Natriuretic Peptide Concentrations and Echocardiography Findings in Patients with Micro-atrial Fibrillation

Aim. Atrial fibrillation (AF) is a rhythm disorder characterized by very rapid and disorganized atrial-derived electrical activations with uncoordinated atrial contractions. Very short periods of AF-like activity (micro-AF) may be precursors of undetected, silent episodes of atrial fibrillation. Here, we examined the relationship between natriuretic peptide concentrations and echocardiography findings in patients with micro-AF.
Material and methods. The electrocardiograms (ECGs) of patients complaining of palpitations were recorded with a 24‑hour Holter monitor, and the patients were consecutively included in the study. Micro-AF was defined as sudden, irregular atrial tachycardia lasting less than 30 sec with episodes of ≥5 consecutive supraventricular depolarizations with the absolute absence of p-waves. After a G-power test, patients were consecutively included in the study: 45 patients in the micro-AF group and 45 patients in the control group. Laboratory parameters, ECG and echocardiographic findings of the two groups were compared.
Results. N-terminal pro B-type natriuretic peptide (Pro-BNP) and serum troponin T concentrations were higher in the micro-AF group, (375.5±63.6 pg / ml vs. 63.1±56.8 pg / ml, p<0.001; 13±11.4 ng / dl vs. 4.4±2.4 ng / dl, p<0.001 respectively.) Each 1 pg / ml increase in serum Pro-BNP increased the risk of micro-AF by 1.8 %. In the ROC analysis, the cut-off value of Pro-BNP for the diagnosis of micro-AF was 63.4 pg / ml, with a sensitivity of 91.1 % and a specificity of 73.3 %. Atrial electro-mechanical delay durations were significantly higher in the micro-AF group. To predict micro-AF, the inter-annulus plane electromechanical delay time (inter-annulus plane AEMD) had a cut-off value of 18.5 sec, with a sensitivity of 93.3 % and a specificity of 91.1 %. Left intra-annulus plane electro-mechanical delay time (intra-annulus AEMD LEFT) had a cut-off value of 11.5 sec with a 95.6 % sensitivity and 75.6 % specificity. In the ECG evaluation, maximum P wave duration (Pmax) (113±10.2 ms vs. 98±10.4 ms; p<0.001), minimum P wave duration (Pmin) (73.8±5.5 ms vs.70±6.3 ms; p<0.001) and P wave dispersion (PWD) (39.1±7.9 ms vs.28±7.6 ms; p<0.001) were longer in the micro-AF group.
Conclusions. Micro-AF in patients may be predicted by evaluating ECG, echocardiographic, and serum natriuretic peptide data.

1. Westerman S, Wenger N. Gender Differences in Atrial Fibrillation: A Review of Epidemiology, Management, and Outcomes. Current Cardiology Reviews. 2019;15(2):136–44. DOI: 10.2174/1573403X15666181205110624

2. Steinberg JS, O’Connell H, Li S, Ziegler PD. Thirty-Second Gold Standard Definition of Atrial Fibrillation and Its Relationship With Subsequent Arrhythmia Patterns: Analysis of a Large Prospective Device Database. Circulation: Arrhythmia and Electrophysiology. 2018;11(7):e006274. DOI: 10.1161/CIRCEP.118.006274

3. Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP et al. Heart Disease and Stroke Statistics – 2019 Update: A Report From the American Heart Association. Circulation. 2019;139(10):e56–528. DOI: 10.1161/CIR.0000000000000659

4. Aronow WS, Banach M. Atrial Fibrillation: The New Epidemic of the Ageing World. Journal of Atrial Fibrillation. 2009;1(6):154. DOI: 10.4022/jafib.154

5. Rodriguez F, Stefanick ML, Greenland P, Soliman EZ, Manson JE, Parikh N et al. Racial and ethnic differences in atrial fibrillation risk factors and predictors in women: Findings from the Women’s Health Initiative. American Heart Journal. 2016;176:70–7. DOI: 10.1016/j.ahj.2016.03.004

6. Seyed Ahmadi S, Svensson A-M, Pivodic A, Rosengren A, Lind M. Risk of atrial fibrillation in persons with type 2 diabetes and the excess risk in relation to glycaemic control and renal function: a Swedish cohort study. Cardiovascular Diabetology. 2020;19(1):9. DOI: 10.1186/s12933-019-0983-1

7. Svennberg E, Friberg L, Frykman V, Al-Khalili F, Engdahl J, Rosenqvist M. Clinical outcomes in systematic screening for atrial fibrillation (STROKESTOP): a multicentre, parallel group, unmasked, randomised controlled trial. The Lancet. 2021;398(10310):1498–506. DOI: 10.1016/S0140-6736(21)01637-8

