High-Sensitivity C-Reactive Protein as a Predictor of Atrial Fibrillation Recurrence after Primary Circumferential Pulmonary Vein Isolation
JUN LIU M.D., Ph.D.
Center for Arrhythmia Diagnosis and Treatment, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Search for more papers by this authorPI-HUA FANG M.D., Ph.D.
Center for Arrhythmia Diagnosis and Treatment, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Search for more papers by this authorYU HOU M.D., Ph.D.
Center for Arrhythmia Diagnosis and Treatment, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Search for more papers by this authorXIAO-FENG LI M.D.
Center for Arrhythmia Diagnosis and Treatment, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Search for more papers by this authorSHU ZHANG
Center for Arrhythmia Diagnosis and Treatment, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Search for more papers by this authorJUN LIU M.D., Ph.D.
Center for Arrhythmia Diagnosis and Treatment, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Search for more papers by this authorPI-HUA FANG M.D., Ph.D.
Center for Arrhythmia Diagnosis and Treatment, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Search for more papers by this authorYU HOU M.D., Ph.D.
Center for Arrhythmia Diagnosis and Treatment, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Search for more papers by this authorXIAO-FENG LI M.D.
Center for Arrhythmia Diagnosis and Treatment, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Search for more papers by this authorSHU ZHANG
Center for Arrhythmia Diagnosis and Treatment, Fu Wai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
Search for more papers by this authorAbstract
Background: Atrial fibrillation (AF) recurrence after circumferential pulmonary vein isolation (CPVI) is difficult to predict. Inflammation is associated with the development of AF. Inflammatory markers, such as high sensitivity C-reactive protein (hsCRP), are related to AF development via atrial remodeling. However, it is unknown whether plasma hsCRP concentration before CPVI can be used as a predictor for AF recurrence.
Methods: A total of 121 patients without structural heart disease who underwent primary CPVI by a single operator were included in the study (paroxysmal/persistent AF: 77/44). Left atrial diameter was measured by transesophageal echocardiography. Plasma hsCRP concentration was determined by enzyme-linked immunosorbent assay. Based on the follow-up outcomes, patients were divided into two groups, a recurrence group and a nonrecurrence group. AF recurrence was defined as AF or atrial flutter or atrial tachycardia episodes lasting for ≥30 s during regular follow-up (>12 months).
Results: A total of 36 (29.8%) patients (paroxysmal/persistent AF: 19 [24.7%]/17 [38.6%]) had AF recurrence in a mean 23 (range, 12–44) month follow-up period. The plasma hsCRP concentration in the recurrence group was significantly higher than that in the nonrecurrence group for all patients (median [quartile range] 2.22 [1.97] mg/L vs 0.89 [1.30] mg/L, P < 0.001), for patients with paroxysmal AF (2.12 [2.78] mg/L vs 0.84 [1.15] mg/L, P = 0.028), and for those with persistent AF (2.29 [1.08] mg/L vs 0.89 [1.53] mg/L, P = 0.005). Multiple logistic regression analyses showed that the higher level of the plasma hsCRP (P < 0.001) was a significant prognostic predictor of AF recurrence, both for patients with paroxysmal AF (P = 0.012) and those with persistent AF (P = 0.003).
Conclusion: Plasma hsCRP concentration before CPVI was associated with AF recurrence after primary CPVI procedure for both paroxysmal and persistent AF patients. Plasma hsCRP concentration could play a role in prediction of AF recurrence after primary CPVI. (PACE 2011; 34:398–406)
References
- 1 Haissaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G, Garrigue S, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998; 339: 659–666.
- 2 Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Damiano RJ Jr, et al. HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: Recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society. Europace 2007; 9: 335–379.
- 3 Liu Y, Liu SW, Ma CS, Lu D, Ma J, Huang CX. Circumferential pulmonary vein with additional linear ablation for persistent and permanent atrial. Zhonghua Yi Xue Za Zhi 2009; 89: 96–99.
