CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Sripal Bangalore, MD, MHA* and
Farooq A. Chaudhry, MD, FACC
* Division of Cardiology, Columbia University College of Physicians and Surgeons, St. Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, New York 10025 (Email: fchaudhr{at}chpnet.org).
We agree with the comment of Dr. Goldberg about the relationships between atrial fibrillation (AF) and left atrial (LA) size. In the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) study of 4,060 patients with AF only 33% of patients had a normal LA size (1). Patients with dilated left atrium are more prone to AF, and patients with AF and a dilated left atrium are more likely to remain in AF than those with normal LA dimensions. Atrial fibrillation is also known to affect LA remodeling and geometry. In a prospective echocardiographic follow-up of patients with AF, atrial enlargement was shown to occur as a consequence of AF (2). Regardless of whether LA enlargement is a cause for or a consequence of AF, the prognosis is worse compared with patients with a normal LA size.
In our study cohort of 2,705 patients undergoing stress echocardiography (3), only 63 (2.3%) patients had either AF or atrial flutter. Analysis performed after excluding this cohort showed that LA size was able to further risk stratify patients undergoing stress echocardiography (Fig. 1). The results were similar for the multivariable analysis and incremental prognostic value analysis. Thus even after excluding patients with AF/atrial flutter, LA size provided independent and incremental value over standard risk factors, including left ventricular systolic dysfunction and ischemia, and was a powerful prognosticator. Therefore, it should be routinely used in the prognostic interpretation of stress echocardiography.
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Figure 1 Kaplan-Meier Survival Curve in Patients Without AF/Atrial Flutter
The number of patients at risk for each follow-up period is given below the graph. An abnormal left atrial (LA) size (indexed) was able to effectively further risk stratify both the normal (NL) and abnormal (Abn) stress echocardiography (SE) subgroups in this group of patients without atrial fibrillation (AF)/atrial flutter and significant mitral valvular heart disease.
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1. AFFIRM Investigators Atrial Fibrillation Follow-up Investigation of Rhythm ManagementBaseline characteristics of patients with atrial fibrillation: the AFFIRM Study. Am Heart J 2002;143:991-1001.[CrossRef][ISI][Medline]2. Sanfilippo AJ, Abascal VM, Sheehan M, et al. Atrial enlargement as a consequence of atrial fibrillationA prospective echocardiographic study. Circulation 1990;82:792-797.[Abstract/Free Full Text] 3. Bangalore S, Yao SS, Chaudhry FA. Role of left atrial size in risk stratification and prognosis of patients undergoing stress echocardiography J Am Coll Cardiol 2007;50:1254-1262.[Abstract/Free Full Text]
Related Article
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Relationship Between Atrial Fibrillation and Left Atrial Size
- Ythan H. Goldberg
J. Am. Coll. Cardiol. 2008 51: 776.
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