Prognosis of Patients with Asymptomatic Atrial Fibrillation

Dalmo Antonio Ribeiro Moreira M.D, PhD

Medical Section of Electrophysiology and Cardiac Arrhythmias
Dante Pazzanese Institute of Cardiology
São Paulo, Brazil

A major concern with the onset of atrial fibrillation that progresses without any symptoms is
the risk of cerebral embolism in patients at high risk. Acute stroke may be the first
manifestation of asymptomatic atrial fibrillation. A Framingham study showed that among
patients with stroke secondary to atrial fibrillation, the diagnosis of this arrhythmia was first
made in 24% of the affected patients. It is possible, in fact, that in many of those cases the
arrhythmia was not asymptomatic, but somehow this did not matter enough to induce the
patient to a doctor to treat. These facts indicate that on many occasions, the detection of
atrial fibrillation is made in unfavorable conditions, when brain damage has already been
installed.

Another relevant aspect related to the absence of symptoms is the development of atrial
remodeling. Because they are asymptomatic, many individuals with atrial fibrillation do not
receive treatment. Intermittent episodes of varying durations can cause changes in the
electrophysiological and histological matrix of the atria, thereby facilitating the creation of
appropriate conditions for maintaining the chronic form of this cardiac arrhythmia. These
changes are essential to allow its perpetuation. In other words, crises of atrial fibrillation,
when frequent, tend to be increasingly protracted, which in turn is important factor to make
it long-lasting.

The concept of remodeling is of the utmost importance, especially as regards the

prevention of chronic atrial fibrillation. The preventive treatment of recurrences can be of
great clinical impact, particularly in elderly patients, a condition in which the arrhythmia is
most common. If the presence of symptoms is the only way to prove the presence of
arrhythmia or even therapeutic efficacy, it is possible that many patients have not being
treated properly. For this reason, frequent clinical assessments are necessary to
demonstrate the benefits of drug therapy. Frequent episodes of asymptomatic atrial
fibrillation can cause changes in ventricular muscle metabolism and lead to ventricular
dysfunction, condition known as tachycardiomyopathy. Depending on how long the
tachycardia is present and also the duration of these episodes, early intervention reducing
the heart rate can make reversible the muscular commitment, including restoration of
normal ventricular function.

Asymptomatic atrial fibrillation and action of antiarrhythmic drugs

Clinical studies involving the use of drugs for the treatment of atrial fibrillation, show that the
medicines themselves, if not prevent the recurrences, reduce the symptoms. This is due to
the reduction of ventricular rate and also the regularization of the ventricular beats. Digoxin,
although not an effective antiarrhythmic therapy in the treatment of atrial fibrillation
(especially with regard to prevention of recurrence), reduces or abolishes the symptoms,
even when the arrhythmia persists, probably for control of heart rate. The same
fact can be observed in patients taking beta-blockers. Wolk et al. using the 24-hour Holter
in patients with paroxysmal atrial fibrillation treated with propranolol and propafenone,
observed that asymptomatic atrial fibrillation was still present in 22% of patients who
received propranolol and 27% receiving propafenone2. It is worth noting that propranolol,
except in cases of atrial fibrillation of sympathetic origin that occurs in individuals with
normal hearts, is not an effective antiarrhythmic agent in preventing recurrences, given its
eletropharmacologic properties, but can decrease symptoms due to the reduction in heart
rate. Propafenone is an effective antiarrhythmic drug, causes atrial stabilization and
reduces arrhythmia recurrences. However, in patients taking this drug, recurrences may be
asymptomatic due to reduction of ventricular rate, because of its discrete beta-blocker as
well as calcium antagonist properties on the atrioventricular junction. Amiodarone has
beneficial effects in reducing recurrences, but when these occur tend to manifest with
controlled ventricular rate. The reduction in heart rate allows better atrial emptying, with
reduction of pulmonary pressure and higher systolic volume ejected per beat.

Some studies comparing the efficacy of quinidine and sotalol in preventing recurrences of
atrial fibrillation demonstrated that both have similar results, however patients who have
recurrence with sotalol are less symptomatic than those using quinidine because of the
lower ventricular rate with sotalol3. Sotalol causes delayed conduction through the
atrioventricular node, reducing the ventricular rate and quinidine due to its
parasympatholytic properties facilitates nodal conduction, favoring the acceleration of heart
rate.

Another study, which evaluated the efficacy of azimilide in the treatment of patients with
atrial fibrillation, used the transtelephonic transmission of the electrocardiogram every two
weeks to assess the state of the heart rhythm. The basic objective of the study was to
assess the time to appear first recurrence after treatment started. The study design was
double-blind placebo-controlled trial. The presence of asymptomatic atrial fibrillation was
detected in 17% of patients in both groups at six months of follow-up, and there was
tendency for a lower incidence in the group receiving azimilide (13%) compared with
patients receiving placebo (18%)4. It was shown also that azimilide reduced by 40% the
incidence of asymptomatic atrial fibrillation.

Atrial fibrillation after ablation of pulmonary veins

Still no consensus regarding the best way to evaluate the success of ablative treatment of
atrial fibrillation and, in many studies, the absence of symptoms is one of the most
important factor taken into consideration. In addition to this clinical criterion, the 24-hour
Holter monitoring and other techniques as the transtelephonic transmission of the
electrocardiogram are often employed. Based on these aspects, one study showed that the
results of ablation of pulmonary veins varied with the technique of evaluation employed5. In
a period of six months, the authors demonstrated that the success of the procedure was
70% when the evaluation criterion was the presence of symptoms. However, when using
Holter electrocardiographic monitoring lasted for one week, such success fell to 50% and
45% when transtelephonic monitoring was utilized. The authors also observed that the
presence of asymptomatic atrial fibrillation rose from 11% before ablation to 53%
afterwards. In another study the occurrence of asymptomatic atrial fibrillation detected by
Holter monitoring of one week was 37% in a follow-up period of six months, and this fact
was observed in a population that was highly symptomatic before the ablation procedure6.
These observations indicate that asymptomatic atrial fibrillation is a factor of paramount
importance because of the risks that entails, mainly when anticoagulants are suspended,
exposing patients to the risk of systemic thromboembolism.

In conclusion, asymptomatic atrial fibrillation occurs in about 20% to 30% of patients and
this has great relevance when considering the risk of systemic thromboembolism. One can
not say yet that the treatment of this population reduces the risk of future complications or
can bring any impact on the quality of life. The risks associated with asymptomatic atrial
fibrillation should be similar to patients with a symptomatic form. Although asymptomatic
atrial fibrillation deserves consideration regarding anticoagulation and control of ventricular
rate, the effects of antiarrhythmic treatment on the clinical condition has not been
established. This can be considered when deciding to whether or not to revert arrhythmia to
sinus rhythm, and the approach be established on an individual basis. It has not yet been
established whether the 24-hour Holter or other cardiac monitoring should be used in
patients at high risk for atrial fibrillation, as occurs in mitral valve heart disease or in
hypertensive patients or in those with dilated cardiomyopathy, to detect asymptomatic
episodes of arrhythmia, but appears to be an interesting way to quickly diagnose a disorder
whose incidence rate is high, and has high morbidity when installing.

References

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The incidence of asymptomatic paroxysmal atrial fibrillation in Patients treated with
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