Scientific letter
Different evolution of atrial fibrillation after the first documented episode
Diferente evolución de la fibrilación auricular tras el primer episodio documentado
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"documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Clin. 2016;146:183-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 19 "formatos" => array:2 [ "HTML" => 8 "PDF" => 11 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta científica</span>" "titulo" => "Diferente evolución de la fibrilación auricular tras el primer episodio documentado" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "183" "paginaFinal" => "184" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Different evolution of atrial fibrillation after the first documented episode" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2028 "Ancho" => 3250 "Tamanyo" => 284594 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Presentación clínica y evolución del ritmo de los pacientes dados de alta del servicio de urgencias, tras el primer episodio documentado de fibrilación auricular (FA) o flúter (FL). Parox: paroxística; Persist: persistente; Recur: recurrencias; RS: ritmo sinusal.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jesús Perea-Egido, Rodolfo Romero-Pareja, Javier García-Ruiz, Francisco G. Cosío" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Jesús" "apellidos" => "Perea-Egido" ] 1 => array:2 [ "nombre" => "Rodolfo" "apellidos" => "Romero-Pareja" ] 2 => array:2 [ "nombre" => "Javier" "apellidos" => "García-Ruiz" ] 3 => array:2 [ "nombre" => "Francisco G." "apellidos" => "Cosío" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020616301206" "doi" => "10.1016/j.medcle.2016.04.055" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616301206?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775315002961?idApp=UINPBA00004N" "url" => "/00257753/0000014600000004/v2_201604080826/S0025775315002961/v2_201604080826/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S238702061630119X" "issn" => "23870206" "doi" => "10.1016/j.medcle.2016.04.054" "estado" => "S300" "fechaPublicacion" => "2016-02-19" "aid" => "3389" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2016;146:185-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Forensic autopsy and clinical autopsy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "185" "paginaFinal" => "186" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Autopsia judicial y autopsia clínica" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1330 "Ancho" => 1616 "Tamanyo" => 93294 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Annual number of clinical (CA) or forensic (FA) autopsies in Catalonia between 2009 and 2013. The CA registered are those in which the question “was an autopsy was performed?” on the death certificate was completed with the “yes” option. To determine the estimated CA, first the proportion of CA registered in connection with deaths without legal intervention was calculated using the question: “was an autopsy performed?” that was completed (“yes” or “no”); second, this ratio was applied to the number of deaths without legal intervention using the question “was an autopsy performed?” that was not completed; and finally, the result of the number of registered CAs. The percentage of deaths without legal intervention with the question “was an autopsy performed?” was not completed in 54.3% in 2009, 31.7% in 2010, 30.5% in 2011, 29.7% in 2012 and 27.1% in 2013. The high percentage of non-completion in 2009 was due to the still frequent use of the former statistical death bulletin, which saw 38.1% of total deaths without legal intervention in that year, a figure which fell to 2.4% in 2010, 0.5% in 2011, 0.3% in 2012 and 0.2% in 2013. <span class="elsevierStyleItalic">Information sources</span>: For FA the Institute of Legal Medicine of Catalonia; For CA The Mortality Register of Catalonia (Servei d’Informació i Estudis, Departament de Salut, Generalitat de Catalunya).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alexandre Xifró, Eneko Barbería, Anna Puigdefàbregas, Adriana Freitas" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Alexandre" "apellidos" => "Xifró" ] 1 => array:2 [ "nombre" => "Eneko" "apellidos" => "Barbería" ] 2 => array:2 [ "nombre" => "Anna" "apellidos" => "Puigdefàbregas" ] 3 => array:2 [ "nombre" => "Adriana" "apellidos" => "Freitas" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S002577531500487X" "doi" => "10.1016/j.medcli.2015.07.016" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S002577531500487X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702061630119X?idApp=UINPBA00004N" "url" => "/23870206/0000014600000004/v1_201606140021/S238702061630119X/v1_201606140021/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020616301218" "issn" => "23870206" "doi" => "10.1016/j.medcle.2016.04.056" "estado" => "S300" "fechaPublicacion" => "2016-02-19" "aid" => "3321" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Clin. 2016;146:182-3" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Acute respiratory infections by human bocavirus in the adult population. Really unfrequent?