Pulmonary arterial hypertension and atrial arrhythmias: incidence, risk factors, and clinical impact

Abstract

Atrial arrhythmia (AA) occurrence in pulmonary arterial hypertension (PAH) may determine clinical deterioration and affect prognosis. In this study we assessed AA incidence in idiopathic (IPAH) and systemic sclerosis related PAH (SSc-PAH) and evaluated risk factors, management, and impact on mortality. We collected baseline data from consecutive IPAH or SSc-PAH patients prospectively enrolled in the Johns Hopkins Pulmonary Hypertension Registry between January 2000 and July 2016. During follow-up AA onset, treatment, and outcome were recorded. Among 317 patients (201 SSc-PAH, 116 IPAH), 42 developed AA (19 atrial fibrillation, 10 flutter-fibrillation, 9 atrial flutter, and 4 atrial ectopic tachycardia) with a 13.2% cumulative incidence. Most events were associated with hospitalization (90.5%). Electrical or pharmacological cardioversion was attempted in most cases. Patients with AA had higher right atrial pressure, pulmonary wedge pressure ( P < 0.005), NT-proBNP ( P < 0.05), and thyroid disease prevalence ( P < 0.005). Higher mortality was observed in patients with AA, though not statistically significant (LogRank P = 0.323). Similar long-term mortality between IPAH with AA and SSc-PAH without AA was observed (LogRank P = 0.098). SSc-PAH with AA had the worst prognosis. In PAH patients AA occurrence is a matter of significant concern. Therapeutic strategies aimed at restoring sinus rhythm may represent an important goal.

Keywords: atrial arrhythmias; pulmonary arterial hypertension; systemic sclerosis.

Fig. 1.

Kaplan–Meier curves for all-cause mortality among PAH patients according to the occurrence of AA. P value PAH with AA vs. PAH without AA: Log Rank P = 0.323; Breslow P = 0.985; Tarone-Ware P = 0.717. PAH, pulmonary arterial hypertension; AA, atrial arrhythmia.

Fig. 2.

Kaplan–Meier curves for all-cause mortality among PAH patients according to the etiology and the occurrence of AA. P value SSc-PAH with AA vs. SSc-PAH without AA: Log Rank P = 0.454; IPAH with AA vs. IPAH without AA: Log Rank P = 0.410; SSc-PAH without AA vs. IPAH without AA: Log Rank P < 0.001; SSc-PAH with AA vs. IPAH with AA: Log Rank P = 0.031; SSc-PAH without AA vs. IPAH with AA: Log Rank P = 0.098; SSc-PAH with AA vs. IPAH without AA: Log Rank P < 0.001. PAH, pulmonary arterial hypertension; AA, atrial arrhythmias; IPAH, idiopathic pulmonary arterial hypertension; SSc-PAH, systemic sclerosis related pulmonary arterial hypertension.