Journal of Cardiology 71 (2018) 125–128

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Journal of Cardiology
journal homepage: www.elsevier.com/locate/jjcc

Original article

Clinical factors associated with the development of atrial fibrillation in

the year following STEMI treated by primary PCI
Hyo-In Rhyou (MD), Tae-Ho Park (MD)*, Young-Rak Cho (MD), Kyungil Park (MD),
Jong-Sung Park (MD), Moo-Hyun Kim (MD), Young-Dae Kim (MD)
Department of Cardiology, Dong-A University Hospital, Busan, Republic of Korea

A R T I C L E I N F O A B S T R A C T

Article history: Background: Advanced age, poor left ventricular function, and congestive heart failure are known
Received 16 May 2017 predictors of atrial fibrillation (AF) in acute myocardial infarction (AMI) patients. Recent advances in AMI
Received in revised form 26 July 2017 treatment may have changed the occurrence of new-onset AF. Thus, we investigated the factors
Accepted 24 August 2017
associated with the development of new-onset AF in ST elevation myocardial infarction (STEMI) patients.
Available online 29 September 2017
Methods: This study included 527 STEMI patients [mean age, 60.6
12.8 years; 102 (19.4%) women] who
underwent primary percutaneous coronary intervention (PCI) in the previous 7 years. New-onset AF was
Keywords:
evaluated following STEMI treated by primary PCI. Patients who developed AF during this follow-up
Cardiogenic shock
Atrial fibrillation
period were compared with those who did not develop AF to identify factors that were associated with
ST elevation myocardial infarction the development of AF.
Results: New-onset AF was documented in 81 patients (15.4%) at 1 year after STEMI. Patients with new-
onset AF (n = 81) tended to be older (p < 0.001); were more often female (p = 0.009); had more
congestive heart failure (p = 0.015); had less use of beta-blockers (p = 0.001); had more often used
antiarrhythmic drugs (p < 0.001); experienced cardiogenic shock more frequently (p = 0.038); had lower
left ventricular ejection fraction (p = 0.024); and had higher E velocity (p < 0.001), E/e0 (p = 0.011), and
left atrial volume index (LAVI; p = 0.029) than the 446 patients with no AF. Multivariate regression
analysis revealed that cardiogenic shock, LAVI, and age were predictors of new-onset AF in STEMI
patients (OR 2.823, 1.254, and 1.124; p = 0.005, <0.001, and 0.028, respectively).
Conclusion: Cardiogenic shock was a new predictor of new-onset AF in STEMI patients.
© 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Introduction occurrence of AF in AMI [8]. Many predictors of AF after AMI such

Atrial fibrillation (AF) is one of the most common supraven-
tricular arrhythmias in acute myocardial infarction (AMI), with an
incidence of 5–18% in patients with AMI [1,2]. Its occurrence in AMI
patients is important because AF increases the risk of cardiovas-
cular events [3]. Notably, structural heart disease, hypertension,
diabetes, and advanced age induce progressive structural remo-
deling in the atria, which leads to the development of AF
[4]. Dysfunctions of the sinoatrial (SA) and atrioventricular (AV)
nodes also contribute to the development of AF. In AMI patients,
acute ischemic insults to the atria and ventricles can induce AF [5–
9]. Moreover, the location of the culprit vessel also affects the
* Corresponding author at: Department of Cardiology, Dong-A University
Hospital, Daeshingongwon-Ro 26, Seo-gu, Busan 602-715, Republic of Korea.
E-mail address: thpark65@dau.ac.kr (T.-H. Park).
as advanced age, female sex, left ventricular hypertrophy, and
congestive heart failure (CHF) have been identified [10], but
predictors of AF in patients with ST elevation myocardial infarction
(STEMI) have yet to be clearly defined. Our aim was to identify
factors that predict the development of AF in STEMI patients.
Methods
STEMI patients who underwent primary percutaneous coro-
nary intervention (PCI) between January 2009 and December
2015 at Dong-A University Hospital (Busan, Korea) were screened.
Of the 545 patients, we excluded 5 patients with a previous history
of AF, 10 patients who died during admission, and 3 patients who
did not complete the 1-year follow-up. Thus, a total of 527 patients
with STEMI were enrolled in the study. The diagnosis of STEMI was
based on typical chest pain symptoms, electrocardiographic (ECG)
changes, and serial elevation of serum cardiac enzymes. The ECG

