Paroxysmal and Non-Paroxysmal Atrial Fibrillation in Middle Eastern Patients: Clinical Features and the Use of Medications. Analysis of the Jordan Atrial Fibrillation (JoFib) Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design and Setting
2.2. Statistical Analysis
3. Results
4. Discussion
Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- Andrade, J.; Khairy, P.; Dobrev, D.; Nattel, S. The clinical profile and pathophysiology of atrial fibrillation: Relationships among clinical features, epidemiology, and mechanisms: Relationships among clinical features, epidemiology, and mechanisms. Circ. Res. 2014, 114, 1453–1468. [Google Scholar] [CrossRef] [PubMed]
- Go, A.S.; Hylek, E.M.; Phillips, K.A.; Chang, Y.; Henault, L.E.; Selby, J.V.; Singer, D.E. Prevalence of diagnosed atrial fibrillation in adults: National implications for rhythm management and stroke prevention: The AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001, 285, 2370–2375. [Google Scholar] [CrossRef] [PubMed]
- Nantsupawat, T.; Nugent, K.; Phrommintikul, A. Atrial fibrillation in the elderly. Drugs Aging 2013, 30, 593–601. [Google Scholar] [CrossRef] [PubMed]
- Staerk, L.; Sherer, J.A.; Ko, D.; Benjamin, E.J.; Helm, R.H. Atrial fibrillation: Epidemiology, pathophysiology, and clinical outcomes. Circ. Res. 2017, 120, 1501–1517. [Google Scholar] [CrossRef] [Green Version]
- Wasmer, K.; Eckardt, L.; Breithardt, G. Predisposing factors for atrial fibrillation in the elderly. J. Geriatr. Cardiol. 2017, 14, 179–184. [Google Scholar]
- January, C.T.; Wann, L.S.; Calkins, H.; Chen, L.Y.; Cigarroa, J.E.; Cleveland, J.C., Jr.; Ellinor, P.T., Jr.; Ezekowitz, M.D.; Field, M.E.; Furie, K.L.; et al. 2019 AHA/ACC/HRS Focused Update of the 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 Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation 2019, 140, e125–e151. [Google Scholar] [CrossRef]
- Kakar, P.; Boos, C.J.; Lip, G.Y.H. Management of atrial fibrillation. Vasc. Health Risk Manag. 2007, 3, 109–116. [Google Scholar]
- Sacco, R.L.; Adams, R.; Albers, G.; Alberts, M.J.; Benavente, O.; Furie, K.; Goldstein, L.B.; Gorelick, P.; Halperin, J.; Harbaugh, R.; et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: A statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: Co-sponsored by the Council on Cardiovascular Radiology and Intervention: The American Academy of Neurology affirms the value of this guideline. Circulation 2006, 113, e409–e449. [Google Scholar]
- Isaew, A.; Adderley, N.J.; Ryan, R.; Fitzmaurice, D.; Marshall, T. The treatment of paroxysmal atrial fibrillation in UK primary care. Heart 2017, 103, 1502–1507. [Google Scholar] [CrossRef]
- Lip, G.Y.; Hee, F.L. Paroxysmal atrial fibrillation. QJM 2001, 94, 665–678. [Google Scholar] [CrossRef]
