Temporal patterns and short-term progression of paroxysmal atrial fibrillation: data from RACE V

Ruben R De With, Ömer Erküner, Michiel Rienstra, Bao-Oanh Nguyen, Frank W J Körver, Dominik Linz, Hugo Cate Ten, Henri Spronk, Abraham A Kroon, Alexander H Maass, Yuri Blaauw, Robert G Tieleman, Martin E W Hemels, Joris R de Groot, Arif Elvan, Mirko de Melis, Coert O S Scheerder, Meelad I H Al-Jazairi, Ulrich Schotten, Justin G L M Luermans, Harry J G M Crijns, Isabelle C Van Gelder, RACE V Investigators, Ruben R De With, Ömer Erküner, Michiel Rienstra, Bao-Oanh Nguyen, Frank W J Körver, Dominik Linz, Hugo Cate Ten, Henri Spronk, Abraham A Kroon, Alexander H Maass, Yuri Blaauw, Robert G Tieleman, Martin E W Hemels, Joris R de Groot, Arif Elvan, Mirko de Melis, Coert O S Scheerder, Meelad I H Al-Jazairi, Ulrich Schotten, Justin G L M Luermans, Harry J G M Crijns, Isabelle C Van Gelder, RACE V Investigators

Abstract

Aims: Atrial fibrillation (AF) often starts as a paroxysmal self-terminating arrhythmia. Limited information is available on AF patterns and episode duration of paroxysmal AF. In paroxysmal AF patients, we longitudinally studied the temporal AF patterns, the association with clinical characteristics, and prevalence of AF progression.

Methods and results: In this interim analysis of the Reappraisal of AF: Interaction Between HyperCoagulability, Electrical Remodelling, and Vascular Destabilisation in the Progression of AF (RACE V) registry, 202 patients with paroxysmal AF were followed with continuous rhythm monitoring (implantable loop recorder or pacemaker) for 6 months. Mean age was 64 ± 9 years, 42% were women. Atrial fibrillation history was 2.1 (0.5-4.4) years, CHA2DS2-VASc 1.9 ± 1.3, 101 (50%) had hypertension, 69 (34%) heart failure. One-third had no AF during follow-up. Patients with long episodes (>12 hours) were often men with more comorbidities (heart failure, coronary artery disease, higher left ventricular mass). Patients with higher AF burden (>2.5%) were older with more comorbidities (worse renal function, higher calcium score, thicker intima media thickness). In 179 (89%) patients, 1-year rhythm follow-up was available. On a quarterly basis, average daily AF burden increased from 3.2% to 3.8%, 5.2%, and 6.1%. Compared to the first 6 months, 111 (62%) patients remained stable during the second 6 months, 39 (22%) showed progression to longer AF episodes, 8 (3%) developed persistent AF, and 29 (16%) patients showed AF regression.

Conclusions: In paroxysmal AF, temporal patterns differ suggesting that paroxysmal AF is not one entity. Atrial fibrillation burden is low and determined by number of comorbidities. Atrial fibrillation progression occurred in a substantial number.

Trial registration number: Clinicaltrials.gov identifier NCT02726698.

Keywords: Atrial fibrillation; Atrial fibrillation burden; Atrial fibrillation progression; Paroxysmal atrial fibrillation; Rhythm monitoring.

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Figure 1
Figure 1
Examples of patients with short (A), intermediate (B), and long (C) episodes during 6-month follow-up. Each day is represented by a bar. White means no AF is present, and blue represents ongoing episodes of AF. AF initiations are shown in red and AF terminations are shown in green. Shaded areas indicate nightly hours. The Y-axis is the time of day and the X-axis represents 6 months of follow-up. AF, atrial fibrillation.
Figure 2
Figure 2
Scatterplot showing a high rate of agreeability between the AF burden (X-axis) and the duration of the longest AF episode (Y-axis), both on logarithmic scales. Data shown for 139 patients with AF recurrence during 6-month follow-up. In turquoise, four patients are identified with long AF episodes, with low AF burden. In green, two patients are identified with short episodes, and high AF burden. AF, atrial fibrillation; CI, confidence interval.
Figure 3
Figure 3
Sankey diagram illustrating the categorization based on the longest AF episode during the first 6 months on the left, and the second 6 months on the right. AF, atrial fibrillation.

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