- 4 Boos CJ, Anderson RA, Lip GY. Is atrial fibrillation an inflammatory disorder? Eur Heart J 2006; 27: 136–149.
- 5 Issac TT, Dokainish H, Lakkis NM. Role of inflammation in initiation and perpetuation of atrial fibrillation: A systematic review of the published data. J Am Coll Cardiol 2007; 50: 2021–2028.
- 6 Kourliouros A, Savelieva I, Kiotsekoglou A, Jahangiri M, Camm J. Current concepts in the pathogenesis of atrial fibrillation. Am Heart J 2009; 157: 243–252.
- 7 Frustaci A, Chimenti C, Bellocci F, Morgante E, Russo MA, Maseri A. Histological substrate of atrial biopsies in patients with lone atrial fibrillation. Circulation 1997; 96: 1180–1184.
- 8 Chung MK, Martin DO, Sprecher D, Wazni O, Kanderian A, Carnes CA, Bauer JA, et al. C-reactive protein elevation in patients with atrial arrhythmias: Inflammatory mechanisms and persistence of atrial fibrillation. Circulation 2001; 104: 2886–2891.
- 9 Yao SY, Chu JM, Chen KP, Tang M, Fang PH, Wang FZ, Zhang S. Inflammation in lone atrial fibrillation. Clin Cardiol 2009; 32: 94–98.
- 10 Aviles RJ, Martin DO, Apperson-Hansen C, Houghtaling PL, Rautaharju P, Kronmal RA, Tracy RP, et al. Inflammation as a risk factor for atrial fibrillation. Circulation 2003; 108: 3006–3010.
- 11 Malouf JF, Kanagala R, Al AF, Rosales AG, Davison DE, Murali NS, Tsang TS, et al. High sensitivity C-reactive protein: A novel predictor for recurrence of atrial fibrillation after successful cardioversion. J Am Coll Cardiol 2005; 46: 1284–1287.
- 12 Wazni O, Martin DO, Marrouche NF, Shaaraoui M, Chung MK, Almahameed S, Schweikert RA, et al. C reactive protein concentration and recurrence of atrial fibrillation after electrical cardioversion. Heart 2005; 91: 1303–1305.
- 13 Mccabe JM, Smith LM, Tseng ZH, Badhwar N, Lee BK, Lee RJ, Scheinman MM, et al. Protracted CRP elevation after atrial fibrillation ablation. Pacing Clin Electrophysiol 2008; 31: 1146–1151.
- 14 Lellouche N, Sacher F, Wright M, Nault I, Brottier J, Knecht S, Matsuo S, et al. Usefulness of C-reactive protein in predicting early and late recurrences after atrial fibrillation ablation. Europace 2009; 11: 662–664.
- 15 Fang PH, Ren ZF, Ma FS, Chu JM, Ma J, Zhang S. Radiofrequency catheter ablation of permanent atrial fibrillation under guidance of Carto merge technique. Zhongguo Yi Xue Ke Xue Yuan Xue Bao 2007; 29: 571–574.
- 16 Yamada T, Mcelderry HT, Epstein AE, Plumb VJ, Kay GN. One-puncture, double-transseptal catheterization manoeuvre in the catheter ablation of atrial fibrillation. Europace 2007; 9: 487–489.
- 17 Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: Results from the National Registry of Atrial Fibrillation. JAMA 2001; 285: 2864–2870.
- 18 Dernellis J, Panaretou M. C-reactive protein and paroxysmal atrial fibrillation: Evidence of the implication of an inflammatory process in paroxysmal atrial fibrillation. Acta Cardiol 2001; 56: 375–380.
- 19 Anderson JL, Allen MC, Lappe DL, Crandall BG, Horne BD, Bair TL, Morris SR, et al. Frequency of elevation of C-reactive protein in atrial fibrillation. Am J Cardiol 2004; 94: 1255–1259.
- 20 Li J, Solus J, Chen Q, Rho YH, Milne G, Stein CM, Darbar D. Role of inflammation and oxidative stress in atrial fibrillation. Heart Rhythm 2010; 7: 438–444.
