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Clinical Articles, Lead Article

“Isolated” AF is not benign

Long-term atrial fibrillation (AF)-related stroke and mortality risks are similar between individuals with and without secondary AF precipitants, according to a study published recently in Circulation.1

Guidelines have proposed that AF can occur as an isolated event, particularly when precipitated by a secondary, or reversible, condition. However, knowledge of long-term AF outcomes after diagnosis during a secondary precipitant is limited, say the authors.

In 1,409 Framingham Heart Study participants with new-onset AF, they examined associations between first-detected AF episodes occurring with and without a secondary precipitant and both long-term AF recurrence and morbidity. The authors selected secondary precipitants based on guidelines (surgery, infection, acute myocardial infarction, thyrotoxicosis, acute alcohol consumption, acute pericardial disease, pulmonary embolism, or other acute pulmonary disease).

Among 439 patients (31%) with AF diagnosed during a secondary precipitant, cardiothoracic surgery (n=131 [30%]), infection (n=102 [23%]), noncardiothoracic surgery (n=87 [20%]), and acute myocardial infarction (n=78 [18%]) were most common. AF recurred in 544 of 846 eligible individuals without permanent AF (5-, 10-, and 15-year recurrences of 42%, 56%, and 62% with versus 59%, 69%, and 71% without secondary precipitants; multivariable-adjusted hazard ratio, 0.65 [95% confidence interval, 0.54–0.78]).

Dr Steve Lubbitz (Massachusetts General Hospital, Boston, USA)

Dr Steve Lubbitz (Massachusetts General Hospital, Boston, USA)

Stroke risk (n=209/1262 at risk; hazard ratio, 1.13 [95% confidence interval, 0.82–1.57]) and mortality (n=1098/1409 at risk; hazard ratio, 1.00 [95% confidence interval, 0.87–1.15]) were similar between those with and without secondary precipitants, although heart failure risk was reduced (n=294/1107 at risk; hazard ratio, 0.74 [95% confidence interval, 0.56–0.97]).

Future studies may determine whether increased arrhythmia surveillance or adherence to general AF management principles in patients with reversible AF precipitants will reduce morbidity, the authors conclude.

Speaking to BJC Arrhythmia Watch, co-author Dr Steve Lubbitz (Massachusetts General Hospital, Boston, USA) said: “In most individuals, clinically detected AF recurs. This was also true among those with secondary precipitants though the absolute magnitude of risk was reduced as compared to those diagnosed without secondary precipitants.”

“We did not have the power to adequately discern whether there are any specific clinical groups more at risk than others, though we did devote an exploratory analysis to this in which we observed that the risk of recurrent AF for all precipitants other than cardiac surgery was increased about 2-fold as compared to cardiac surgery alone,” Dr Lubbitz added.


1. Lubitz SA, Yin X, Rienstra M, et al. Long-term outcomes of secondary atrial fibrillation in the community. Circulation 2015;131:1648–55.

Published on: May 28, 2015

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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