Chronic atrial fibrillation and coronary artery disease

J. ELECTROCARDIOLOGY 11 (1), 1978, 67-69

Chronic Atrial Fibrillation and Coronary Artery Disease BY ALI H. HADDAD, M.D.,* VASSIL K. PRCHKOV, M.D., F.A.C.C.t AND DAVID C. DEAN, M.D., F.A.C.P., F.A.C.C.**

f r e q u e n c y of t h i s disease. L. R e s n i k o v ~ listed chronic i s c h e m i a as a cause in 16 out of 180 cases w i t h AF, w i t h o u t g i v i n g c r i t e r i a for the d i a g n o s i s of chronic ischemia. I t is r e m a r k a b l e t h a t no c e n t e r w h i c h h a s a g r e a t v o l u m e of c o r o n a r y a r t e r i o g r a p h i c procedures has provided any statistical data a b o u t t h e p r e v a l e n c e of chronic a t r i a l fibrillation in p a t i e n t s w i t h d o c u m e n t e d CAD. During. o u r w o r k a t the c a r d i a c c a t h e t e r i z a tion l a b o r a t o r y , it b e c a m e a p p a r e n t t h a t A F w a s r e m a r k a b l y a b s e n t in p a t i e n t s w i t h CAD. I n o r d e r to find t h e incidence of a t r i a l fibrillat i o n in p a t i e n t s w i t h c o r o n a r y a r t e r y disease, we u n d e r t o o k t h i s study.

SUMMARY Retrospective study of the incidence of atrial fibrillation (AF) in 841 c o n s e c u t i v e pat i e n t s w h o had selective c o r o n a r y a r t e r i o g raphy and left ventricular catheterization f r o m J a n u a r y 1, 1966 to D e c e m b e r 31, 1976 w a s u n d e r t a k e n . T h e r e w e r e 496 p a t i e n t s w i t h c o r o n a r y a r t e r y disease (CAD), 138 w i t h v a l v u l a r disease or c a r d i o m y o p a t h y , and 207 were normal. C h r o n i c atrial fibrillation was present in 45 p a t i e n t s , of w h o m 35 h a s v a l v u l a r disease or c a r d i o m y o p a t h y . O n e had c o r o n a r y a r t e r y disease and 9 w e r e n o r m a l . C h r o n i c atrial fibrillation in c o r o n a r y artery disease was rarely found. T h e m e d i c a l l i t e r a t u r e a b o u n d s w i t h articles dealing with the electrophysiology, m e c h a n i s m , h e m o d y n a m i c s a n d t r e a t m e n t of a t r i a l fibrillation. I t s e e m s t h a t t h e role of c o r o n a r y disease as a l e a d i n g etiological fact o r h a s b e e n u n i v e r s a l l y accepted. In the s t a n d a r d t e x t b o o k s , a t h e r o s c l e r o t i c h e a r t d i s e a s e is c o n s i d e r e d e i t h e r t h e m a i n 1 or one of t h e m a i n 2-4 d i s e a s e s a s s o c i a t e d w i t h AF. I t is of i n t e r e s t t h a t no r e f e r e n c e is g i v e n for t h e s e s t a t e m e n t s . A b i l d s k o v 5 s t a t e s t h a t t h e l a r g e s t a b s o l u t e n u m b e r of cases is associated w i t h a t h e r o s c l e r o s i s b e c a u s e of t h e

MATERIALS AND METHODS All patients who had selective coronary arteriography with left heart catheterization from J a n u a r y 1, 1966 to December 31, 1976 at the Cardio Pulmonary Laboratory of the Veterans Administration Hospital in Buffalo entered the study group. The majority of patients who had valvular disease or congestive heart failure in addition to that had right heart catheterization. Patients who had two or more studies were entered once. The Judkins technique for coronary arteriography was used, w i t h m u l t i p l e views t a k e n d u r i n g the cineangiography. The indications for cardiac catheterization and coronary arteriography were chest pain, symptoms of valvular disease, and occasionally congestive heart failure. No one was catheterized for cardiac arrhythmia as the only indication. The data retrieval was done by reviewing the cardiac catheterization reports, EKG reports, and, in the majority of cases, reviewing the cineangiograms. On the basis of the cardiac catheterization and coronary arteriographic findings, all patients were classified into three groups: 1. Coronary artery disease; 2. Valvular disease or cardiomyopathy; 3. Normal. Coronary artery disease was defined as the presence of at least one vessel stenosis with more than 50% diameter reduction. One vessel disease was considered when such stenosis was present in one of the following arteries: left anterior descending, left circumflex, the larger obtuse marginal branch or the right coronary artery. Valvular disease or cardiomyopathy were diagnosed on the basis of abnormal hemodynamics and a n g i o g r a p h i c findings. P r e r e q u i s i t e for cardiomyopathy was normal coronary arteriography. Patients who had CAD in addition to the valvular a b n o r m a l i t y remained in the v a l v u l a r disease group. Patients without any of the above abnormalities were entered into the normal group. On the basis

