Clinical Investigation
Left Ventricular Strain Mechanics: Clinical Application
Echocardiographic Predictors of Progression to Persistent or Permanent Atrial Fibrillation in Patients with Paroxysmal Atrial Fibrillation (E6P Study)

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Backgrounds

Paroxysmal atrial fibrillation (AF) frequently, but not always, progresses to persistent/permanent AF. The aim of this study was to evaluate the echocardiographic predictors of AF progression in patients with paroxysmal AF.

Methods

A multicenter, prospective, observational study was conducted that included 313 patients with paroxysmal AF who underwent two-dimensional speckle-tracking echocardiography. The diameter, volume, and mechanical function of the left atrium, including global strain (ε) and ε rate, were measured.

Results

Progression to persistent or permanent AF occurred in 52 patients (16.6%) during a median follow-up period of 26 months. Echocardiographic measure of left atrial (LA) diameter, volume, and function (E velocity, E/A and E/e′ ratio, LA expansion index, active emptying fraction, global longitudinal ε and ε rate) were associated with AF progression. LA ε ≤ 30.9% was the strongest predictor of AF progression, which was associated with a more than fourfold hazard increase for AF progression (hazard ratio, 4.224; P = .001). LA diameter > 39 mm and maximal LA volume index > 34.2 mL/m2 were associated with about a twofold hazard increase for AF progression (hazard ratios, 1.994 and 2.649; P = .016 and P = .001, respectively). When adjusted for a model combining maximal LA volume index, E velocity, LA expansion index, and active emptying fraction, LA ε ≤ 30.9% maintained a more than threefold hazard increase for AF progression (adjusted hazard ratio, 3.970; P = .003).

Conclusions

Echocardiographic measures of LA diameter, volume, and mechanical function, including LA ε, were associated with AF progression. LA ε was the strongest independent predictor of AF progression and is expected to serve as a valuable predictor of AF progression.

Section snippets

Methods

The Echocardiographic Predictors of Progression to Persistent or Permanent Atrial Fibrillation in Patients with Paroxysmal Atrial Fibrillation (E6P) study was designed as a multicenter, prospective, observational study and was conducted at four sites in Korea (Seoul National University Bundang Hospital, Seongnam; Hallym University Medical Center, Anyang; Korea University Medical Center, Seoul; and Chungnam University Hospital, Daejeon). The study protocol was approved by the institutional

Results

A total of 313 patients (194 men; mean age, 57 ± 14 years) were included. During follow-up (median, 26 months; interquartile range, 16–37 months), progression to either persistent or permanent AF (28 and 24, respectively) was observed in 52 patients (16.6%), resulting in an annualized AF progression rate of 5.7% (Figure 1). Clinical characteristics, including the CHADS2, CHA2DS2-VASc, and HATCH scores, were similar between patients with and without AF progression (Table 1). However, patients

Discussion

The present investigation is the first and largest multicenter observational study evaluating the echocardiographic predictors of AF progression in patients with paroxysmal AF. We found that 16.6% of patients with first paroxysmal AF progressed to persistent or permanent AF during a median follow-up period of 26 months, resulting in an annualized event rate of 5.7%, even though those with congestive heart failure symptoms, LV dysfunction, valvular heart disease, and secondary causes of AF were

Conclusions

In this study, many patients with paroxysmal AF progressed to persistent or permanent AF, despite the exclusion of those with underlying heart disease. Echocardiographic measures of LA diameter, volume, and mechanical function, including LA global ε, were found to be associated with AF progression. In particular, LA global ε was the strongest and independent predictor of AF progression and is expected to serve as a valuable predictor of AF progression.

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