Download Post-PCI Atrial Fibrillation: Possible Clinical and Prognostic

Post-PCI Atrial Fibrillation: Possible Clinical and Prognostic
Significance
B. GORENEK
Atrial fibrillation (AF) is a major arrhythmia that has a high prevalence
among the population. It is clinically important because affected patients
have a higher risk of mortality; a deterioration in haemodynamics due to
increased heart rate, loss of atrioventricular synchrony, and progressive dysfunction of the left atrium and left ventricle; and stroke and other embolic
events resulting from atrial thrombi [1, 2]. In addition, AF may cause significant symptoms and impair both functional status and the quality of life.
Percutaneous coronary interventions (PCI) have been the fastest growing
major invasive procedure in the past decade. Accompanying the obvious
benefit, there are certain risks, including cardiac arrhythmias. Several kind
of arrhythmias, especially ventricular arrhythmias and conduction disturbances, can occur during PCI. These arrhythmias may result from excess
catheter manipulation, intracoronary dye injection, new ischaemic events, or
reperfusion injury. Lethal ventricular arrhythmias, including serious ventricular tachycardia and ventricular fibrillation, have been reported to occur in
1.5–4.4% of patients undergoing coronary angioplasty. The frequency of
these arrhythmias after primary PCI was analyzed in a study of 3065 patients
participating in the PAMI trials [3]. Ventricular arrhythmias occurred in 133
patients (4.3%). Smoking, lack of preprocedural beta-blockers, shorter time
from symptom onset to emergency room arrival, initial TIMI flow grade 0,
and infarct of the right coronary artery were variables independently associated with a risk of serious ventricular arrhythmias. Those patients also had
higher rates of complications, including cardiopulmonary resuscitation and
intubation, in the catheterisation laboratory but had similar frequencies of
major adverse cardiac events in-hospital and at 1 year.
Osmangazi University, Cardiology Department, Eskisehir, Turkey
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B. Gorenek
Supraventricular arrhythmias, including atrial flutter and atrial AF, may
also occur during or after PCI, as a complication or a sequel of the revascularisation procedure. However, these are not as frequent as ventricular
arrhythmias. In general, AF has prognostic significance in patients treated
with PCI, as it can be induced by cardiac catheterisation, especially in
response to catheter placement into or out of the right atrium. Atrial dysfunction (due to atrial ischaemia or atrial stretching in heart failure), sinoatrial and AV nodal ischaemia, congestive heart failure, sympathetic stimulation, and iatrogenic factors are the possible causes of AF in patients undergoing primary PCI for acute myocardial infarction (MI). AF, by contrast, can
cause clinical sequelae in the setting of a rapid ventricular response or if the
loss of atrial systole results in hypotension, as in a patient with mitral stenosis or diastolic ventricular dysfunction.
Importance of Clinical Features
The clinical characteristics of patients play important roles in the occurrence
of AF in PCI. Kinjo et al. assessed the prognostic significant of AF and atrial
flutter in patients with acute MI that had been treated with PCI [4]. In their
study, patients with AF were older, were in higher Killip classes, had higher
rates of previous MI and previous cerebrovascular accident, had systolic
blood pressures of < 100 mmHg and heart rates ≥ 100 beats/min, were less
likely to smoke, and had higher prevalence of multivessel disease and poorer
reperfusion of infarct-related artery than those without AF. AF was a common complication in patients with MI who were treated with PCI and independently influenced 1-year mortality. Cardiogenic shock, congestive heart
failure, cardiac rupture, ventricular tachycardia and/or ventricular fibrillation, and stroke occurred more often in patients with AF than in those without AF. No significant difference was observed in the rates of recurrent
infarction or recurrent ischaemia. The unadjusted in-hospital mortality rate
was significantly higher in patients with AF than in those without AF. But,
after adjustment for demographic characteristics and clinical factors, AF was
not associated with in-hospital mortality. Furthermore, when stratified by
the timing of AF, both AF at admission and AF that developed during hospitalisation were not independent predictors for in-hospital mortality.