From the Department of Medicine, State University of New York at Buffalo, and the Veterans Administration Hospital, Buffalo, New York. *Clinical Assistant Instructor in Medicine, State University of New York at Buffalo, and Fellow in Cardiology, Veterans Administration Hospital, Buffalo. ~Clinical Assistant Professor of Medicine, State University of New York at Buffalo, and Staff Cardiologist, Veterans Administration Hospital, Buffalo. **Clinical Associate Professor of Medicine, State University of New York at Buffalo, and Chief, Cardio P u l m o n a r y L a b o r a t o r y , V e t e r a n s Administration Hospital, Buffalo. The costs of publication of this article were defrayed in part by the payment of page charges. This article m u s t therefore be hereby m a r k e d "advertisement" in accordance with 18 U.S.C. w solely to indicate this fact. Reprint requests to: Vassil K. Prchkov, M.D., Brooklyn Hospital, Cardiology, 121 DeKalb Ave., Brooklyn, NY 11201. 67

HADDAD ET AL

68

TABLE I Results of Cardiac Catheterization and Selective Coronary Arteriography During Ten Year Survey

Normal Coronary Artery Disease Valvular disease or Cardiomyopathy

SINUS RHYTHM Mean Age No. % In Years 198 95.7 49 (25-64) 495 99.8 51.7 (25-78) 103 74.6 52.7 (29-81) 796 94.6

of EKG findings, all patients were divided into those with sinus rhythm and those with atrial fibrillation. In the atrial fibrillation group, all patients had chronic atrial fibrillation. Those who developed AF during the procedure were not included in the AF group.

RESULTS Eight h u n d r ed and forty-one patients were reviewed; the results of this review are given in Table 1. As can be seen, the coronary a r t e r y disease group is the largest, having 496 patients, or 59% of all patients. In this group, one vessel disease was represented by 141 patients, two vessel disease by 143, and three vessel disease by 177; 35 patients had main left coronary stenosis, four of whom had one vessel, 12, two vessel, and 19, th r e e vessel disease. The absence of AF in this group is remarkable. Only one patient with AF had CAD. The valvular disease and cardiomyopathy group consists of 138 patients, or 16% of all patients, yet they are represented by 35 of the

ATRIAL FIBRILLATION Mean Age No. % In Years 9 4.3 50.7 (40-62) 1 0.2 62 (62) 35 25.4 52 (39-65) 45 5.4

Total 207 496 138 841

45 patients with atrial fibrillation; t h a t is, 78% of patients with AF had valvular disease or cardiomyopathy in our study. Of these 35 patients, three had cardiomyopathy. The normal group consists of 207 patients, or 25% of all patients. Nine out of 45, or 20% of patients having AF were in this group. In Table 2 are listed patients with atrial fibrillation who did not have valvular disease or cardiomyopathy. There is a striking incidence of chronic alcoholism in this group. Even in the p a t i e n t with CAD, there was a history of chronic alcoholism, and although his disease involved three major vessels, the e n l a r g e m e n t and diffuse i m pai rm ent o f the left ventricle was quite compatible with alcoholic c a r d i o m y o p a t h y ; n e v e r t h e l e s s , because of the presence of coronary stenosis, we listed him in t h e c o r o n a r y a/,tery disease group.