- Kato, T.; Yamashita, T.; Sagara, K.; Iinuma, H.; Fu, L.-T. Progressive Nature of Paroxysmal Atrial Fibrillation. Circ. J. 2004, 68, 568–572. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Chiang, C.-E.; Naditch-Brûlé, L.; Murin, J.; Goethals, M.; Inoue, H.; O’Neill, J.; Silva-Cardoso, J.; Zharinov, O.; Gamra, H.; Alam, S.; et al. Distribution and risk profile of paroxysmal, persistent, and permanent atrial fibrillation in routine clinical practice: Insight from the real-life global survey evaluating patients with atrial fibrillation international registry. Circ. Arrhythm. Electrophysiol. 2012, 5, 632–639. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Boriani, G.; Laroche, C.; Diemberger, I.; Fantecchi, E.; Popescu, M.I.; Rasmussen, L.H.; Dan, G.-A.; Kalarus, Z.; Tavazzi, L.; Maggioni, A.P.; et al. “Real-world” management and outcomes of patients with paroxysmal vs. non-pmal atrial fibrillation in Europe: The EURObservational Research Programme-Atrial Fibrillation aroxys (EORP-AF) General Pilot Registry. EP Eur. 2016, 18, 648–657. [Google Scholar]
- Al-Khatib, S.M.; Thomas, L.; Wallentin, L.; Lopes, R.D.; Gersh, B.; Garcia, D.; Ezekowitz, J.; Alings, M.; Yang, H.; Alexander, J.H.; et al. Outcomes of apixaban vs. warfarin by type and duration of atrial fibrillation: Results from the ARISTOTLE trial. Eur. Heart J. 2013, 34, 2464–2471. [Google Scholar] [CrossRef] [Green Version]
- Lévy, S.; Maarek, M.; Coumel, P.; Guize, L.; Lekieffre, J.; Medvedowsky, J.L.; Sebaoun, A. Characterization of different subsets of atrial fibrillation in general practice in France: The ALFA study. The College of French Cardiologists. Circulation 1999, 99, 3028–3035. [Google Scholar] [CrossRef]
- Petersen, P.; Godtfredsen, J. Embolic complications in paroxysmal atrial fibrillation. Stroke 1986, 17, 622–626. [Google Scholar] [CrossRef] [Green Version]
- Steinberg, B.A.; Hellkamp, A.S.; Lokhnygina, Y.; Patel, M.R.; Breithardt, G.; Hankey, G.J.; Becker, R.C.; Singer, D.E.; Halperin, J.L.; Hacke, W.; et al. Higher risk of death and stroke in patients with persistent vs. paroxysmal atrial fibrillation: Results from the ROCKET-AF Trial. Eur. Heart J. 2015, 36, 288–296. [Google Scholar] [CrossRef] [Green Version]
- Gažová, A.; Leddy, J.J.; Rexová, M.; Hlivák, P.; Hatala, R.; Kyselovič, J. Predictive value of CHA2DS2-VASc scores regarding the risk of stroke and all-cause mortality in patients with atrial fibrillation (CONSORT compliant). Medicine 2019, 98, e16560. [Google Scholar] [CrossRef]
- Meinertz, T.; Kirch, W.; Rosin, L.; Pittrow, D.; Willich, S.N.; Kirchhof, P.; Atrium investigators. Management of atrial fibrillation by primary care physicians in Germany: Baseline results of the ATRIUM registry. Clin. Res. Cardiol. 2011, 100, 897–905. [Google Scholar] [CrossRef] [Green Version]
