- Email: [email protected]
Value of routine echocardiography in new-onset atrial fibrillation
106 IJC 0555E
Value of routine echocardiography atria1 fibrillation
in new-onset
Markku Kupari, Hannu Leinonen, Pekka Koskinen Firs! Department
of Medicine, Helsinki University Central Hospitab Helsinki, Finland
(Received 10 November 1986; revision accepted 6
February 1987)
We studied 100 patients with new-onset atrial fibrillation to assess the role of echocardiography in their initial cardiac evaluation. Cliuical examination with routine laboratory tests and chest radiography was sufficient in estabfiihing or excluding an underlying condition in %%I of the cases. FAmcardiography uncovered a heart condition in three of 38 patients (8%) classified as having isolated atrial fibrillation, but this had no effect on short-term treatment. Routine echocardiography adds very liffle to a careful clinical examination in these patients.
Key words: Atrial fibrillation;
Echocardiography
Most patients presenting with new-onset atrial fibrillation have a clinically detectable heart disease or other underlying abnormality. In 5 to 30%, however, the background of the arrhythmia defies identification. Whether a heart condition is found or not makes prognostic difference because patients with isolated (lone) atrial fibrillation fare better, at least when the arrhythmia presents an episodic form [l]. Recent studies have raised doubts about whether mere clinical assessment is sufficient to classify atrial fibrillation and to guide its treatment [2,3]. We report herein on the usefulness of routinely adding cardiac ultrasound to the initial evaluation of new-onset atrial fibrillation. Patients and Methods
We prospectively studied 100 consecutive patients younger than 65 years presenting to our hospital for their first documented episode of atrial fibrillation. The initial evaluation comprised a history and physical examination (after restoration of the sinus rhythm if possible), a 1Zlead electrocardiogram, chest radiography, and routine laboratory tests including serum electrolytes and thyroxine. Lung function studies and exercise electrocardiography were done when indicated by the clinical findings. The patients were also questioned in detail regarding their alcohol consumption; these data are reported separately. After the initial evaluation and decision making, the patients underwent a combined cross-sectional and M-mode echocardiographic study (Irex System III) using parastemal long and short-axis
Correspondence to: Dr. Markku Kupari, Cardiovascular Hospital, SF-00290 Helsinki, Finland. International Journal of Cardiology, 16 (1987) 106-108 0 Elsevier Science Publishers B.V. (Biomedical Division)
Laboratory,
Helsinki University Central
107
approaches as well as apical 2- and 4-chamber views, M-mode tracings of the aorta and left atrium, the mitral valve and the left ventricle were recorded for later analysis.
Of the 100 patients, 82 were men and 18 were women. Their mean age was 48 years. The initial evaluation revealed a cardiovascular disease or other etiologically significant abnormality in 62 patients. The remaining 38 had, according to the clinical findings, isolated atria1 fibrillation. The most common diagnoses in the former group were coronary heart disease (20 patients, 5 of whom also had hypertension), essential hypertension (13 patients), cardiomyopathy (6 patients), chronic obstructive pulmonary disease (5 patients), old myopericarditis (4 patients), and valvar heart disease (3 patients). The other patients in the first group had miscellaneous cardiac or noncardiac diagnoses such as athlete’s heart, syndrome-X, toxic shock, thyrotoxicosis and so on. A cross-sectional cardiac ultrasound study could be performed in 95 patients and the M-mode recordings were of acceptable quality in most. The findings were compatible with the preceding clinical evaluation in 91 patients (96%). Three patients (8%) of the 38 classified as having isolated atrial fibrillation proved to have heart disease on echocardiography. Two of them had segmental left ventricular thinning and hypokinesia indicating an old myocardial infarction or other injury and one had a slightly enlarged and hypocontractile left ventricle consistent with dilated cardiomyopathy. The fourth patient in whom diagnosis was altered had hypertrophic cardiomyopathy instead of an old myocardial infarction. Although ultrasound helped us evaluate the significance of valve lesions and the severity of cardiomyopathies, it otherwise added relatively little to the clinical assessment. Four patients with essential hypertension had left ventricular hypertrophy on echocardiography versus two on clinical grounds. The short-term strategy of the treatment and prevention of the arrhythmia was not changed in any patient.