DISCUSSION Chronic a t r i a l f i b r i l l a t i o n is one of t he c o m m o n e s t a r r h y t h m i a s e n c o u n t e r e d in

TABLE II Chronic Atrial Fibrillation Without any Evidence of Valvular Disease

62 48 47

Indication for Coronary Arteriography Chest pain R/0 CAD,Chest pain, CHF R/0 CAD Chest pain R/O CAD W/U palpitations R/0 CAD, R/0 VHD Dyspnea Chest pain, Dyspnea CHF, R/O CAD

47 51

Chest pain Chest pain

Age in Years 62 60 43 59

40

Associated Conditions Alcoholism Heavy Drinking Alcoholism, Hypertension Hypertension. At least 1 beer daily Heavy drinking

Duration of Atrial Fibrillation One year at least One year at least 3 weeks at least 5 months at least

Coronary Ejection Arteries Fraction 3 vessel disease 38 Normal 84 Normal 62 Normal 60

12 years

Normal

68

Normal Normal Normal

65 76 58

Normal Normal

65 68

Alcoholism 5 months at least Possible Alcoholism 9 years Hypertension 3 years Drinks on weekends Alcoholism 2 years None 3 weeks at least Mean Age 50.7 (40-62 years)

J. ELECTROCARDIOLOGY, VOL. 11, NO. 1, 1978

ATRIAL FIBRILLATION AND CAD

practice, and one which automatically draws a t t e n t i o n to o r g a n i c h e a r t d i s e a s e or hyperthyroidism. It has been standard teaching t h a t coronary a r t e r y disease is one of the main causes of this a r r h y t h m i a . This has been accepted to such a degree t h a t no references are given for such statements. It is surprising t h a t no statistical data about the incidence of this a r r h y t h m i a are given by those cardiac c a t h e t e r i z a t i o n laboratories which deal mostly with coronary a r t e r y disease and w her e the diagnosis of CAD can be made most objectively. The r a r i t y of this a r r h y t h m i a in our study group with coronary a r t e r y disease is striking. We are aware of limitations of our study. It is biased toward a special group of patients in whom CAD was the main consideration, and, as such, is not representative of a group of patients in whom chronic atrial fibrillation is most prevalent, as in chronic congestive h e a r t failure. However, if CAD is a significant etiological factor in chronic AF, we would expect to see this a r r h y t h m i a more often in our CAD group. Perhaps the idea t hat coronary a r t e r y disease is a common cause of atrial fibrillation originated from the fact t hat m a n y congestive cardiomyopathies are associated with AF. It is k n o w n f a c t t h a t m a n y of t h e s e c a r diomyopathies h a ve E K G findings compatible with an old myocardial infarction, so some of t h e m w e r e c o n s i d e r e d as i s c h e m i c c a r diomyopathies. Observations in the coronary care units t h a t acute myocardial infarctions complicated by congestive h e a r t failure are frequently associated with AF s t r e n g t h e n the notion of CAD causing atrial fibrillation. It is

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worth mentioning, however, t h a t atrial fibrillation in acute myocardial infarction is most commonly a t ransi ent a r r h y t h m i a . It m ay be argued t h a t only in the advanced stage of coronary a r t e r y disease, when t here is serious i m p a i r m e n t of the left ventricular function with chamber dilatation, is atrial fibrillation present. In our study in patients with severe left ventricular failure with multiple n a r r o w i n g s and low ejection fraction (15-25%), no atrial fibrillation was present. Another point is worth mentioning. In the normal group with atrial fibrillation, a history of heavy alcoholism was present in five of nine patients, although it was not reflected in the left vent ri cul ar function as evaluated by the ejection fraction. 1. 2.

3. 4.

5. 6.

REFERENCES DAMATO,A N: Cardiac Arrhythmia, Textbook of Medicine, 14th ed. W B Saunders Co, Philadelphia, 1975, p 1025 BRAUNWALD,E AND BURTON, S E: Cardiac Arrhythmias, Harrison's Principles of Internal Medicine, 7th ed. McGraw-Hill Book Co, New York, 1974, p 1136 SILBER, E N AND KATZ, L N: Heart Disease. MacMillan Publishing Co, Inc, New York, 1975, p 482 MARRIOTT,H J L ANDMYERBURG,R J; Recognition and Treatment of Cardiac Arrhythmia and Conduction Disturbances, The Heart, Arteries and Veins, 3rd ed. McGraw-Hill Book Co, New York, 1974, p 529 ABILDSKOV, J A, MILLAR, K AND BURGESS, M J O: Atrial fibrillation. Am J Cardiol 28"263, 1971 RESNIKOV, L AND McDONALD, L: Appraisal of electroconversion in treatment of cardiac dysrhythmias. Br Heart J 30"786, 1968