Therefore, AF was not significantly associated with in-hospital mortality in
patients with MI who underwent PCI. One-year mortality was higher in
patients with AF than in those without AF. Most deaths were due to cardiovascular causes. Patients with AF had a greater incidence of death due to
pump failure than those without AF. After adjustment for demographic characteristics and clinical factors, patients with AF remained at significantly
Post-PCI Atrial Fibrillation: Possible Clinical and Prognostic Significance
139
greater risk for mortality at 1 year. Furthermore, when stratified by the timing of AF, AF during hospitalisation was independently associated with 1year mortality but AF at admission was not. The 1-year mortality of patients
discharged alive was higher in those with AF than in those without AF. After
adjustment for demographic characteristics, clinical factors, and antiarrhythmic drug use at discharge, patients with AF remained at significantly
greater risk for mortality at 1 year [4].
Importance of Electrophysiological Predictors
Inhomogeneous prolongation of sinus impulses may predict the recurrence
of AF [5, 6]. The heterogeneity of the structural and electrophysiological
properties of the atrium prone to fibrillate results in an inhomogeneous and
discontinuous prolongation of sinus impulses [7]. Electrophysiological studies have demonstrated that individuals with a clinical history of AF have a
significantly longer intra-atrial and inter-atrial conduction time of sinus
impulses [8–10]. This has been confirmed by the finding of P-wave prolongation on 12-lead surface ECG and signal-averaged ECG recordings [11–13].
The importance of P-wave dispersion in predicting recurrence of AF in
patients with paroxysmal AF has also been elucidated [5, 14]. Thus, P-wave
signal-averaged ECG could be useful to identify patients at risk for recurrence of AF after internal cardioversion [15].
Ozmen et al. investigated the effects of angioplasty induced-ischaemia on
atrial conduction abnormalities as estimated by P-wave maximum and Pwave dispersion [16]. Both were significantly higher during balloon occlusion compared with the baseline condition in coronary dilatation procedures. However, the P-wave minimum was not found to differ between baseline and during balloon occlusion. These data demonstrate that prolongation
of P-wave dispersion might be a simple and useful additional marker of
myocardial ischaemia during PCI.
Budeus et al. examined the incidence of atrial late potentials in patients
with a proximal stenosis of the right coronary artery and new onset of AF
[17]. They also investigated the anti-ischaemic effect of a successful percutaneous transluminal coronary angioplasty (PTCA) of the right coronary
artery. After successful PTCA only three out of 15 patients were affected after
1 day, as well as after 1 month. None of the patients with a history of AF suffered from an arrhythmic recurrence within the following 6 months after
successful PTCA. In that study, stenosis of the right coronary artery was
associated with atrial late potentials. The authors concluded that a successful
PTCA of the right coronary artery eliminates pre-existent atrial late potentials and may reduce the risk of AF.
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B. Gorenek
Atrial Fibrillation in Acute MI. Thrombolytic Therapy vs Primary PCI
Given the primary role of thrombus in the genesis of acute coronary occlusion, the introduction of thrombolytic therapy was a major advance in the
treatment of acute ST-elevation MI. But, compared to thrombolysis, primary
PCI achieves a higher rate of TIMI 3 flow, does not carry the risk of intracranial haemorrhage, and is associated with improved outcomes. The ACC/AHA
task force gave a class I recommendation to the use of primary PCI for any
patient with an acute MI who presents within 12 h of symptom onset and
who can undergo the procedure within 90 min of presentation by persons
skilled in the procedure [18]. The task force also identified specific considerations for choosing primary PCI, including the experience of the person performing the procedure, the timing of the procedure, and the specific clinical
setting.
Several studies in the thrombolytic era showed that the prognostic significance of AF on mortality was attenuated by improved treatment [19, 20].
Randomised studies performed in the past few years have demonstrated that
PCI is a more effective reperfusion strategy than intravenous thrombolysis
[21, 22]. Therefore, the incidence of AF may have decreased and the prognostic significance of AF may have been attenuated in patients with AMI who
underwent PCI. However, little is known concerning the incidence of AF and
its effects on the prognosis of patients with AMI who are treated with PCI.