- Friberg, L.; Hammar, N.; Rosenqvist, M. Stroke in paroxysmal atrial fibrillation: Report from the Stockholm Cohort of Atrial Fibrillation. Eur. Heart J. 2010, 31, 967–975. [Google Scholar] [CrossRef] [Green Version]
- Okawa, K.; Miyoshi, T.; Tsukuda, S.; Hara, S.; Matsuo, N.; Nishibe, N.; Sogo, M.; Okada, T.; Nosaka, K.; Sakane, K.; et al. Differences in endothelial dysfunction induced by paroxysmal and persistent atrial fibrillation: Insights from restoration of sinus rhythm by catheter ablation. Int. J. Cardiol. 2017, 244, 180–185. [Google Scholar] [CrossRef] [PubMed]
- Kim, Y.G.; Shim, J.; Boo, K.Y.; Kim, D.Y.; Oh, S.-K.; Lee, K.-N.; Choi, J.-I.; Kim, Y.-H. Different influence of cardiac hemodynamics on thromboembolic events in patients with paroxysmal and non-paroxysmal atrial fibrillation. PLoS ONE 2019, 14, e0214743. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Goette, A.; Lip, G.Y.; Jin, J.; Heidbuchel, H.; Cohen, A.-A.; Ezekowitz, M.; Merino, J.L. Differences in thromboembolic complications between paroxysmal and persistent atrial fibrillation patients following electrical cardioversion (from the ENSURE-AF study). Am. J. Cardiol. 2020, 131, 27–32. [Google Scholar] [CrossRef] [PubMed]
- Waldo, A.L.; Becker, R.C.; Tapson, V.F.; Colgan, K.J.; NABOR Steering Committee. Hospitalized patients with atrial fibrillation and a high risk of stroke are not being provided with adequate anticoagulation. J. Am. Coll. Cardiol. 2005, 46, 1729–1736. [Google Scholar] [CrossRef] [Green Version]
- Vanassche, T.; Lauw, M.N.; Eikelboom, J.W.; Healey, J.S.; Hart, R.G.; Alings, M.; Avezum, A.; Díaz, R.; Hohnloser, S.H.; Lewis, B.S.; et al. Risk of ischaemic stroke according to pattern of atrial fibrillation: Analysis of 6563 aspirin-treated patients in ACTIVE-A and AVERROES. Eur. Heart J. 2015, 36, 281–287. [Google Scholar] [CrossRef]
- Kühlkamp, V.; Bosch, R.; Mewis, C.; Seipel, L. Use of beta-blockers in atrial fibrillation. Am. J. Cardiovasc. Drugs 2002, 2, 37–42. [Google Scholar] [CrossRef]
- Lip, G.Y.; Laroche, C.; Dan, G.-A.; Santini, M.; Kalarus, Z.; Rasmussen, L.H.; Oliveira, M.M.; Mairesse, G.; Crijns, H.J.; Simantirakis, E.; et al. A prospective survey in European Society of Cardiology member countries of atrial fibrillation management: Baseline results of EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry. Europace 2014, 16, 308–319. [Google Scholar] [CrossRef]
- An, Y.; Ogawa, H.; Esato, M.; Ishii, M.; Iguchi, M.; Masunaga, N.; Aono, Y.; Ikeda, S.; Doi, K.; Tsuji, H.; et al. Age-dependent prognostic impact of paroxysmal versus sustained atrial fibrillation on the incidence of cardiac death and heart failure hospitalization (the Fushimi AF Registry). Am. J. Cardiol. 2019, 124, 1420–1429. [Google Scholar] [CrossRef]
