Risk factors for the development of AF and detection in HCM

Studies have described multiple clinical, electrocardiogram (ECG), and echocardiogram (ECHO)
features as independent FACTORS of AF in HCM patients. Left atrial diameter, age, and heart
failure class are the strongest independent predictors of the development of AF.
One of the most important risk factors for the development of AF in HCM patients is left atrial
size. A cohort study by Olivotto I et al . In 2001, the United States and the Italian population.
The study included 480 consecutive HCM patients (age at diagnosis, >50 years) who were
followed up for 9 years. About 107 patients were diagnosed with atrial fibrillation. And the study
concluded that there is a significant association of left atrial size in HCM with the development
of Atrial fibrillation[47].

Guttmann OP et al in 2013 conducted a study review of metanalysis for the prevalence and
incidence of AF in HCM patients due to left Atrial size in 7381 patients in which the LA
diameter was 38 mm in HCM patients with sinus rhythm, compared to 45 mm in those with AF
in HCM patients [48].

The volume of the left atrium and the index of the left atrium to body surface area found in
patients with PAF exceeded that of patients without Paroxysmal atrial fibrillation(PAF)
significantly, the maximum left atrial volume being the most sensitive and specific parameter for
detecting PAF in patients with hypertrophic cardiomyopathy. The left atrial volume index
(LAVI) provides additional information on left atrial remodeling and predicts AF better than
right atrial remodeling. It is more important to measure LA diameter in HCM patients. When
Tani T et al . in 2004 studied 141 HCM patients. Results showed that LAVI >40 ml/m2 is seen in
these patients and concluded that this is a significant prognostic tool to identify the development
of AF in HCM patients [49].

With age, HCM patients are more likely to have AF than age-matched cohorts; however, AF
rarely occurs in those with HCM who are 30 years or younger and becomes more frequent with
age. In both the general population and HCM patients, age is a well-known predictor of AF, age
has been found as a risk factor for the development of AF in several studies, with age thresholds
ranging from 40 to 50 years being independently predictive of AF in HCM patients [47].

As a result of obstructive physiology, intrinsic myocardial stiffness, mitral regurgitation, and

irregular heart rhythm left atrial enlargement occurs in HCM, Patients with AF were more likely
to have severe or moderate mitral regurgitation, Some studies have shown that NYHA class
III/IV, moderate to severe mitral regurgitation, and LV ejection fraction less than 50% are
associated with an elevated risk of AF. Siontis KC et al.2014 Conducted a retrospective analysis
of >3500 patients with HCM from 1975 to 2012 and studies concluded that several
echocardiographic markers in HCM patients like LV wall thickness, LV increased stiffness are
associated with increased development of AF due to structure abnormality [50].

Paroxysmal AF can be estimated using P wave dispersion (PWD) reflecting inhomogeneous

atrial conduction. By measuring LA diameter and PWD value we could easily identify patients
with a high risk of developing AF with HCM, and prescribe necessary treatment and follow-up
protocols for those patients, Researchers reported 92% sensitivity and 89% specificity in the
separation of patients with AF and controls with P wave duration > 134.5 ms, In another study of
80 patients, The authors reported a sensitivity of 96% and specificity of 91% for detecting AF as
measured by P wave dispersion greater than 52.5 ms of the P wave. Ozdemir O et.al. 2003
conducted a study a clinical study on 30 patients from 1998 to 2001 and results show that there is
a significant correlation between P wave dispersion and AF in HCM patients [51].

Clinical impact of AF in HCM

AF was defined as paroxysmal when it terminated spontaneously or successfully cardioverted to

sinus rhythm, or as chronic when it became established, based on ECG recordings obtained
either following the acute onset of symptoms or by chance during a routine medical examination.
A study conducted by Olivotto I et al. In 2001 in 480 patients, found that ischemic stroke was
eight times as common in the AF group as it was in the control group (21% AF; 2.6% non-AF)
[47].
Patients in this group were mostly affected by symptoms of progressive heart failure. In AF,
irregular ventricular filling results from uncoordinated atrial contraction and rapid ventricular
response. Left ventricular (LV) compliance is reduced in hypertrophied ventricles. This can lead
to a wide range of hemodynamic complications, Due to reduced cardiac output, HCM patients
with LVOT obstruction may experience hypotension, presyncope, or syncope. A study
conducted by Rowin EJ et al. in Tufts Medical Center Hypertrophic Cardiomyopathy Institute
from 2004 to 2014 in 1558 patients with him, results showed that 304 had AF episodes in that
226 have symptoms of AF, and concluded that the frequency and timing of transient
symptomatic episodes of AF, which often impair quality of life, are unpredictable [52].
HCM patients with AF have an increased risk of mortality by up to fourfold compared with
individuals with sinus rhythm. Cardiovascular deaths in AF patients are most commonly
associated with thromboembolism and worsening heart failure. There are few cases of sudden
death due to deterioration of AF into ventricular tachycardia, especially when pre-excitation is
present[47]. 
In HCM, AF is common and associated with a high risk of thromboembolism. Although LA
dimension and age are independently associated with AF, the literature is not sufficient for
creating robust predictive tools. Most data suggest anticoagulation should be considered for AF
patients. There is also evidence that AF increases the risk of systemic thromboembolism (TE) in
HCM patients. Guttmann OP 2016 conducted a retrospective longitudinal cohort study from
1986 and 2008 and he concluded that there is a higher risk of thromboembolism in HCM patients
with AF and development TE in is a poor prognostic [48,53].

 
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