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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 150-154

Clinical evaluation and management strategy of hospitalized patients with atrial fibrillation at tertiary care centre -IGIMS, Patna, Bihar


1 Associate Professor, Dept. of Cardiology, IGIMS, Patna, Bihar, India
2 Senior Resident, Dept. of Cardiology, IGIMS, Patna, Bihar, India
3 Professor & Head, Dept. of Cardiology, IGIMS, Patna, Bihar, India

Date of Submission17-May-2019
Date of Acceptance20-Jul-2019
Date of Web Publication12-Aug-2019

Correspondence Address:
Ravi Vishnu Prasad
Associate Professor, Dept. of Cardiology, IGIMS, Patna
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia diagnosed in the general population. The study was conducted at tertiary care centre-IGIMS, Patna to study clinical profile of hospitalized AF patients and various management strategies employed in these patients. A total of 132 patients with AF were enrolled in the study. The most patients fall below 50- year of age group. Elderly (>60 years) age group comprise 24% of AF patients. There was marginal female predominance - female (53.8%) and male patients (46.2%) with ratio of 1.2: 1. Rheumatic heart disease (RHD) was the most common etiology of AF (59.8%), followed by coronary artery disease(CAD) (11.3%), hypertension (7.5%) and cardiomyopathy (6%). Rheumatic etiology commonly presented below 50 years but CAD and hypertension presented after 50 years. Palpitation was the most common presentation (88%), followed by dyspnea (56%), chest pain (40%), pedal edema (32%) and hypotension (28%). The rate control strategy was adapted in 76 % cases. Stroke prevention strategy was oral anticoagulation (warfarin or acitrom) in 63.6% cases and antiplatelets in 30.3% patients. The beta blockers (59%) were the most common pharmacological treatment followed by amiodarone (39.9%), calcium channel blockers and digoxin (31.8% each). Novel oral anticoagulants (NOAC) were used in 10 patients of non- valvular origin. Heart failure (49.2%) was most common complication noted in AF patients followed by angina (25%), hemoptysis (18.2%) and stroke (7.5%). Among valvular involvement, most patients have mitral valve involvement. Out of 79 cases, 88% have mitral valve involvement ranging from mild to severe variety in isolation and combinations with other valves. Commonest cause was mixed lesion (mitral stenosis with mitral regurgitation). AF with valvular heart disease has shown maximum LA enlargement, normal LV Ejection fraction and predominance LA clot as compared to non valvular AF.

Keywords: Atrial fibrillation, clinical profile, tertiary center


How to cite this article:
Prasad RV, Talreja S, Kumar N, Singh B P. Clinical evaluation and management strategy of hospitalized patients with atrial fibrillation at tertiary care centre -IGIMS, Patna, Bihar. J Indira Gandhi Inst Med Sci 2019;5:150-4

How to cite this URL:
Prasad RV, Talreja S, Kumar N, Singh B P. Clinical evaluation and management strategy of hospitalized patients with atrial fibrillation at tertiary care centre -IGIMS, Patna, Bihar. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2022 Oct 2];5:150-4. Available from: http://www.jigims.co.in/text.asp?2019/5/2/150/301101




  Introduction : Top


Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia diagnosed in the general population[1]. The prevalence of AF increases substantially with age [2]. The lifetime risk of developing AF is approximately 25% [3]. The adjusted incidence and prevalence of AF is roughly double for each advancing decade of life[4]. The incidence of AF is 0.1% per year in the population below forty years and this increases to 2% in those over 80 years [5]. The cardiovascular risk factors such as hypertension, diabetes, congestive heart failure, coronary artery disease and stroke are important predictors of AF [6]. Valvular heart disease is also the most important aetiology of AF in our country[7]. It is characterized by disorganized atrial activation which leads to uncoordinated contraction. ECG demonstrate fibrillatory waves with changing morphology and ventricular rhythm that is irregularly irregular with no obvious P wave \ This is clinically identified as irregularly irregular pulse with rates varying from normal to 200 and pulse deficit >10 beats.

