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A new piece of puzzle: inflammation in the prediction of recurrence after successful electrical cardioversion in patients with nonvalvular atrial fibrillation/Bulmacanin yeni bir parcasi: nonvalvuler atriyal fibrilasyon hastalarinda basarili elektriksel kardiyoversiyon sonrasi nuksu ongormede enflamasyonun rolu.

Dear Editor,

We have read with great enthusiasm the recently published article entitled "Can neutrophil/lymphocyte ratio (N/L ratio) predict recurrence after electrical cardioversion in non-valvular atrial fibrillation (AF)" by Aribas et al. (1). In that well-presented study the authors tried to investigate effectiveness of N/L ratio for prediction of recurrence after electrical cardioversion (ECV) in patients with non-valvular AF They concluded that high sensitive C reactive protein (hs-CRP), left atrium (LA) diameter, spontaneous echo contrast (SEC) positivity, and systolic blood pressure (BP) were independent predictors of recurrence. However they did not detect a statistically significant relationship between N/L ratio and AF recurrence after successful ECV in that patient group.

Atrial fibrillation induces remodeling of the left atrium. In a previously published study LA volume index (LAVI), which is more accurate measure of LA size, was found to be a significant predictor of recurrence of AF after cardioversion (2). This study showed that larger LAVI before cardioversion, as a more accurate measure of LA remodeling than LA diameter, is strongly and independently associated with higher risks of AF recurrence (2). Besides it was examined predictive value of the LAVI in the recurrence of AF after a successful ECV in patients with non-valvular AF In that study the authors concluded that lower LAVI values before the ECV are strong and independent predictors of the success of the ECV and the maintenance of SR after a successful ECV (3).

P-wave dispersion (PWD) is an electrocardiographic measurement, which reflects a disparity in an atrial conduction. In a well-designed study, the authors aimed to analyze diagnostic accuracy of PWD in predicting recurrence of AF in patients with sinus rhythm restoration after external cardioversion. Patients with recurrent AF had significantly higher PWD than those who continued to have a sinus rhythm. This study suggests that PWD analysis after successful external cardioversion has diagnostic accuracy to predict the recurrence of AF (4).

Antiarrhythmic drugs used for SR maintenance after successful ECV in patients with chronic AF (1). The authors conducted a prospective study of the efficacy of sequential antiarrhythmic drug therapy in SR maintenance after a successful ECV in individuals with chronic AF. Sequential antiarrhythmic drug therapy improves arrhythmia prognosis in AF within a 12-month. Amiodarone seems to be the most effective antiarrhythmic drug also in patients who required second ECV proceeded by amiodarone treatment to restore SR (5). Some medications such as antihypertensive therapy and statin used (6) can also affect the incidence and shortens the duration of atrial fibrillation. In the previous large population-based study, greater levels of serum phosphorus and the related calcium-phosphorus product were also associated with a greater incidence of AF (7). Proteinuria were also apparently linked to the persistent form of AF (8).

A complete blood count is an practical laboratory test gives us information about the patient's formed blood contents; the red and white cells, the platelets, the count and dimensions of subgroups of cells, and parameters like the distribution weights. White blood cell count is one of the useful inflammatory biomarkers in clinical practice. Leukocyte subtype, and N/L ratio are also indicators of systemic inflammation. Although white blood cells are in normal range, subtypes of white blood cells may predict cardiovascular mortality. The N/L ratio is also an inflammatory marker of major adverse cardiac events (9). However, sometimes acute conditions like bacterial or viral infections, chronic inflammatory disease and drug treatments might affect neutrophil and lymphocyte counts and so the ratio of these parameters might be changed (10). Therefore, N/L ratio itself alone without other inflammatory markers may not give information to clinicians about the chronic endothelial inflammatory condition of the patient. So, we think that it should be evaluated together with other serum inflammatory markers.

In conclusion, we strongly believe that future large-scale prospective clinical studies are needed to clarify the essential pathophysiologic mechanisms in the recurrence of AF after ECV in patients with non valvular AF.

