AF is the most common arrhythmia encountered in clinical practice and is associated with high morbidity and mortality (15). Some patients suffering from AF may have no or mild symptoms (subclinical episodes), which results in a significant underestimation of the incidence of AF. In an aging patient population, it is frequently necessary to implant a permanent pacemaker. Current dual-chamber permanent pacemakers (PPMs) that incorporate atrial leads are able to detect and store AHREs occurrence which have been shown to be a reliable surrogate of atrial tachyarrhythmia, especially for AF (16). It has been suggested that AHREs lasting 5 minutes or more identify patients who are 2 times as likely to die or have strokes. The increased risk associated with developing AHREs may be similar to that for AF, reinforcing the concept that AHREs and AF are likely to represent a clinical continuum in the spectrum of atrial tachyarrhythmia (17)
The Silent AF Detection With Stored EGMs (SAFE) registry was the first prospective registry to evaluate the incidence, duration, and predictors of newly diagnosed AF in a general population of patients with no history of AF after dual chamber pacemaker implantation, its main findings were: 10% of its patients experienced ≥1 AHREs, most of these episodes were asymptomatic (18).
Left ventricular (LV) diastolic dysfunction is potentially linked to AF (19). LV diastolic wall strain (DWS) can identify a subgroup of subtle LV diastolic dysfunction, as it measures LV compliance (20). Increased LV stiffness estimated by DWS has been reported to be a strong determinant of AF prevalence in structurally normal patients(21). So, the link between echocardiographic parameters, clinical data of patients on permanent pacemakers and occurrence of AF need more extensive studies.
Current study showed that; AF group was older in age, in agreement with Lopes RD et al (22), Pastori et al., (23) and Skanes et al. (24) who reported that older age, could predict the development of chronic AF in patients with a pacemaker.
We found that hypertension was the most common risk factor found among the studied groups, more in AF group but it did not reach statistical significance difference in concordance with Healey, Connolly (25), Pioger (26) and H. Kishima et al.( 27) but they found significance, this may be due differences between the study populations. Rovaris et al. (28) indicated that the incidence of AF increased with increasing CHA2DS2-VASc score, in agreement with these findings, we found that patients in AF group had higher CHA2DS2-VASc score but not reached significance.
Current study showed that anticoagulants, beta blockers and diuretics were used more in AF group compared to non AF group and this is in agreement with H. Kishima et al. (27) but different results were observed by Uetake et al. (21) who found no significant difference between studied groups in medications.
We detected that P wave dispersion was more in AF group, in agreement with Dilaveris and Gialafos (29).
We found that LAVI was higher among AF group, in agreement with Antoni et al. ( 30) and Lopes RD, et al(22), PWs was lesser among AF group compared to non-AF group , in agreement with Takeda et al. (13) and H. Kishima et al.(27).
We found that the AF group had higher E/é ratio, in agreement with H. Kishima et al (27).
We found that DWS was lesser in AF group ,in agreement with Takeda et al.(13 ), Uetake et al.(21) and H. Kishima et al(27). And we found that DWS at a cut off value <0.34 had a sensitivity of 80.5%, a specificity of 75.6%, NPV of 86.8%, PPV of 66% and an accuracy of 77.4% (AU=0.79, p<0.001) in prediction of AF among the studied cases, this is near to the results of Uetake et al.(21) who found that DWS<0.38 was the strongest indicator of AF.
The following mechanism correlated low DWS and AF; as Low DWS -which indicates increased LV stiffness and decreased compliance- augments LV filling pressure which in turn raises the LA wall stress, leading to LA remodeling, interstitial fibrosis, with alterations in atrial conduction, and dilatation, that may then lead to AF, so early stage of diastolic dysfunction could start with a decreased DWS even in patients with normal LV diastolic function Kang et al. (20).
We detected that the AF group had higher degree of LV stiffness index, in agreement with Ryu et al. (31) and we found that LV stiffness index at a cut off value >0.13 had a sensitivity of 61.1%, a specificity of 78.6%, NPV of 77.4%, PPV of 62.7% and an accuracy of 69.95% (AUC=0.78, p<0.001) in prediction of AF among the studied cases; this new echocardiographic index estimating LV stiffness was compared to the gold standard of cardiac catheterization using pressure-volume loop analysis and was found to be accurate as a surrogate measure of LV stiffness, as it correlates the diastolic function assed by tissue Doppler against the measured end-diastolic volume (14).
Also we found that EDV were lower among AF group, in agreement with Ngiam et al. (32) who stated that the higher the LV stiffness, the lower EDV and SVI.
We detected that the LV stiffness index had significant +ve correlation with older age, LAVI and P wave dispersion and had significant -ve correlation with EDV, SVI, EF and DWS in AF group. DWs had significant-ve correlation with LAVI, P wave dispersion and LV stiffness, also DWS had significant +ve correlation with age, EDV, SVI and EF among AF group.
On multivariable analysis we found that AF was only associated with reduced DWS and increased LV stiffness index, which are contributing factors in subtle diastolic dysfunction, patients with reduced DWS (<0.33) and high LV stiffness index (>0.13 ml-1 ) had a higher risk to develop AF.
Asymptomatic AF delays clinical diagnosis, which can result in ischemic stroke or other embolic complications, early detection (which is difficult by conventional methods) of asymptomatic AF and timely initiation of anticoagulants according to CHA2DS2-VASc score are essential for management of this group of patients.
On the other hand, our study went with other many studies (18,21,33) that evaluated development of AHREs and they showed that it is very common during follow-up of pacemaker-equipped patients.