Predictors of 5-year arrhythmia recurrence after treatment of typical atrial flutter in patients with coronary artery disease

BACKGROUND: There is no consensus on the predictors of arrhythmia recurrence following treatment for typical atrial flutter.

AIM: The study aimed to identify the factors associated with arrhythmia recurrence in patients with coronary artery disease and typical atrial flutter after cardioversion.

METHODS: The study included 165 patients who underwent different treatment modalities, including pharmacological cardioversion with amiodarone (61 patients), electrical cardioversion (20 patients), transesophageal atrial pacing (48 patients), and radiofrequency ablation (36 patients). Patients underwent a 5-year follow-up at intervals of 6, 12, 24, 36, 48, and 60 months.

The predictors of arrhythmia recurrence were determined by analyzing correlation coefficients using Pearson’s (r) and Spearman’s (R) tests, depending on data distribution, followed by multiple regression analysis and receiver operating characteristic (ROC) analysis, including area under the curve (AUC) calculation. The statistical analysis assessed the influence of sex, age, height, weight, body mass index, body surface area, smoking status, arrhythmia characteristics, and comorbidities (atrial flutter type, arrhythmia duration, time since last recurrence, history of atrial fibrillation, symptom severity using the EHRA scale, CHA₂DS₂-VASc and HAS-BLED scores, presence of silent myocardial ischemia and ventricular arrhythmias based on 24-hour Holter ECG monitoring, lipid profile, functional class of angina and heart failure, prior percutaneous coronary intervention with stenting, and history of coronary artery bypass grafting). Structural and functional parameters of the atria and left ventricle were assessed using transthoracic echocardiography. Statistical significance was set at p < 0.05.

RESULTS: The success rates in restoring sinus rhythm were as follows: 54.1% with pharmacological cardioversion, 87.5% with transesophageal atrial pacing combined with amiodarone, 95.0% with electrical cardioversion, and 100% with radiofrequency ablation with cryoisolation of the pulmonary vein ostia. Arrhythmia recurrence was identified in 62.42% of patients. Significant predictors of atrial flutter recurrence included obesity grade ≥2 (AUC = 0.655; p = 0.0117), regular-type atrial flutter (AUC = 0.736; p < 0.0001), and a history of coronary angioplasty with stenting (AUC = 0.687; p < 0.0001). Following conservative cardioversion, a history of atrial fibrillation was the primary predictor of atrial fibrillation recurrence. After ablation, recurrence was predicted by age >62 years (AUC = 0.703; p = 0.0211) and left ventricular diastolic diameter >5.3 cm (AUC = 0.703; p = 0.0305). Predictors of atrial flutter-to-fibrillation recurrence included a history of atrial fibrillation (AUC = 0.702; p = 0.0193), left atrial dilation (AUC = 0.714; p = 0.0439), and left ventricular hypertrophy (AUC = 0.703; p = 0.0121).

CONCLUSION: The five-year recurrence of atrial flutter is associated with the severity of underlying cardiovascular pathology, whereas atrial fibrillation recurrence is linked to a history of atrial fibrillation, patient age, and structural remodeling of the left heart chambers.