Atrial fibrillation has been classified into first detected episode, two or more episode(recurrent), paroxysmal (terminates within 7 days), persistent (persist for more than 7 days) and permanent (sustained for more than 1 year or has failed cardio version)[8]. AF poses a high risk for complications such as thromboembolism and heart failure (HF). Uncontrolled AF often leads to frequent hospitalizations and reduced quality of life[9]. Cerebrovascular complications are further important cause of functional limitation of such patients. In non- valvular AF, thromboembolic episodes are 2-7 times more than those in sinus rhythm whereas in valvular AF, it is 17 times more than controls[10]. To reduce the clinical and economic burden occurring due to these complications, optimal control of AF is essential.


  Aim and Objectives Top


  1. To study clinical profile of AF patients.
  2. To study various management strategies employed in AF patients.



  Material and Methods : Top


This was a single centre prospective observational clinical study done in 132 patients selected from indoor wards of Cardiology department, IGIMS, Patna between duration of April 2018 to September 2018 (6 months) after approval from institutional ethics committee (Letter No. 272/IEC/2018/IGIMS dated 09/04/2018). The diagnosis of AF was confirmed with 12 leads ECG. Any patient(s) developing AF during hospitalization were also included in this study. Any differences in analysing/ diagnosing AF was discussed with another consultant and solved by consensus.

Inclusion Criteria

  1. All male and female patients with AF admitted and/or developed during hospitalization in indoor ward of cardiology department.
  2. Patients willing to give informed consent for study.


Exclusion Criteria

  1. Pregnancy
  2. Unwilling or unable to comply with protocol
  3. Patients within three months after surgery
  4. Patients participating concomitantly in a clinical trial in the field of AF or antithrombotic treatment within a month.


Each patient was evaluated in detail as per prescribed Performa:

  • The demographic features of all patients, their presenting symptoms and type of AF were recorded
  • History of rheumatic fever, rheumatic heart disease, hypertension, renal diseases, drugs, smoking, alcohol, liver disorder, sleep disorder, blood loss, surgery, lung disease etc. were elicited in detail.
  • Complete physical examination, cardiovascular examination and systemic examinations were performed. Emphasis were made for any evidence of cardiac failure and cerebrovascular complications.
  • Routine hemogram, blood sugar, urine analysis, renal, liver and thyroid function tests, prothrombin time with INR, 12 lead ECG and 2D Echo were done in all cases.
  • Drugs like rate controlling drugs like digoxin, verapamill, diltiazem, metoprolol; antiarrthymics drugs like amiodarone; anticoagulation; DC shock and their effects on treatment were evaluated.
  • Follow up of patients was planned to do to know whether ventricular rate is controlled or not, whether patients were relieved of symptoms or not and whether patient developed any complications like HF or cerebrovascular complications.


Statistical analysis was done with SPSS. Categorical data were analysed by the chi square test. Descriptive statistics were computed and analysed as mean and standard deviation for continuous variables. Less than 0.05 was taken as level of significance at 95% confidence interval. results were presented using percentages


  Results Top


A total of 132 patients with AF were enrolled in the study who were admitted in indoor ward of cardiology department. These patients were followed for at least one month. Age and gender distribution are shown in [Table 1]. The patients were aged from 15 to 92 years. The most patients fall below 50-year of age group. The maximum patients were from 30-39 age group followed by 40-49 age group. Elderly (>60 years) age group comprise 24% of AF patients. There was marginal female predominance - female (53.8%) and male patients (46.2%) with ratio of 1.2:1.
Table 1: Age and Gender distribution in AF

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The etiology of these AF patients is detailed in [Table 2]. Rheumatic heart disease (RHD) was the most common etiology of AF (59.8%), followed by coronary artery disease(CAD) (11.3%), hypertension (7.5%) and cardiomyopathy (6%). Rheumatic etiology commonly presented below 50 years but CAD and hypertension presented after 50 years.
Table 2: Etiology of AF

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Valvular AF was seen in 60% cases while non-valvular cases were seen in 40% cases [Table 3].
Table 3: Classification of AF

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The presentations in AF are well described in [Table 4]. Palpitation was the most common presentation (88%), followed by dyspnea (56%), chest pain (40%), pedal edema (32%) and hypotension (28%).Nausea/vomiting was seen in 15% cases and probably due to digoxin effect/toxicity. Stroke comprised of 7.5% cases and mainly was ischemic type.
Table 4: Presentations in AF

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The rate control strategy was adapted in 76 % cases [Table 5]. Rate control was defined as resting heart rate less than 90 bpm.
Table 5: Response to Therapy

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Table 6: Medications used in AF

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Stroke prevention strategy was oral anticoagulation (warfarin or acitrom) in 63.6% cases and antiplatelets in 30.3% patients. The beta blockers (59%) were the most common pharmacological treatment followed by amiodarone (39.9%), calcium channel blockers and digoxin (31.8% each). 35% patients received both beta blockers and calcium channel blockers. Cardioversion was given in 16% cases. Novel oral anticoagulants (NOAC) were used in 10 patients of non valvular origin. Of RHD patients,85% received anticoagulation and in non-RHD cases, 53% were prescribed anticoagulation.