- Taillandier, S.; Bernard, A.B.; Lallemand, B.; Simeon, E.; Pericart, L.; Clementy, N.; Babuty, D.; Fauchier, L. Prognosis in patients hospitalized with permanent and nonpermanent atrial fibriltion in heart failure. Am. J. Cardiol. 2014, 113, 1189–1195. [Google Scholar] [CrossRef]
- Boriani, G.; Laroche, C.; Diemberger, I.; Fantecchi, E.; Popescu, M.I.; Rasmussen, L.H.; Sinagra, G.; Petrescu, L.; Tavazzi, L.; Maggioni, A.P.; et al. Asymptomatic Atrial Fibrillation: Clinical Correlates, Management, and Outcomes in the EORP-AF Pilot General Registry. Am. J. Med. 2015, 128, 509–518.e2. [Google Scholar] [CrossRef]
- Guerra, F.; Brambatti, M.; Nieuwlaat, R.; Marcucci, M.; Dudink, E.; Crijns, H.J.; Matassini, M.V.; Capucci, A. Symptomatic atrial fibrillation and risk of cardiovascular events: Data from the Euro Heart Survey. EP Eur. 2017, 19, 1922–1929. [Google Scholar] [CrossRef] [PubMed]
- Westerman, S.; Wenger, N. Gender Differences in Atrial Fibrillation: A Review of Epidemiology, Management, and Outcomes. Curr. Cardiol. Rev. 2019, 15, 136–144. [Google Scholar] [CrossRef] [PubMed]
- Volgman, A.S.; Benjamin, E.J.; Curtis, A.B.; Fang, M.C.; Lindley, K.J.; Naccarelli, G.V.; Pepine, C.J.; Quesada, O.; Vaseghi, M.; Waldo, A.L.; et al. Women and atrial fibrillation. J. Cardiovasc. Electrophysiol. 2021, 32, 2793–2807. [Google Scholar] [CrossRef] [PubMed]
Variable | Paroxysmal (769) | Non–Paroxysmal (1380) | p-Value | Total (2160) * |
---|---|---|---|---|
Stroke and systemic embolization | 119 (15.5%) | 261 (18.9%) | 0.045 | 380 (17.7%) |
Male | 366 (47.6%) | 624 (45.2%) | 0.288 | 989 (46.1%) |
Female | 403 (52.4%) | 756 (54.8%) | 0.288 | 1158 (53.9%) |
Age | 63.7 (14.7) | 70.2 (11.2) | <0.001 | |
Body mass index (kg/m²) | 0.084 | |||
Normal (<25) | 151 (21.0%) | 303 (24.4%) | 454 (23.2%) | |
Abnormal (≥25) | 568 (79.0%) | 938 (75.6%) | 1506 (76.8%) | |
Hypertension | 546 (71.0%) | 1058 (76.7%) | 0.004 | 1604 (74.6%) |
Diabetes mellitus | 301 (39.1%) | 645 (46.7%) | 0.001 | 946 (44.0%) |
Current smoker | 131 (17.1%) | 158 (11.4%) | <0.001 | 289 (13.5%) |
Dyslipidemia | 349 (45.4%) | 604 (43.8%) | 0.488 | 953 (44.4%) |
First atrial fibrillation episode | 379 (49.3%) | 227 (16.4%) | <0.001 | 606 (28.2%) |
CHA2DS2-VASc score | <0.001 | |||
Low and intermediate risk (<2 for males or <3 for females) | 250 (32.5%) | 188 (13.6%) | 438 (20.4%) | |
High risk (≥2 for males or ≥3 for females) | 519 (67.5%) | 1190 (86.4%) | 1709 (79.6%) | |
HAS-BLED score | <0.001 | |||
Low and moderate risk (<3) | 663 (86.2%) | 1060 (76.8%) | 1723 (80.2%) | |
High risk (≥3) | 106 (13.8%) | 320 (23.2%) | 426 (19.8%) | |
Outpatient or inpatient | 0.368 | |||
Outpatient | 533 (69.3%) | 982 (71.2%) | 1515 (70.5%) | |
Inpatient | 236 (30.7%) | 398 (28.8%) | 634 (29.5%) | |
Left ventricle hypertrophy | 0.017 | |||
Present | 247 (36.0%) | 521 (41.5%) | 768 (39.6%) | |
Absent | 439 (64.0%) | 733 (58.5%) | 1172 (60.4%) | |