http://dx.doi.org/10.1016/j.jjcc.2017.08.004
0914-5087/© 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
126 H.-I. Rhyou et al. / Journal of Cardiology 71 (2018) 125–128

criterion for the diagnosis of STEMI was an ST-segment elevation of
0.2 mV in 2 contiguous leads or new left bundle branch block.
AF was defined as the absence of P waves with irregular RR
intervals. Cardiogenic shock was defined as a state of systolic blood
pressure less than 80 mmHg due to STEMI in the absence of
hypovolemia that was associated with clinical signs of hypoperfu-
sion or CHF [11]. CHF was diagnosed based on a known history of
CHF and/or Killip class 2 at any time during hospitalization with
the need for diuretics [12]. Dyslipidemia was defined by either
documentation of the diagnosis in the patient's history, current use
of lipid-modifying drugs, a fasting total cholesterol level 200 mg/
dl, or a low-density lipoprotein cholesterol level of 130 mg/dl.
Hypertension and diabetes were defined based on documentation
of the clinical diagnosis. All patients received standard pharmaco-
logical therapies [13] and revascularization, had continuous
ECG monitoring in the coronary care unit, and had 12-lead ECG
performed daily during their hospital admission. After hospital
discharge, all patients were followed up with ECG check up within
1 month and every 2 or 3 months after. New-onset AF patients
were divided into two groups. Early AF was defined as AF
documented during admission, and late AF was defined as new-
onset AF within 1 year after discharge. This retrospective study was
approved by our institutional review board.
Echocardiography
All patients underwent echocardiography within 48 h after
hospital admission. Echocardiography was performed using the
iE33 ultrasound system with 2.5-MHz transducer (Philips,
Amsterdam, The Netherlands). Standard 2D and Doppler echocar-
diography were performed according to the recommendations of
the American Society of Echocardiography [14,15]. Left ventricular
end-diastolic dimension (LVEDD) and left ventricular end-systolic
dimension (LVESD) were measured using 2D echocardiography.
Left ventricular ejection fraction (LVEF) was assessed semi-
quantitatively with visual estimation and the wall-motion score
index. Left atrial (LA) volume was measured using the biplane
Simpson method at end-systole from apical 4- and 2-chamber views.
LA volume index (LAVI) was calculated as the LA volume divided
by the body surface area. LV diastolic function was assessed by
conventional Doppler (mitral E, mitral A, and the E/A ratio) and by
tissue Doppler imaging (TDI). Peak systolic (s0 ), early diastolic (e0 ), and
late diastolic velocities (a0 ) were obtained at the lateral mitral annulus
from the apical 4-chamber view. LV systolic and diastolic dysfunction
were defined as LVEF <40% and E/e0 ratio >15, respectively.
Coronary angiography
with STEMI. Variables with p-values 0.20 in univariate analyses
were candidates for the multivariable logistic regression model. A
backward stepwise elimination algorithm reduced the variables
until only significant variables (p < 0.05) remained in the
multivariate model. All statistical comparisons were two-sided,
and the statistical significance was set at p < 0.05. The statistical
analysis was performed using the Statistical Package for Social
Science v. 20.0 (SPSS; IBM, Chicago, IL, USA).
Results
A total of 527 STEMI patients with primary PCI were enrolled in
the study. The mean age was 60.6
12.8 years, and 102 patients
(19.4%) were female. New-onset AF was documented in 81 (15.4%)
at 1 year after STEMI. Early AF was identified in 67 patients (12.7%)
and late AF in 14 patients (2.7%). In the STEMI patients, the culprit
vessel was LAD in 271 patients (51.4%), RCA in 203 patients (38.5%),
LCX in 50 patients (9.5%), and LMCA in 3 patients (0.6%). However,
in patients with new-onset AF, the most common culprit vessel
was the RCA (35 patients; 43.2%), followed by the LAD (34 patients;
42.0%), the LCX (10 patients; 12.3%), and the LMCA (2 patients;
2.5%) (Table 1).
Patients with new-onset AF were older (65.9
12.4 years vs.
59.7
12.7 years, p < 0.001), more often female (30.9% vs. 17.3%,
p = 0.009), and more often had cardiogenic shock (16.0% vs. 8.3%,
p = 0.038). Patients with new-onset AF had less use of beta-
blockers (86.7% vs. 53.6%, p = 0.001) and had more often used
antiarrhythmic drugs (21.0% vs. 4.5%, p < 0.001) than patients with
no AF. However, there was no significant difference with respect to
the location of the culprit vessel between the AF group vs. the no AF
group (Table 1). An implantable cardioverter defibrillator was
implanted in one patient with no AF.
Echocardiographic characteristics
In echocardiographic analysis, patients who developed new-
onset AF had lower LVEF (46.0
8.6% vs. 48.4
8.8%, p = 0.024),
higher E velocity (75.9
24.4 cm/s vs. 66.4
19.4 cm/s, p < 0.001),
higher E/e0 (12.1
6.7 vs. 10.1
3.9, p = 0.011), and higher LAVI
(34.4
13.1 ml/m2 vs. 29.4
8.6 ml/m2, p = 0.002) than the
446 patients without AF (Table 2). The incidence of AF develop-
ment increased as LAVI increased (Fig. 1).
Table 1
Baseline clinical and angiographic characteristics.
All (n = 527) No AF (n = 446) AF (n = 81) p-value