- 21 Anselmi A, Possati G, Gaudino M. Postoperative inflammatory reaction and atrial fibrillation: Simple correlation or causation? Ann Thorac Surg 2009; 88: 326–333.
- 22 Halonen J, Halonen P, Jarvinen O, Taskinen P, Auvinen T, Tarkka M, Hippelainen M, et al. Corticosteroids for the prevention of atrial fibrillation after cardiac surgery: A randomized controlled trial. JAMA 2007; 297: 1562–1567.
- 23 Baker WL, White CM, Kluger J, Denowitz A, Konecny CP, Coleman CI. Effect of perioperative corticosteroid use on the incidence of postcardiothoracic surgery atrial fibrillation and length of stay. Heart Rhythm 2007; 4: 461–468.
- 24 Marik PE, Fromm R. The efficacy and dosage effect of corticosteroids for the prevention of atrial fibrillation after cardiac surgery: A systematic review. J Crit Care 2009; 24: 458–463.
- 25 Lo B, Fijnheer R, Nierich AP, Bruins P, Kalkman CJ. C-reactive protein is a risk indicator for atrial fibrillation after myocardial revascularization. Ann Thorac Surg 2005; 79: 1530–1535.
- 26 Liu T, Li G, Li L, Korantzopoulos P. Association between C-reactive protein and recurrence of atrial fibrillation after successful electrical cardioversion: A meta-analysis. J Am Coll Cardiol 2007; 49: 1642–1648.
- 27 Henningsen KM, Therkelsen SK, Bruunsgaard H, Krabbe KS, Pedersen BK, Svendsen JH. Prognostic impact of hs-CRP and IL-6 in patients with persistent atrial fibrillation treated with electrical cardioversion. Scand J Clin Lab Invest 2009; 69: 425–432.
- 28 Verma A, Wazni OM, Marrouche NF, Martin DO, Kilicaslan F, Minor S, Schweikert RA, et al. Pre-existent left atrial scarring in patients undergoing pulmonary vein antrum isolation: An independent predictor of procedural failure. J Am Coll Cardiol 2005; 45: 285–292.
- 29 Rotter M, Jais P, Vergnes MC, Nurden P, Takahashi Y, Sanders P, Rostock T, et al. Decline in C-reactive protein after successful ablation of long-lasting persistent atrial fibrillation. J Am Coll Cardiol 2006; 47: 1231–1233.
- 30 Koyama T, Sekiguchi Y, Tada H, Arimoto T, Yamasaki H, Kuroki K, Machino T, et al. Comparison of characteristics and significance of immediate versus early versus no recurrence of atrial fibrillation after catheter ablation. Am J Cardiol 2009; 103: 1249–1254.
- 31 Letsas KP, Weber R, Burkle G, Mihas CC, Minners J, Kalusche D, Arentz T. Pre-ablative predictors of atrial fibrillation recurrence following pulmonary vein isolation: The potential role of inflammation. Europace 2009; 11: 158–163.
- 32 Lin YJ, Tsao HM, Chang SL, Lo LW, Tuan TC, Hu YF, Udyavar AR, et al. Prognostic implications of the high-sensitive C-reactive protein in the catheter ablation of atrial fibrillation. Am J Cardiol 2010; 105: 495–501.
- 33 Kurotobi T, Iwakura K, Inoue K, Kimura R, Okamura A, Koyama Y, Toyoshima Y, et al. A pre-existent elevated C-reactive protein is associated with the recurrence of atrial tachyarrhythmias after catheter ablation in patients with atrial fibrillation. Europace 2010; 12: 1213–1218.
- 34 Visser M, Bouter LM, Mcquillan GM, Wener MH, Harris TB. Elevated C-reactive protein levels in overweight and obese adults. JAMA 1999; 282: 2131–2135.
- 35 Wang TJ, Parise H, Levy D, D’Agostino RS, Wolf PA, Vasan RS, Benjamin EJ. Obesity and the risk of new-onset atrial fibrillation. JAMA 2004; 292: 2471–2477.