Left ventricle ejection fraction | <0.001 | |||
Normal (≥50) | 618 (86.2%) | 905 (68.9%) | 1523 (75.0%) | |
Mild-Moderate reduction (30–50) | 85 (11.9%) | 316 (24.1%) | 401 (19.8%) | |
Severe reduction (<30) | 14 (2.0%) | 92 (7.0%) | 106 (5.2%) | |
Left atrial size (centimetre) | 4.0 (0.7) | 4.5 (0.7) | <0.001 | |
Valvular vs. non-valvular atrial fibrillation | <0.001 | |||
Valvular | 37 (4.8%) | 146 (10.6%) | 183 (8.5%) | |
Non-valvular | 732 (95.2%) | 1234 (89.4%) | 1966 (91.5%) | |
Symptoms | ||||
Asymptomatic | 196 (25.5%) | 488 (35.4%) | <0.001 | 684 (31.8%) |
Palpitations | 426 (55.4%) | 507 (36.7%) | <0.001 | 933 (43.4%) |
Fatigue | 156 (20.3%) | 323 (23.4%) | 0.096 | 479 (22.3%) |
Dizziness | 96 (12.5%) | 160 (11.6%) | 0.542 | 256 (11.9%) |
Shortness of breath | 236 (30.7%) | 495 (35.9%) | 0.015 | 731 (34.0%) |
Syncope | 22 (2.9%) | 26 (1.9%) | 0.142 | 48 (2.2%) |
Chest pain | 18 (2.3%) | 17 (1.2%) | 0.052 | 35 (1.6%) |
Comorbid diseases | ||||
Pulmonary Hypertension | 133 (17.3%) | 420 (30.6%) | <0.001 | 553 (25.9%) |
Sleep apnea | 33 (4.3%) | 59 (4.3%) | 0.986 | 92 (4.3%) |
Lung disease (COPD or lung fibrosis) | 29 (3.8%) | 66 (4.8%) | 0.274 | 95 (4.4%) |
Thyroid disease | 82 (10.7%) | 148 (10.7%) | 0.965 | 230 (10.7%) |
CKD | 56 (7.3%) | 141 (10.2%) | 0.024 | 197 (9.2%) |
Active cancer | 39 (5.1%) | 78 (5.7%) | 0.570 | 117 (5.4%) |
Heart failure | 91 (11.8%) | 429 (31.1%) | <0.001 | 520 (24.2%) |
Coronary artery disease | 84 (10.9%) | 151 (10.9%) | 0.989 | 235 (10.9%) |
Treatments/Drugs | Paroxysmal | Non-Paroxysmal | p-Value |
---|---|---|---|
Anticoagulant agents | 506 (65.8%) | 1188 (86.1%) | |
Warfarin | 141 (18.3%) | 560 (40.6%) | <0.001 |
DOAC | 365 (47.5%) | 628 (45.5%) | 0.383 |
Antiarrhythmic medications | |||
Beta blockers | 590 (76.7%) | 1132 (82.0%) | 0.003 |
Amiodarone | 207 (26.9%) | 210 (15.2%) | <0.001 |
CCB (diltiazem or verapamil) | 59 (7.7%) | 173 (12.5%) | <0.001 |
Digoxin | 68 (8.8%) | 263 (19.1%) | <0.001 |
Antiplatelet agents | |||
Aspirin | 299 (38.9%) | 532 (38.6%) | 0.880 |
Clopidogrel | 119 (15.5%) | 176 (12.8%) | 0.079 |
Dual antiplatelets therapy | 54 (7.0%) | 87 (6.3%) | 0.512 |
RAAS inhibitor (ACEi/ARB/Sacubitril/valsartan) | 282 (36.7%) | 549 (39.8%) | 0.156 |
Statins | 297 (38.6%) | 513 (37.2%) | 0.507 |
Diuretics | 217 (28.2%) | 629 (45.6%) | <0.001 |
Paroxysmal | Non-Paroxysmal | |
---|---|---|
Reason for admission | ||
Atrial fibrillation | 99 (41.9%) | 91 (22.9%) |
Acute coronary syndrome | 39 (16.5%) | 54 (13.6%) |
Heart failure | 13 (5.5%) | 74 (18.6%) |
Cerebrovascular accident | 17 (7.2%) | 28 (7.0%) |
Systemic embolization other than the brain | 0 0. (0%) | 5 (1.3%) |
Bleeding | 2 (0.8%) | 18 (4.5%) |
COPD | 0 (0.0%) | 6 (1.5%) |
Cardiac operation | 0 (0.0%) | 2 (0.5%) |
Syncope | 1 (0.4%) | 2 (0.5%) |