Coronary angiography was performed in all patients. The culprit Age 60.6
12.8 59.7
12.7 65.9
12.4 <0.001
vessel was defined as a vessel with complete closure or the most Female sex 102 (19.4%) 77 (17.3%) 25 (30.9%) 0.009
Hypertension 265 (50.3%) 220 (49.3%) 45 (55.6%) 0.335
significant stenosis corresponding to ECG changes. Patients were Diabetes mellitus 153 (29.0%) 135 (30.3%) 18 (22.2%) 0.183
further classified by the site of occlusion: left anterior descending Dyslipidemia 399 (75.7%) 344 (77.1%) 55 (67.9%) 0.090
artery (LAD), left circumflex artery (LCX), right coronary artery DBT, min 61.5
68.9 60.7
67.9 66.0
74.7 0.530
(RCA), and left main coronary artery (LMCA). CHF 148 (28.0%) 114 (25.5%) 34 (42.0%) 0.015
Cardiogenic shock 50 (9.5%) 37 (8.3%) 13 (16.0%) 0.038
Culprit LAD 271 (51.4%) 237 (53.1%) 34 (42.0%) 0.070
Statistical analysis Culprit LCX 50 (9.5%) 40 (9.0%) 10 (12.3%) 0.310
Culprit RCA 203 (38.5%) 168 (37.7%) 35 (43.2%) 0.385
Baseline clinical, echocardiographic, and angiographic data Culprit LMCA 3 (0.6%) 1 (0.2%) 2 (2.5%) 0.063
were collected and analyzed. The data are presented as mean Aspirin 517 (98.1%) 438 (98.2%) 79 (97.5%) 0.821
Beta-blocker 432 (82.0%) 387 (86.7%) 45 (55.6%) 0.001
values with standard deviations for normally distributed continu-
ACEI/ARB 448 (85.0%) 380 (85.2%) 68 (84.0%) 0.732
ous variables and as numbers and percentages for categorical Statin 456 (86.5%) 387 (86.7%) 69 (85.2%) 0.634
variables. The differences between the two groups were assessed Antiarrhythmic drugs 37 (7.0%) 20 (4.5%) 17 (21.0%) <0.001
with the unpaired 2-tailed t-test for normally distributed AF, atrial fibrillation; CHF, congestive heart failure; DBT, door to balloon time;
continuous values and with the chi-square test for categorical LAD, left anterior descending artery; LCX, left circumflex artery; RCA, right
variables. Logistic regression analysis was used to identify coronary artery; LMCA, left main coronary artery; ACEI, angiotensin-converting
independent risk factors for the development of AF in patients enzyme inhibitor; ARB, angiotensin-receptor blocker.
 H.-I. Rhyou et al. / Journal of Cardiology 71 (2018) 125–128 127