8. Fredriksson T, Gudmundsdottir KK, Frykman V, Friberg L, Al-Khalili F, Engdahl J et al. Brief episodes of rapid irregular atrial activity (micro-AF) are a risk marker for atrial fibrillation: a prospective cohort study. BMC cardiovascular disorders. 2020;20(1):167. DOI: 10.1186/s12872-020-01453-w

9. Binici Z, Intzilakis T, Nielsen OW, Køber L, Sajadieh A. Excessive Supraventricular Ectopic Activity and Increased Risk of Atrial Fibrillation and Stroke. Circulation. 2010;121(17):1904–11. DOI: 10.1161/CIRCULATIONAHA.109.874982

10. Richards M, Di Somma S, Mueller C, Nowak R, Peacock WF, Ponikowski P et al. Atrial Fibrillation Impairs the Diagnostic Performance of Cardiac Natriuretic Peptides in Dyspneic Patients: results from the BACH Study (Biomarkers in ACute Heart Failure). JACC: Heart Failure. 2013;1(3):192–9. DOI: 10.1016/j.jchf.2013.02.004

11. Camm AJ, Kirchhof P, Lip GYH, Schotten U, Savelieva I, Ernst S et al. Guidelines for the management of atrial fibrillation. EP Europace. 2010;12(10):1360–420. DOI: 10.1093/europace/euq350

12. Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Archives of Internal Medicine. 1995;155(5):469–73. PMID: 7864703

13. Ellinor PT, Low AF, Patton KK, Shea MA, MacRae CA. Discordant atrial natriuretic peptide and brain natriuretic peptide levels in lone atrial fibrillation. Journal of the American College of Cardiology. 2005;45(1):82–6. DOI: 10.1016/j.jacc.2004.09.045

14. Abe H, Kosugi S, Ozaki T, Mishima T, Date M, Ueda Y et al. Prognostic Impact of Echocardiographic Congestion Grade in HFpEF With and Without Atrial Fibrillation. JACC: Asia. 2022;2(1):73–84. DOI: 10.1016/j.jacasi.2021.10.012

15. Cannone V, Cabassi A, Volpi R, Burnett JC. Atrial Natriuretic Peptide: A Molecular Target of Novel Therapeutic Approaches to Cardio-Metabolic Disease. International Journal of Molecular Sciences. 2019;20(13):3265. DOI: 10.3390/ijms20133265

16. Nakagawa Y, Nishikimi T, Kuwahara K. Atrial and brain natriuretic peptides: Hormones secreted from the heart. Peptides. 2019;111:18–25. DOI: 10.1016/j.peptides.2018.05.012

17. Chen Q, Mohanty S, Trivedi C, Gianni C, Della Rocca DG, Canpolat U et al. Association between prolonged P wave duration and left atrial scarring in patients with paroxysmal atrial fibrillation. Journal of Cardiovascular Electrophysiology. 2019;30(10):1811–8. DOI: 10.1111/jce.14070

18. Achmad C, Tiksnadi BB, Akbar MR, Karwiky G, Sihite TA, Pramudya A et al. Left Volume Atrial Index and P-wave Dispersion as Predictors of Postoperative Atrial Fibrillation After Coronary Artery Bypass Graft: A Retrospective Cohort Study. Current Problems in Cardiology. 2023;48(3):101031. DOI: 10.1016/j.cpcardiol.2021.101031

19. Aytemir K, Özer N, Atalar E, Sade E, Aksöyek S, Övünç K et al. P Wave Dispersion on 12-Lead Electrocardiography in Patients with Paroxysmal Atrial Fibrillation. Pacing and Clinical Electrophysiology. 2000;23(7):1109–12. DOI: 10.1111/j.1540-8159.2000.tb00910.x

20. Cha Y-M, Wokhlu A, Asirvatham SJ, Shen W-K, Friedman PA, Munger TM et al. Success of ablation for atrial fibrillation in isolated left ventricular diastolic dysfunction: a comparison to systolic dysfunction and normal ventricular function. Circulation. Arrhythmia and Electrophysiology. 2011;4(5):724–32. DOI: 10.1161/CIRCEP.110.960690

21. Çalık AN, Özcan KS, Çağdaş M, Güngör B, Karaca G, Gürkan U et al. Electromechanical delay detected by tissue Doppler echocardiography is associated with the frequency of attacks in patients with lone atrial fibrillation. Cardiology Journal. 2014;21(2):138–43. DOI: 10.5603/CJ.a2013.0106

22. Ari H, Ari S, Akkaya M, Aydin C, Emlek N, Sarigül OY et al. Predictive value of atrial electromechanical delay for atrial fibrillation recurrence. Cardiology Journal. 2013;20(6):639–47. DOI: 10.5603/CJ.2013.0164