.
    1. Curnock AL, Dweik RA, Higgins BH, et al. High prevalence of hypothyroidism in patients with primary pulmonary hypertension. Am J Med Sci 1999; 318: 289–292.
    1. Chu JW, Kao PN, Faul JL, et al. High prevalence of autoimmune thyroid disease in pulmonary arterial hypertension. Chest 2002; 122: 1668–1673.
    1. Richter MJ, Sommer N, Schermuly R, et al. The prognostic impact of thyroid function in pulmonary hypertension. J Heart Lung Transplant 2016; 35: 1427–1434.
    1. Sivak JA, Raina A, Forfia PR. Assessment of the physiologic contribution of right atrial function to total right heart function in patients with and without pulmonary arterial hypertension. Pulm Circ 2016; 6: 322–328.
    1. Fukuda Y, Tanaka H, Motoji Y, et al. Utility of combining assessment of right ventricular function and right atrial remodeling as a prognostic factor for patients with pulmonary hypertension. Int J Cardiovasc Imaging 2014; 30: 1269–1277.
    1. Sato T, Tsujino I, Ohira H, et al. Right atrial volume and reservoir function are novel independent predictors of clinical worsening in patients with pulmonary hypertension. J Heart Lung Transplant 2015; 34: 414–423.
    1. Sato T, Tsujino I, Oyama-Manabe N, et al. Right atrial volume and phasic function in pulmonary hypertension. Int J Cardiol 2013; 168: 420–426.
    1. Kawut SM, Taichman DB, Archer-Chicko CL, et al. Hemodynamics and survival in patients with pulmonary arterial hypertension related to systemic sclerosis. Chest 2003; 123: 344–350.
    1. Fisher MR, Mathai SC, Champion HC, et al. Clinical differences between idiopathic and scleroderma-related pulmonary hypertension. Arthritis Rheum 2006; 54: 3043–3050.
    1. Tedford RJ, Mudd JO, Girgis RE, et al. Right ventricular dysfunction in systemic sclerosis-associated pulmonary arterial hypertension. Circ Heart Fail 2013; 6: 953–963.
    1. Bradfield J, Shapiro S, Finch W, et al. Catheter ablation of typical atrial flutter in severe pulmonary hypertension. J Cardiovasc Electrophysiol 2012; 23: 1185–1190.
    1. Showkathali R, Tayebjee MH, Grapsa J, et al. Right atrial flutter isthmus ablation is feasible and results in acute clinical improvement in patients with persistent atrial flutter and severe pulmonary arterial hypertension. Int J Cardiol 2011; 149: 279–280.
    1. Luesebrink U, Fischer D, Gezgin F, et al. Ablation of typical right atrial flutter in patients with pulmonary hypertension. Heart Lung Circ 2012; 21: 695–699.

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