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "182" "paginaFinal" => "183" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infecciones respiratorias agudas por bocavirus humanos en la población adulta ¿una rareza?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jordi Reina, Antonio Iñigo, Javier Murillas" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Jordi" "apellidos" => "Reina" ] 1 => array:2 [ "nombre" => "Antonio" "apellidos" => "Iñigo" ] 2 => array:2 [ "nombre" => "Javier" "apellidos" => "Murillas" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775315002742" "doi" => "10.1016/j.medcli.2015.05.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775315002742?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616301218?idApp=UINPBA00004N" "url" => "/23870206/0000014600000004/v1_201606140021/S2387020616301218/v1_201606140021/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Different evolution of atrial fibrillation after the first documented episode" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "183" "paginaFinal" => "184" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Jesús Perea-Egido, Rodolfo Romero-Pareja, Javier García-Ruiz, Francisco G. Cosío" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Jesús" "apellidos" => "Perea-Egido" "email" => array:1 [ 0 => "jpereaegido@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Rodolfo" "apellidos" => "Romero-Pareja" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Javier" "apellidos" => "García-Ruiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Francisco G." "apellidos" => "Cosío" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Cardiología y Urgencias, Hospital Universitario de Getafe, Getafe, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina, Universidad Europea de Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diferente evolución de la fibrilación auricular tras el primer episodio documentado" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2024 "Ancho" => 3250 "Tamanyo" => 296555 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical symptoms and evolution of the rhythm of patients admitted to the emergency room after the first documented episode of atrial fibrillation (AF) or atrial flutter (AFL). Parox: paroxysmal; Persist: persistent; Recur: recurrences; RS: sinus rhythm.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Atrial fibrillation (AF) is considered a progressive disease, that begins with self-limited episodes (paroxysmal) and progresses persistently.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> However, this hypothesis is unproven, and some studies suggest that only between 30% and 50% of cases can be persistent from the beginning and that only a minority of paroxysmal AF evolves long term.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–4</span></a> The different classification criteria in paroxysmal or persistent, and the different nature of the populations studied confuse the problem.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,4</span></a> To investigate the issue we registered all patients between 2008 and 2010, who had a first episode of AF or atrial flutter (AFL) seen in A&E of a hospital that attended an industrial population of 200,000 inhabitants. AF was diagnosed when the electrocardiogram showed irregular and sustained atrial and ventricular activity and AFL when atrial activity was regular. Including the first AFL episodes as this is often an initial step towards the AF.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> We excluded those requiring electrical cardioversion (ECV) or hospitalisation because of poor AF/AFL tolerance or concomitant diseases (cardiac or other). Management was based on recommendations from current guidelines, including anticoagulation, at the discretion of the principal doctor.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,6</span></a> After ≤48<span class="elsevierStyleHsp" style=""></span>h observation, stable patients were discharged for consultation and echocardiography at 2 weeks. The follow-up was every 3–6 months, until June 2012. A specific management protocol was not applied, and the head cardiologist noted a rhythm or frequency control at their discretion. The study was approved by the hospital's Ethics Committee. The continuous variables were compared using the Student <span class="elsevierStyleItalic">t</span> or Mann–Whitney tests for independent variables, as appropriate. Categorical variables were analysed by the <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span> test.</p><p id="par0010" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> summarises the evolution of the rhythm. 