Heart failure (49.2%) was most common complication noted in AF patients followed by angina (25%), hemoptysis (18.2%) and stroke (7.5%) as shown in [Table 7]. Death was noted in 5 patients. 7.5% case were asymptomatic.
Table 7: Complications in AF

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Table 8: Valvular involvement in RHD
cases (n= 79(59.8%); male= 45, female = 34)


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Table 9: CHADS2 Score in Non-Valvular AF (n= 53)

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Among valvular involvement, most patients have mitral valve involvement. Out of 79 cases, 88% have mitral valve involvement ranging from mild to severe variety in isolation and combinations with other valves. Commonest cause was mixed lesion (mitral stenosis with mitral regurgitation). In 16% cases, aortic valve was involved with mitral valve in various combinations.

Correlation of various LA Size, LVEF >50% & reduced ejection fractions and LA clot with various clinical conditions are tabulated in [Table 10].
Table 10: Echocardiographic observations in various clinical conditions

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  Discussion : Top


This was the one of the largest clinical evaluation and management strategy of hospitalized patients with AF in Bihar which is done at IGIMS which is super-speciality tertiary centre. Till date, Vidhya, N et.al evaluated etiological profile of AF from rural area of Bihar[11]. The IHRS-AF registry is the largest evaluation of the clinical presentation, management, and outcomes in patients with AF in India [12].

In the present study, AF was seen more common below 50 years of age group and commonest cause of AF is RHD, found in 59.8% of patients. This is in sharp contrast to the findings in the studies from West, where RHD is a very uncommon cause of AF. The reason is that RHD is still a common cause of heart disease in India and developing countries. The IHRS-AF registry reveals that the Indian AF patients are more than a decade younger than the AF patients in the western world [12]. A study by Bhardwaj showed that the most common cause of AF was RHD (61.34%) [13]. The sex ratio of female to male is 1.2:1 in our study. This is consistent with findings of Nadeem et al and Bharadwaj who also found that AF was more common in women[13],[14]

In the present study, palpitations (88%), dyspnea (56%) and chest pain (40 %) were the most common presentations. In Lok NS et.al study, dyspnea and palpitation were also the most common symptoms [15]. We also noticed that the symptoms are of longer duration in rheumatic etiology and are of shorter duration in other causes.

In our study, congestive heart failure was the most common associated condition, nearly in 49.2% cases. CHF was a powerful independent predictor of the occurrence of AF as well as complication in Dharma rao V et.al study [16]. In our study stroke is seen in 7.5% of cases only. In a study from Trieste, Italy, 34% of patients with chronic AF had a significantly higher rate of thromboembolism, suggesting that in addition to age, chronicity may be a risk factor for stroke in the lone AF population[17] .

The predominant strategy of rate control for AF is understandable with a higher prevalence of RHD and more persistent/ permanent AF. Resting heart rate of <90 bpm was achievable in only 76% cases of the patients. Nonavailability of class IC antiarrhythmic drugs like propafenone and flecainide during the study period led to predominant use of amiodarone as the rhythm-control drug. The overall use of anticoagulants was 63.6%, reasonable when compared to other medicines. In RHD patients, the utilization of anticoagulants was better at 85%.

The commonest lesion in RHD associated with AF was mixed mitral valve lesion. This is because the largest LA size is seen in mixed mitral valve lesions. Several studies have shown a strong correlation between LA size and new onset AF. In the Framingham Heart Study, every 5 mm increase in LA diameter was associated with around 39% increase in incidence of AF [18]. Cardiovascular health study showed that LA size more than 50 mm was associated with 4- fold increase in incidence of AF [19]. CHADS2 Score was validated in non valvular AF. Score 0 was seen in 13.2% cases while 32% cases comprises of score 3. AF with valvular heart disease has shown maximum LA enlargement, normal LV Ejection fraction and predominance LA clot as compared to non valvular AF.


