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European Heart Journal 2001 22(4):333-339; doi:10.1053/euhj.2000.2517
Copyright © 2001 by the European Society of Cardiology.
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The role of atrial ectopics in initiating paroxysmal atrial fibrillation

J.E.P Waktaref1, K Hnatkova, S.M Sopher, F.D Murgatroyd, X Guo, A.J Camm and M Malik

Cardiological Sciences, St George's Hospital Medical School, London, U.K.

revised October 30, 2000; accepted November 1, 2000

Abstract

Aims To characterize the nature and timing of atrial ectopics preceding clinical episodes of paroxysmal atrial fibrillation.

Methods and Results Holter recordings (n=177, 60 patients, 58% male, mean age 61·7±11·5 years) were performed on patients with paroxysmal atrial fibrillation. These were subjected to standard analysis and recordings containing atrial fibrillation episodes suitable for analysis were identified (n=74). Beat interval files differentiating sinus rhythm from atrial fibrillation were generated and atrial ectopics were identified. Atrial ectopics preceding atrial fibrillation were found to be more frequent (5·07±7·39min–1) and more premature (ratio of coupling interval to that of surrounding sinus cycles=0·56±0·08) compared to ectopics occurring remote from atrial fibrillation episodes (frequency=3·60±7·32min–1P=5x 10–24, prematurity ratio=0·60±0·10, P=2x10–73). Atrial ectopic coupling interval frequency histograms were generated and analysed visually and by an automated statistically based test. Many ectopics were seen to occur at one coupling interval in 27 recordings (in eight this occurred only preceding atrial fibrillation onset, while in a further 19 cases this was also seen remote from atrial fibrillation onset). Overall 45% of ectopics preceding atrial fibrillation episodes occurred in isolation, 13% as part of a bigeminal rhythm, 22% as couplets and 20% as runs. This pattern did not differ from that seen remote from atrial fibrillation episodes.

Conclusion Paroxysmal atrial fibrillation is preceded by ectopics of a fixed coupling interval in a significant proportion of patients. If, as seems likely, this is a marker of ‘focally mediated’ atrial fibrillation, then Holter techniques may provide a useful screening tool with which to identify patients suitable for fuller electrophysiological assessment.

Key Words: Atrial fibrillation, computerized analysis, arrhythmia mechanisms, atrial ectopic beats

f1 Correspondence: Dr Johan Waktare, Cardiological Sciences, St George's Hospital Medical School, Cramner Terrace, London SW17 0RE, U.K.

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