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CLINICAL RESEARCH: HEART RHYTHM DISORDER

Are Transthoracic Echocardiographic Parameters Associated With Atrial Fibrillation Recurrence or Stroke?

Results From the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study

Brian Olshansky, MD^_*,_*, Eliot N. Heller, MD, L. Brent Mitchell, MD, Mary Chandler, MD, William Slater, MD^||, Martin Green, MD^¶, Michael Brodsky, MD^#, Patrick Barrell, BS, H. Leon Greene, MD and the AFFIRM Investigators

^_* University of Iowa, Iowa City, Iowa
Bronx Lebanon Hospital Center, Bronx, New York
Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
Axio Research Corporation, Seattle, Washington
^|| New York University Medical Center, New York, New York
^¶ University of Ottawa, Ottawa, Ontario, Canada
^# University of California Irvine, Irvine, California.

Manuscript received November 23, 2004; revised manuscript received January 25, 2005, accepted March 1, 2005.

^_* Reprint requests and correspondence: Dr. Brian Olshansky, University of Iowa Hospitals, 200 Hawkins Drive, Iowa City, Iowa 52242. (Email: brian-olshansky{at}uiowa.edu).

OBJECTIVES: The purpose of this study was to evaluate the associations of transthoracic echocardiographic parameters with recurrent atrial fibrillation (AF) and/or stroke.

BACKGROUND: The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study, an evaluation of elderly patients with AF at risk for stroke, provided an opportunity to evaluate the implications of echocardiographic parameters in patients with AF.

METHODS: Transthoracic echocardiographic measures of mitral regurgitation (MR), left atrial (LA) diameter, and left ventricular (LV) function were evaluated in the AFFIRM rate- and rhythm-control patients who had sinus rhythm resume and had these data available. Risk for recurrent AF or stroke was evaluated with respect to transthoracic echocardiographic measures.

RESULTS: Of 2,474 patients studied, 457 had 2⁺/4⁺ MR, and 726 had a LA diameter >4.5 cm. The LV ejection fraction was abnormal in 543 patients. The cumulative probabilities of at least one AF recurrence/stroke were 46%/1% after 1 year and 84%/5% by the end of the trial (> 5 years), respectively. Multivariate analysis showed that randomization to the rhythm-control arm (hazard ratio [HR] = 0.64; p < 0.0001) and a qualifying episode of AF being the first known episode (HR = 0.70; p < 0.0001) were associated with decreased risk. Duration of qualifying AF episode >48 h (HR = 1.55; p < 0.0001) and LA diameter (p = 0.008) were associated with an increased risk of recurrent AF. Recurrent AF was more likely with larger LA diameters (HR = 1.21, 1.16, and 1.32 for mild, moderate, and severe enlargement, respectively). No transthoracic echocardiographic measures were associated with risk of stroke.

CONCLUSIONS: In the AFFIRM study, large transthoracic echocardiographic LA diameters were associated with recurrent AF, but no measured echocardiographic parameter was associated with stroke.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   AF = atrial fibrillation   AFFIRM = Atrial Fibrillation Follow-Up Investigation of Rhythm Management   CAD = coronary artery disease   CHF = congestive heart failure   ECG = electrocardiogram   LA = left atrial/atrium   LV = left ventricular/ventricle   MR = mitral regurgitation

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