  Limitations of Study : Top


It was relatively a small study. Being a hospital based study, it doesn’t truly reflect the population prevalence. More duration is required for true prevalence of AF.


  Conclusion : Top


In India and also in Bihar, AF patients are younger, and RHD is widely prevalent necessitating specific treatment with respect to anticoagulation, rate control, and valvular interventions.



 
  References Top

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E N Prystowsky ,BJ Padanilam ,AL Waldo. Hurst’s: The Heart. Eds. Fuster V, Walsh RA, Harrington RA et al. McGraw Hill, 13th Edition 2011: 963-81.  Back to cited text no. 1
    
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W M Feinberg , JL Blackshear, A Laupacis et al. Prevalence, age distribution, and gender of patients with atrial fibrillation: analysis and implications. Arch Intern Med. 1995; 155:469- 473.  Back to cited text no. 2
    
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DM Lloyd-Jones ,TJ Wang, EP Leip , et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. 2004;110: 1042-6.  Back to cited text no. 3
    
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AS Go, EM Hylek, KA Phillips et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001; 285:2370-5.  Back to cited text no. 4
    
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Wolf PA , Abbott RD, Kannel WB, Atrial fibrillation: A major contributor to stroke in the elderly. The Framingham study. Arch Intern Med 1987; 147:1561-4. ?  Back to cited text no. 5
    
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GY Lip, DG Beevers. ABCs of atrial fibrillation: history, ?epidemiology and importance of atrial fibrillation. Br Med J. 1995;311: 1361-1363. ?  Back to cited text no. 6
    
7.
MD Seckeler, TR Hoke. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease. Clin Epidemiol.2011;3:67  Back to cited text no. 7
    
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Fuster, V Ryden LE. Asinger RW et al. ACC/ AHA /ESC guidelines for the management of patient with atrial fibrillation (committee to develop guidelines for the management of patients with AF ) circulation 2001; 104: 2118-2150.  Back to cited text no. 8
    
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CD Furberg , BM Psaty , TA Manolio,et al. Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health Study). Am J Cardiol. 1994; 74:236-241.  Back to cited text no. 9
    
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Wolf PA, Abort RD, Kannel WB, Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke 1991; 22:983-8. ?  Back to cited text no. 10
    
11.
Nand, Vidhya et.al. Etiological profile and clinical presentation of patients with atrial fibrillation from a rural area of Bihar. National Journal of Medical Research. Volume 2 Issue 2 Apr - June 2012.  Back to cited text no. 11
    
12.
Vora A et.al. Clinical presentation, management, and outcomes in the Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF) registry. Indian Heart J. 2017 Jan - Feb;69(1):43-47.  Back to cited text no. 12
    
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Rajeev Bhardwaj. Atrial fibrillation in a tertiary care institute e A prospective study. Indian heart journal 64 (2012) 476e478  Back to cited text no. 13
    
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Nadeem MA, Wassem T, Mahmood K, Imran SF, Khan AH. Differences in clinical profile and echocardiographic finding in patient with valvular and nonvalvular origin of atrial fibrillation. Ann KEMC. 1999; 5:44-47.  Back to cited text no. 14
    
15.
Lok NS et.al. Presentation and Management of patients admitted with atrial fibrillation. International Jr. of Cardiology.1995; 48 (3): 271 - 278.  Back to cited text no. 15
    
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Dharma Rao V et.al. To study the prevalence and clinical profile of chronic atrial fibrillation in hospitalized patients. NUJHS Vol. 4, No.2, June 2014, ISSN 2249-7110.  Back to cited text no. 16
    
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Scardi S, Mazzone C, Pandullo C, Goldstein D, Polett A, Humar F. Lone atrial fibrillation: prognostic differences between paroxysmal and chronic forms after 10 years of follow-up. Am Heart J 1999; 137:686-691.  Back to cited text no. 17
    
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Vaziri SM, Larson MG, Benjamin EJ, Levy D. Echocardiographic predictors of non-rheumatic atrial fibrillation. The Framingham Heart Study. Circulation. 1994;89(2):724e730.  Back to cited text no. 18
    
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Psaty BM, Manolio TA, Kuller LH, et al. Incidence of and risk factors for atrial fibrillation in older adults. Circulation. 1997;96(7):2455e2461.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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