Discussion
Although isolated atrial fibrillation is a benign disorder in its episodic form [l], recent follow-up data of the Framingham study have suggested that the chronic form of this arrhythmia carries a surprisingly high risk of late cardiovascular events [3]. These data have been questioned, however, because they contrast with a wide clinical experience and also because only clinical methods were used to exclude heart disease [4]. The investigators themselves have indicated that additional tests such as treadmill exercise or echocardiography could be necessary to ascertain if subclinical cardiovascular disease can be found in these patients [5]. Our study shows that at least echocardiography fails to add much to a classification of atria1 fibrillation based on a careful clinical examination, chest radiography and routine laboratory tests. We admit, of course, that subclinical coronary artery disease or incipient cardiomyopathy cannot be excluded by ultrasound. If responsible for the persistence of “isolated” atria1 fibrillation, these diseases could partly account for its poor prognosis. The clinical message of the present study is that echocardiography is not necessary for the initial evaluation and treatment of new-onset atrial fibrillation. We consider it nowadays only to assess the severity of the underlying heart disease and to guide its specific therapy.
108
References 1 Gajewski J, Singer BB. Mortality in an insured population with atrial fibrillation. 1981;245:1540-1544. 2 Godtfredsen J, Egeblad H, Beming J. Echocardiography in lone atrial fibrillation. 1983;213:111-113. 3 Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic features fibrillation. The Framingham study. N EngJ J Med 1982;306:1018-1022. 4 Seizer A. Atrial fibrillation revisited. N Engl J Med 1982;306:1044-1045. 5 Brand FN, Abbott RD, Kannel WB, Wolf PA. Characteristics and prognosis of lone 30-year follow-up in the Framingham study. J Am Med Assoc 1985;254:3449-3453.
J Am Med Assoc Acta
Med Stand
of chronic
atrial
atria1 fibrillation.
Value of routine echocardiography atria1 fibrillation
in new-onset
Markku Kupari, Hannu Leinonen, Pekka Koskinen Firs! Department
of Medicine, Helsinki University Central Hospitab Helsinki, Finland
(Received 10 November 1986; revision accepted 6
February 1987)
We studied 100 patients with new-onset atrial fibrillation to assess the role of echocardiography in their initial cardiac evaluation. Cliuical examination with routine laboratory tests and chest radiography was sufficient in estabfiihing or excluding an underlying condition in %%I of the cases. FAmcardiography uncovered a heart condition in three of 38 patients (8%) classified as having isolated atrial fibrillation, but this had no effect on short-term treatment. Routine echocardiography adds very liffle to a careful clinical examination in these patients.
Key words: Atrial fibrillation;
Echocardiography
Most patients presenting with new-onset atrial fibrillation have a clinically detectable heart disease or other underlying abnormality. In 5 to 30%, however, the background of the arrhythmia defies identification. Whether a heart condition is found or not makes prognostic difference because patients with isolated (lone) atrial fibrillation fare better, at least when the arrhythmia presents an episodic form [l]. Recent studies have raised doubts about whether mere clinical assessment is sufficient to classify atrial fibrillation and to guide its treatment [2,3]. We report herein on the usefulness of routinely adding cardiac ultrasound to the initial evaluation of new-onset atrial fibrillation. Patients and Methods
We prospectively studied 100 consecutive patients younger than 65 years presenting to our hospital for their first documented episode of atrial fibrillation. The initial evaluation comprised a history and physical examination (after restoration of the sinus rhythm if possible), a 1Zlead electrocardiogram, chest radiography, and routine laboratory tests including serum electrolytes and thyroxine. Lung function studies and exercise electrocardiography were done when indicated by the clinical findings. The patients were also questioned in detail regarding their alcohol consumption; these data are reported separately. After the initial evaluation and decision making, the patients underwent a combined cross-sectional and M-mode echocardiographic study (Irex System III) using parastemal long and short-axis
Correspondence to: Dr. Markku Kupari, Cardiovascular Hospital, SF-00290 Helsinki, Finland. International Journal of Cardiology, 16 (1987) 106-108 0 Elsevier Science Publishers B.V. (Biomedical Division)
Laboratory,
Helsinki University Central
107
approaches as well as apical 2- and 4-chamber views, M-mode tracings of the aorta and left atrium, the mitral valve and the left ventricle were recorded for later analysis.