Non-cardiovascular causes | 65 (27.5%) | 118 (29.6%) |
In Patients outcome | ||
Discharged home | 219 (93.2%) | 377 (95.0%) |
In hospital death | 15 (6.4%) | 18 (4.6%) |
Cause of in-hospital death | ||
Acute myocardial infarction | 1 (0.4%) | 2 (0.5%) |
Stroke | 3 (1.3%) | 6 (1.5%) |
Sepsis | 9 (3.8%) | 4 (1.0%) |
Cardiac arrest of an undetermined etiology | 1 (0.4%) | 1 (0.3%) |
Cardiogenic shock | 0 (0.0%) | 2 (0.5%) |
Upper GI bleeding | 0 (0.0%) | 3 (0.8%) |
Acute respiratory failure | 1 (0.4%) | 0 (0.0%) |
Variable | Odds Ratio | 95% CI | p-Value | |
---|---|---|---|---|
Lower | Upper | |||
High risk CHA2DS2-VASc score | 1.86 | 1.39 | 2.50 | <0.001 |
First AF episode | 0.23 | 0.18 | 0.30 | <0.001 |
Current smoker | 0.97 | 0.70 | 1.35 | 0.874 |
Left ventricular hypertrophy | 1.07 | 0.84 | 1.35 | 0.574 |
Left atrial size (centimetre) | 1.61 | 1.36 | 1.92 | <0.001 |
Valvular heart disease | 0.83 | 0.50 | 1.40 | 0.502 |
Palpitations | 0.65 | 0.49 | 0.87 | 0.004 |
Shortness of breath | 1.43 | 1.08 | 1.89 | 0.011 |
Asymptomatic | 1.41 | 1.00 | 2.01 | 0.050 |
Pulmonary Hypertension | 1.25 | 0.94 | 1.66 | 0.117 |
Chronic kidney disease | 1.11 | 0.74 | 1.66 | 0.590 |
Warfarin | 2.05 | 1.55 | 2.71 | <0.001 |
Beta blockers | 1.41 | 1.06 | 1.89 | 0.018 |
Amiodarone | 0.66 | 0.50 | 0.87 | 0.004 |
CCB | 1.60 | 1.09 | 2.33 | 0.015 |
Digoxin | 2.39 | 1.64 | 3.49 | <0.001 |
Diuretcs | 1.29 | 1.01 | 1.66 | 0.038 |
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Al-Makhamreh, H.; Alrabadi, N.; Haikal, L.; Krishan, M.; Al-Badaineh, N.; Odeh, O.; Barqawi, T.; Nawaiseh, M.; Shaban, A.; Abdin, B.; et al. Paroxysmal and Non-Paroxysmal Atrial Fibrillation in Middle Eastern Patients: Clinical Features and the Use of Medications. Analysis of the Jordan Atrial Fibrillation (JoFib) Study. Int. J. Environ. Res. Public Health 2022, 19, 6173. https://doi.org/10.3390/ijerph19106173
Al-Makhamreh H, Alrabadi N, Haikal L, Krishan M, Al-Badaineh N, Odeh O, Barqawi T, Nawaiseh M, Shaban A, Abdin B, et al. Paroxysmal and Non-Paroxysmal Atrial Fibrillation in Middle Eastern Patients: Clinical Features and the Use of Medications. Analysis of the Jordan Atrial Fibrillation (JoFib) Study. International Journal of Environmental Research and Public Health. 2022; 19(10):6173. https://doi.org/10.3390/ijerph19106173
Chicago/Turabian StyleAl-Makhamreh, Hanna, Nasr Alrabadi, Lubna Haikal, Mohammad Krishan, Noor Al-Badaineh, Osama Odeh, Tawfiq Barqawi, Mohammed Nawaiseh, Ala Shaban, Basil Abdin, and et al. 2022. "Paroxysmal and Non-Paroxysmal Atrial Fibrillation in Middle Eastern Patients: Clinical Features and the Use of Medications. Analysis of the Jordan Atrial Fibrillation (JoFib) Study" International Journal of Environmental Research and Public Health 19, no. 10: 6173. https://doi.org/10.3390/ijerph19106173