Table 2 volume was significantly associated with the development of new-

Baseline echocardiographic characteristics.
onset AF in this study. (iii) The location of the culprit vessel was not
All (n = 527) No AF (n = 446) AF (n = 81) p-value significantly related to the occurrence of new-onset AF in STEMI
LVEDD (mm) 49.7
5.4 49.8
5.2 48.9
6.1 0.156
patients.
LVPW (mm) 9.5
1.2 9.5
1.2 9.5
1.2 0.968 Structural remodeling, which is characterized by increased LA
LVSW (mm) 9.3
1.5 9.3
1.5 9.3
1.5 0.733 size and atrial fibrosis, is perhaps the most obvious mechanism of
LVEF (%) 48.0
8.8 48.4
8.8 46.0
8.6 0.024 AF, but it may not be the major effect in STEMI patients. In contrast,
Mitral E (cm/s) 67.8
20.5 66.4
19.4 75.9
24.4 <0.001
acute atrial ischemia and impaired atrial perfusion may directly
Mitral A (cm/s) 76.0
20.7 75.3
20.0 80.4
24.1 0.058
Mitral E/A 0.93
0.44 0.95
3.9 0.75
0.64 0.190 cause AF in STEMI patients. Cardiogenic shock in STEMI patients is
e0 (lateral) (cm/s) 7.0
2.2 7.1
2.2 6.9
2.1 0.398 a severe form of CHF that predisposes patients to AF. Patients with
E/e0 10.4
4.5 10.1
3.9 12.1
6.7 0.011 cardiogenic shock tend to have more severe myocardial ischemia,
LAVI (ml) 20.1
9.6 29.4
8.6 34.4
13.1 0.002 which can induce atrial ischemia and provoke new-onset AF.
LVEF <40% 60 (11.4%) 46 (10.5%) 13 (11.4%) 0.178
E/e0 >15 54 (10.2%) 36 (8.2%) 17 (21.5%) 0.001
Cardiogenic shock is the leading cause of death in AMI patients,
and mortality from cardiogenic shock is greater than 50%
LAVI, left atrial volume index; LVEDD, left ventricular end-diastolic dimension;
[16–18]. The incidence of AF is more common in patients who
LVPW, left ventricular posterior wall; LVEF, left ventricular ejection fraction;
LVSW, left ventricular septal wall. had cardiogenic shock after STEMI than in those who had no
cardiogenic shock [19]. In the present study, 50 STEMI patients had
cardiogenic shock, and 13 (26.0%) of them developed new-onset
AF, which was more common than in the total group of STEMI
patients (15.3%). Although Kinjo et al. reported that Killip class IV
(cardiogenic shock) was an independent predictor of new-onset AF
[20], cardiogenic shock was not highlighted in past studies. Rather,
previous studies showed that CHF is a predictor of new-onset AF in
AMI [1,10,21]. In this study, cardiogenic shock was the strongest
predictor of new-onset AF in STEMI patients. Thus, we speculate
that cardiogenic shock is a more potent risk factor than CHF for the
development of AF in STEMI patients.
AF can be secondary to structural remodeling of the LA, and
both LA pressure and LA remodeling may be increased in patients
with diastolic dysfunction. New-onset AF occurs more frequently
in patients with diastolic dysfunction [22,23]. Measurement of the
LA volume is helpful in evaluating LV diastolic function because it
often reflects the LV filling pressure as well as the chronicity of
diastolic dysfunction. Furthermore, LAVI 34 ml/m2 is an inde-
pendent predictor of AF [14]. Likewise, in this study, LAVI was an
independent index that predicted new-onset AF in STEMI patients.
Fig. 1. Incidence of AF according to LAVI. The incidence of AF increased as LAVI However, the cut-off value of LAVI for predicting new-onset AF was
increased. AF, atrial fibrillation; LAVI, left atrial volume index. 30 ml/m2, which is lower than the upper normal limit of 34 ml/m2
[24]. Accordingly, the sensitivity and specificity for using LAVI as a
predictor of new-onset AF was not high in this study, but our
Prediction of new-onset AF results may still indicate that upper normal size of LA can cause the
development of new-onset AF in STEMI.