- 36 Frost L, Hune LJ, Vestergaard P. Overweight and obesity as risk factors for atrial fibrillation or flutter: The Danish Diet, Cancer, and Health Study. Am J Med 2005; 118: 489–495.
- 37 Tedrow UB, Conen D, Ridker PM, Cook NR, Koplan BA, Manson JE, Buring JE, et al. The long- and short-term impact of elevated body mass index on the risk of new atrial fibrillation the WHS (women's health study). J Am Coll Cardiol 2010; 55: 2319–2327.
- 38 Crandall MA, Horne BD, Day JD, Anderson JL, Muhlestein JB, Crandall BG, Weiss JP, et al. Atrial fibrillation and CHADS2 risk factors are associated with highly sensitive C-reactive protein incrementally and independently. Pacing Clin Electrophysiol 2009; 32: 648–652.
- 39 Nakamura Y, Nakamura K, Fukushima-Kusano K, Ohta K, Matsubara H, Hamuro T, Yutani C, et al. Tissue factor expression in atrial endothelia associated with nonvalvular atrial fibrillation: Possible involvement in intracardiac thrombogenesis. Thromb Res 2003; 111: 137–142.
- 40 Engelmann MD, Svendsen JH. Inflammation in the genesis and perpetuation of atrial fibrillation. Eur Heart J 2005; 26: 2083–2092.
- 41 Nattel S, Burstein B, Dobrev D. Atrial remodeling and atrial fibrillation: Mechanisms and implications. Circ Arrhythm Electrophysiol 2008; 1: 62–73.
- 42 Lee SH, Chen YC, Chen YJ, Chang SL, Tai CT, Wongcharoen W, Yeh HI, et al. Tumor necrosis factor-alpha alters calcium handling and increases arrhythmogenesis of pulmonary vein cardiomyocytes. Life Sci 2007; 80: 1806–1815.
- 43 Volanakis JE, Wirtz KW. Interaction of C-reactive protein with artificial phosphatidylcholine bilayers. Nature 1979; 281: 155–157.
- 44 Mevorach D. Opsonization of apoptotic cells. Implications for uptake and autoimmunity. Ann N Y Acad Sci 2000; 926: 226–235.
- 45 Korantzopoulos P, Kolettis T, Siogas K, Goudevenos J. Atrial fibrillation and electrical remodeling: The potential role of inflammation and oxidative stress. Med Sci Monit 2003; 9: A225–A229.
- 46 Boyden PA, Tilley LP, Albala A, Liu SK, Fenoglio JJ Jr, Wit AL. Mechanisms for atrial arrhythmias associated with cardiomyopathy: A study of feline hearts with primary myocardial disease. Circulation 1984; 69: 1036–1047.
- 47 Li D, Fareh S, Leung TK, Nattel S. Promotion of atrial fibrillation by heart failure in dogs: Atrial remodeling of a different sort. Circulation 1999; 100: 87–95.
- 48 Verheule S, Sato T, Everett TT, Engle SK, Otten D, der Rubart-Von LM, Nakajima HO, et al. Increased vulnerability to atrial fibrillation in transgenic mice with selective atrial fibrosis caused by overexpression of TGF-beta1. Circ Res 2004; 94: 1458–1465.
- 49 Sanders P, Morton JB, Davidson NC, Spence SJ, Vohra JK, Sparks PB, Kalman JM. Electrical remodeling of the atria in congestive heart failure: Electrophysiological and electroanatomic mapping in humans. Circulation 2003; 108: 1461–1468.
- 50 Dudley SC Jr, Hoch NE, Mccann LA, Honeycutt C, Diamandopoulos L, Fukai T, Harrison DG, et al. Atrial fibrillation increases production of superoxide by the left atrium and left atrial appendage: Role of the NADPH and xanthine oxidases. Circulation 2005; 112: 1266–1273.
Citing Literature
