Association between atrial fibrillation and appropriate implantable cardioverter defibrillator therapy:: Results from a prospective study

Introduction: Atrial fibrillation (AF) is associated with significant morbidity and mortality that may be related to hemodynamic impairment, thromboembolic events, or enhanced electrical instability of the ventricular myocardium. There is, however, a lack of data concerning the association of AF and ventricular tachyarrhythmias, Methods and Results: Consecutive patients with indication for an implantable cardioverter defibrillator (ICD) were classified for the presence or absence of persistent AF at the time of device implantation, Incidence of device therapy, stored electrograms, and clinical events during follow-up were evaluated prospectively. Two hundred fifty patients were included. During follow-up (20 +/- 14 months), patients in AF experienced appropriate device therapy for recurrent ventricular arrhythmias more frequently compared with patients in sinus rhythm (SR) (63% vs 38%, P = 0.01). On multivariate analysis, AF was an independent predictor of appropriate ICD therapy (relative risk 1.8; 95% confidence interval [CI] 1.2 to 2.9) and inappropriate device therapy (relative risk 2.3; 95% CI 1.2 to 4.5). Predefined clinical events (cluster endpoint: death, syncope, and hospitalizations) were observed more frequently in AF than in SR patients (55% vs 31%, P = 0.01). Analysis of device-stored electrograms revealed a higher incidence of short-long-short cycles preceding ventricular arrhythmias in AF compared with SR patients (50% vs 16%, P = 0.002). Baseline heart rate preceding ventricular arrhythmias did not differ between the two groups. Conclusion: AF is an independent predictor of recurrent ventricular arrhythmias in ICD recipients. The underlying electrophysiologic mechanism seems to be irregular rather than rapid ventricular activation, with a high incidence of short-long-short sequences preceding ventricular tachyarrhythmias in AF patients.