The natural history of atrial fibrillation in patients with permanent pacemakers: is atrial fibrillation a progressive disease?

R. A. Veasey, C. Sugihara, K. Sandhu, G. Dhillon, N. Freemantle, S. S. Furniss, A. N. Sulke

Atrial fibrillation (AF) is thought to be a progressive arrhythmia, starting with short paroxysmal episodes, until eventually, it becomes permanent. Evidence for this is limited to studies with short follow-up or with minimal cardiac rhythm monitoring. We utilised the continuous rhythm monitoring capabilities of implanted pacemakers to define better the natural history of AF. The study included 356 patients with pacemaker devices capable of continuous atrial rhythm monitoring (186 male, mean age (±SD) 79.5 ± 8.9 years). All clinical records, including history/physical examination reports, laboratory results, ECGs and Holter monitoring data were reviewed. Patients were included if AF episodes >30 s were documented. Permanent pacemaker diagnostic data were reviewed at least every 12 months. ACC/AHA/ESC guidelines were used to define AF episodes as paroxysmal, persistent or long-standing persistent/permanent. Study follow-up period (±SD) was 7.2 ± 3.1 years. Over the study period, 179 of 356 patients (50.3 %) had at least one episode of persistent AF. Of the 356 patients, 314 (88.2 %) had paroxysmal AF and 42 (11.8 %) had persistent AF at the time of diagnosis. The predominant AF subtype, at latest follow-up, was paroxysmal for 192 patients (53.9 %), persistent for 77 (21.6 %) and long-standing persistent/permanent for 87 (24.4 %). Univariable predictors of progression to persistent AF were (1) male gender, (2) increasing left atrial diameter (LAD), (3) reduced atrial pacing (AP) and (4) increasing ventricular pacing. Although many patients with AF will have persistent episodes, long-term continuous pacemaker follow-up demonstrates that the majority will have a paroxysmal, as opposed to persistent, form of the arrhythmia.