Multivariate regression analysis revealed that cardiogenic Since acute atrial ischemia can be a mechanism underlying
shock, LAVI, and age were predictors of new-onset AF in STEMI new-onset AF in STEMI, we hypothesized that new-onset AF may
patients (OR 2.823, 1.254, and 1.124, p = 0.005, <0.001, and 0.028, be more related to the LCX or the RCA as the culprit vessel than to
respectively) (Table 3). In the early AF group, cardiogenic shock (OR LAD as the culprit vessel. Some studies have reported that new-
2.232, 95% CI 1.047–4.758, p = 0.038) was a predictor of new-onset onset AF is more frequent when RCA or LCX is the culprit vessel
AF, whereas, age (OR 1.059, 95% CI 0.010–1.108, p = 0.017) was a than when LAD is the culprit vessel [3,20,25]. In this study, out of
predictor in the late AF group. 81 STEMI patients with new-onset AF, the culprit vessel was RCA in
35 (43.2%) patients, LAD in 34 (42.0%), LCX in 10 (12.3%), and LMCA
in 2 (2.5%). However, when we grouped STEMI patients according
Discussion to the culprit vessel, excluding LMCA as the culprit vessel, the
incidence of new-onset AF was highest in the LCX group (20%),
The major findings of the present study were as follows: (i) followed by the RCA group (17.2%) and the LAD group (12.5%).
cardiogenic shock was a strong predictor of new-onset AF in STEMI Although new-onset AF was more common when the culprit vessel
patients, which was not highlighted in the past studies. (ii) LA was not the LAD than when it was the LAD, this did not reach
statistical significance in this study.
The mechanisms underlying new-onset AF in STEMI patients
Table 3 remain unclear, and multiple mechanisms may be involved.
Independent predictors of new-onset AF in STEMI patients. Although the use of beta-blockers was not an independent
OR 95% CI p-value predictor of new-onset AF, lower beta-blocker use affected the
development of new-onset AF in this study. Thus, an increased
Cardiogenic shock 2.823 1.372–5.808 0.005
LAVI 1.254 1.026–1.083 <0.001 catecholamine level is another mechanism underlying new-onset
Age 1.124 1.003–1.046 0.028 AF in STEMI patients. Our findings suggest that the predictors of
LAVI, left atrial volume index.
new-onset AF in STEMI patients are different between early and
late phase AF. For early phase AF, cardiogenic shock was the only
128 H.-I. Rhyou et al. / Journal of Cardiology 71 (2018) 125–128
predictor for new-onset AF in STEMI, implying that atrial ischemia
and hemodynamic overload are main causes of AF. However, in late
phase AF, atrial remodeling and fibrosis (due to advanced age) may
lead to new-onset AF, even in STEMI.
Advanced age, poor LV function, and CHF are common
predictors of new-onset AF in AMI patients. However, this study
found that cardiogenic shock, LAVI, and advanced age were
predictors of the development of new AF in STEMI patients. Thus,
acute atrial ischemia due to cardiogenic shock, as well as
structural remodeling of the LA due to advanced age and diastolic
dysfunction, might be related to AF development in STEMI
patients.
This study had limitations. First, it was a relatively small study
that was conducted at a single center. Second, new-onset AF was
diagnosed by retrospective chart review with ECG, the actual
number of AF could have underestimated.
In conclusion, this study demonstrated that cardiogenic shock,
LAVI, and age were predictors of new-onset AF in STEMI patients.
Additional prospective studies in a larger population are needed to
confirm and clarify our findings.
Funding
None.
Conflict of interest
The authors declare that there is no conflict of interest.
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