A study was conducted to compare the effects of reperfusion either by
thrombolytic therapy or primary PTCA on P-wave duration and dispersion
in patients with acute anterior-wall MI. The authors evaluated 72 consecutive
patients retrospectively experiencing acute anterior-wall MI for the first
time. Patients were grouped according to the reperfusion therapy, PTCA versus thrombolytic therapy. There were no significant differences between the
groups regarding age, gender, left ventricular ejection fraction (LVEF), left
atrial diameter and volume, cardiovascular risk factors, and duration from
symptom onset to treatment. P-wave dispersions and P-wave durations were
significantly decreased after PTCA. In that study, primary PTCA reduced the
incidence of AF by decreasing the P-wave maximum and P-wave dispersion
[23].
We investigated the coronary angiographic findings of patients who
developed AF during acute MI, and the effects of primary PCI and thrombolytic therapy for restoration of sinus rhythm [24]. The study consisted of
52 patients with acute MI who underwent primary PCI or had thrombolytic
therapy and developed AF during the first 12 h of hospitalisation. On admission, and 1 month later, coronary angiography was performed in all
patients. In 26 of the 52 patients primary PCI was performed and in the
other 26 patients thrombolytic therapy was applied (streptokinase or r-TPA)
Post-PCI Atrial Fibrillation: Possible Clinical and Prognostic Significance
141
following angiography. Right coronary artery occlusions were the most frequent causes of AF (73%). In repeated coronary angiography, the coronary
artery affected by the infarct was still totally occluded in five patients in the
primary PCI group and eight patients in the thrombolytic therapy group (P
< 0.01). At least TIMI-3 flow was observed in rest of the patients. Twentyone patients in PCI group, and 16 patients in thrombolytic therapy group
were in sinus rhythm (SR) at the time of second coronary angiography,
although there was no difference between the LVEFs of the groups, as determined by echocardiography at the time of the first coronary angiography.
However, the LVEF of patients in the PCI group was higher at the time of second angiography. Our data showed that, because the patency of the infarctrelated artery is better with primary PCI, this mode of treatment is superior
to thrombolytic therapy in restoring sinus in acute MI patients.
Recommendations for Management
Post-PCI AF tends to revert spontaneously over a period of minutes to hours,
and thus usually does not usually require immediate treatment unless it produces ischaemia or haemodynamic instability. Specific recommendations for
therapy in those patients are preliminary and based on consensus since no
adequate trials have tested alternate strategies.
Electrical cardioversion is very rarely required. But, when haemodynamic
decompensation is prominent, electrical cardioversion is indicated, beginning with 50–100 joules with gradual increase if the initial shock is not successful. When necessary, a beta-blocker can be used for rate control because
of the combined effects of ischaemia and sympathetic tone which usually
present in patients with AF. If an intravenous beta-blocker is preferred but it
is uncertain whether such therapy will be tolerated by the patient, esmolol
may be cautiously administrated since its very short half-life permits a therapeutic trial to be performed at reduced risk. If esmolol is tolerated, then a
moderate or long-acting beta-blocker can be given. These drugs can be
administered in combination as indicated. Intravenous doses of verapamil or
diltiazem are attractive alternatives because of their ability to slow the ventricular rate promptly, but they should be used with caution if at all in
patients with pulmonary congestion. Due to the increased risk of embolism,
intravenous anticoagulation with heparin should be instituted in the absence
of any contraindications and if it is still present while the patient is in the
coronary care unit or in his or her room. Amidorone and dofetelide are also
effective for acute control of the ventricular response, but generally are not
recommended as the drug of choice for rate control. Digoxin is one of the
drugs of choice and can be used especially in patients with congestive heart
B. Gorenek
142
failure. Atrial flutter is generally well tolerated and also tends to revert spontaneously; when necessary, it can be treated with either burst atrial pacing or
electrical or pharmacologic cardioversion.
Conclusions
Atrial flutter may occur as a complication of PCI, but most of the time the
patients’ characteristics play important roles in the occurrence of this type
of arrhythmia. For instance, ongoing acute MI can be the real reason for AF.
Generally, AF tends to revert spontaneously, but when necessary treatment
must be given promptly. If the patient is compromised by ventricular rate or
by the loss of atrial contribution to cardiac output, synchronised DC cardioversion should be performed without delay. Intravenous beta-blockade
can be effective for acute rate control. Calcium-channel blockers can be
administered to promptly control ventricular rate. Digoxin, amiodarone and
dofetilide are the drugs of choice for treating patients with acute MI with
heart failure.
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