Of the 100 patients, 82 were men and 18 were women. Their mean age was 48 years. The initial evaluation revealed a cardiovascular disease or other etiologically significant abnormality in 62 patients. The remaining 38 had, according to the clinical findings, isolated atria1 fibrillation. The most common diagnoses in the former group were coronary heart disease (20 patients, 5 of whom also had hypertension), essential hypertension (13 patients), cardiomyopathy (6 patients), chronic obstructive pulmonary disease (5 patients), old myopericarditis (4 patients), and valvar heart disease (3 patients). The other patients in the first group had miscellaneous cardiac or noncardiac diagnoses such as athlete’s heart, syndrome-X, toxic shock, thyrotoxicosis and so on. A cross-sectional cardiac ultrasound study could be performed in 95 patients and the M-mode recordings were of acceptable quality in most. The findings were compatible with the preceding clinical evaluation in 91 patients (96%). Three patients (8%) of the 38 classified as having isolated atrial fibrillation proved to have heart disease on echocardiography. Two of them had segmental left ventricular thinning and hypokinesia indicating an old myocardial infarction or other injury and one had a slightly enlarged and hypocontractile left ventricle consistent with dilated cardiomyopathy. The fourth patient in whom diagnosis was altered had hypertrophic cardiomyopathy instead of an old myocardial infarction. Although ultrasound helped us evaluate the significance of valve lesions and the severity of cardiomyopathies, it otherwise added relatively little to the clinical assessment. Four patients with essential hypertension had left ventricular hypertrophy on echocardiography versus two on clinical grounds. The short-term strategy of the treatment and prevention of the arrhythmia was not changed in any patient.
Discussion
Although isolated atrial fibrillation is a benign disorder in its episodic form [l], recent follow-up data of the Framingham study have suggested that the chronic form of this arrhythmia carries a surprisingly high risk of late cardiovascular events [3]. These data have been questioned, however, because they contrast with a wide clinical experience and also because only clinical methods were used to exclude heart disease [4]. The investigators themselves have indicated that additional tests such as treadmill exercise or echocardiography could be necessary to ascertain if subclinical cardiovascular disease can be found in these patients [5]. Our study shows that at least echocardiography fails to add much to a classification of atria1 fibrillation based on a careful clinical examination, chest radiography and routine laboratory tests. We admit, of course, that subclinical coronary artery disease or incipient cardiomyopathy cannot be excluded by ultrasound. If responsible for the persistence of “isolated” atria1 fibrillation, these diseases could partly account for its poor prognosis. The clinical message of the present study is that echocardiography is not necessary for the initial evaluation and treatment of new-onset atrial fibrillation. We consider it nowadays only to assess the severity of the underlying heart disease and to guide its specific therapy.
108
References 1 Gajewski J, Singer BB. Mortality in an insured population with atrial fibrillation. 1981;245:1540-1544. 2 Godtfredsen J, Egeblad H, Beming J. Echocardiography in lone atrial fibrillation. 1983;213:111-113. 3 Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic features fibrillation. The Framingham study. N EngJ J Med 1982;306:1018-1022. 4 Seizer A. Atrial fibrillation revisited. N Engl J Med 1982;306:1044-1045. 5 Brand FN, Abbott RD, Kannel WB, Wolf PA. Characteristics and prognosis of lone 30-year follow-up in the Framingham study. J Am Med Assoc 1985;254:3449-3453.
J Am Med Assoc Acta
Med Stand
of chronic
atrial
atria1 fibrillation.