168 patients (149 AF and 19 AFL) were registered. In 76 cases the symptoms clearly started <span class="elsevierStyleMonospace"><</span>48<span class="elsevierStyleHsp" style=""></span>h before admission, while the onset of the arrhythmia could not accurately be determined in 92. Digoxin, beta blockers or calcium antagonists were administered for frequency control, if necessary, and 22 of the 76 cases with AF/AFL of <48<span class="elsevierStyleHsp" style=""></span>h received a dose of flecainide, propafenone or amiodarone. Upon emergency admission 71 of 76 (95%) cases with AF/AFL <48<span class="elsevierStyleHsp" style=""></span>h and 12 of 92 (13%) cases with imprecise length were in RS. At admission patients with AF/AFL were treated with frequency control and anticoagulation. One patient in RS was admitted with flecainide and one with AF amiodarone.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Upon a follow-up at 15<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2 days of admission, 98 patients (58%) were in RS and 70 (41%) in persistent AF/AFL. No patient in RS at admission was in AF/AFL at 2 weeks, and 15 (17.6%) with AF/AFL at admission passed to RS. Patients with persistent AF/AFL were older (70.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.9 vs 58.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.2; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) and had a higher prevalence of hypertension (61.4 vs 37.4%; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.002), cardiac weakness (12.9 vs 1.9%; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001) and coronary disease (11.4 vs 2%; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.01). 49% of patients in RS at 2 weeks had no AF risk factor, compared with 19% of persistent AF/AFL (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). The diameter of the left atrial echocardiographic in parasternal plane was greater in 58 (83%) patients with persistent AF/AFL (45.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.6<span class="elsevierStyleHsp" style=""></span>mm) than in the 96 (95%) patients with RS (39.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.1<span class="elsevierStyleHsp" style=""></span>mm; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Of the 70 patients with persistent AF/AFL 26 (37%) passed to RS after ECV and 15 still had it at the 4–54 months follow-up (31.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11.6). The other 6 (8.6%) spontaneously recovered the RS. Of the 98 patients in RS at 2 weeks, 65 (66%) had no recurrences of AF/AFL, 24 (24%) patients developed AF/AFL paroxysmal and 9 (9%) progressed to persistent AF, of which 3 maintained RS after ECV. At follow-up, 48 (69%) patients who had persistent AF/AFL at 2 weeks were in persistent AF and one in persistent AFL, compared with 6 (6%) patients who had RS at 2 weeks (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) with the same follow-up length. AF was diagnosed in the first episode in 20 patients, of whom 9 also had episodes of AFL. The AF showed a tendency to evolve to AFL (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Our patients fit into what is generally understood as “isolated” AF/AFL (not due to structural cardiac disease). The classification as persistent or paroxysmal has been made along the monitoring process, revealing that most cases of persistent AF are not preceded by paroxysmal AF, and could be manifestations of different arrhythmogenic substrates.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> On the other hand, 66% of self-limiting episodes do not recur in the medium term and cannot be considered paroxysmal. This perspective may have important practical consequences, especially in a first episode of persistent AF, which should not be considered a more advanced or terminal stage of the arrhythmic process, but the first and perhaps only opportunity to stop the arrhythmogenic process.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> A long-term monitoring of patients without recurrence in the medium-term is needed, including extended rhythm monitoring to detect possible asymptomatic AF,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> and to clarify the prognosis of these apparently isolated episodes and the need, or not, for anticoagulation.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Perea-Egido J, Romero-Pareja R, García-Ruiz J, Cosío FG. Diferente evolución de la fibrilación auricular tras el primer episodio documentado. Med Clin (Barc). 2016;146:183–184.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2024 "Ancho" => 3250 "Tamanyo" => 296555 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical symptoms and evolution of the rhythm of patients admitted to the emergency room after the first documented episode of atrial fibrillation (AF) or atrial flutter (AFL). Parox: paroxysmal; Persist: persistent; Recur: recurrences; RS: sinus rhythm.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.J. Camm" 1 => "P. Kirchhof" 2 => "G.Y. Lip" 3 => "U. Schotten" 4 => "I. Savelieva" 5 => "S. 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