Sevket Balta, Murat Unlu (1), Sait Demirkol, Turgay Celik

Department of Cardiology, GATA, Ankara-Turkey

(1) Department of Cardiology, Beytepe Military Hospital, Ankara-Turkey

References

(1.) Aribas A, Akilli H, Gul EE, Kayrak M, Demir K, Duman C, et al. Can neutrophil/lymphocyte ratio predict recurrence after electrical cardioversion in non-valvular atrial fibrillation? Anadolu Kardiyol Derg 2012 Dec 7 doi: 10.5152/akd.2013.036. [Epub ahead of print] [CrossRef]

(2.) Marchese P Bursi F Delle Donne G, Malavasi V, Casali E, Barbieri A, et al. Indexed left atrial volume predicts the recurrence of non-valvular atrial fibrillation after successful cardioversion. Eur J Echocardiogr 2011; 12: 214-21. [CrossRef]

(3.) Akdemir B, Altekin RE, Kucuk M, Yanikoglu A, Karakas MS, Aktas A, et al. The significance of the left atrial volume index in cardioversion success and its relationship with recurrence in patients with non-valvular atrial fibrillation subjected to electrical cardioversion: a study on diagnostic accuracy. Anadolu Kardiyol Derg 2013; 13: 18-25.

(4.) Basar N, Malcok Gurel O, Ozcan F, Ozlu MF Bicer Yesilay A, Cagli K, et al. Diagnostic accuracy of P-wave dispersion in prediction of maintenance of sinus rhythm after external cardioversion of atrial fibrillation. Anadolu Kardiyol Derg 2011; 11: 34-8. [CrossRef]

(5.) Kosior D, Opolski G, Torbicki A. Efficacy of sequential antiarrhythmic treatment in sinus rhythm maintenance after successful electrocardioversion in patients with chronic non-valvular atrial fibrillation. Med Sci Monit 2001; 7: 68-73.

(6.) Ozaydin M, Dogan A, Varol E, Kapan S, Tuzun N, Peker O, et al. Statin use before by-pass surgery decreases the incidence and shortens the duration of postoperative atrial fibrillation. Cardiology 2007; 107: 117-21. [CrossRef]

(7.) Lopez FL, Agarwal SK, Grams ME, Loehr LR, Soliman EZ, Lutsey PL, et al. Relation of serum phosphorus levels to the incidence of atrial fibrillation (from the Atherosclerosis Risk In Communities [ARIC] Study). Am J Cardiol 2013; 13: 857-62. [CrossRef]

(8.) Suzuki S, Sagara K, Otsuka T, Kanou H, Matsuno S, Uejima T, et al. Estimated glomerular filtration rate and proteinuria are associated with persistent form of atrial fibrillation: analysis in Japanese patients. J Cardiol 2013; 61: 53-7. [CrossRef]

(9.) Turak O, Ozcan F Isleyen A, Tok D, Sokmen E, Buyukkaya E, et al. Usefulness of the neutrophil-to-lymphocyte ratio to predict bare-metal stent restenosis. Am J Cardiol. 2012; 110: 1405-10. [CrossRef]

(10.) Karaman M, Balta S, Ay SA, Cakar M, Naharci I, Demirkol S, et al. The comparative effects of valsartan and amlodipine on vWf Levels and N/L ratio in patients with newly diagnosed hypertension. Clin Exp Hypertens 2013 Jan 4. [Epub ahead of print] [CrossRef]

Address for Correspondence/Yazisma Adresi: Dr. Sevket Balta

GATA Kardiyoloji Bolumu, Etlik, Ankara-Turkiye

Phone: +90 312 304 42 81

E-mail: drsevketb@gmail.com

doi: 10.5152/akd.2013.121

Author's Reply

Dear Editor,

We thank the authors for the interest and constructive comments on our article titled with "Can neutrophil/lymphocyte ratio(NLR) predict recurrence after electrical cardioversion in non-valvular atrial fibrillation (AF)" (1).

Atrial substrate determines the risk of recurrence on rhythm control. Importance of arterial remodeling and dilatation has been known for continuation and permanence of AF A previous 3D-electrocardiography study shown that left atrial (LA) volume was more efficient than LA diameter and LA area for left atrial dilatation (2). Marchese et al. (3) showed that LA volume index (LAVI) was better predictor of AF recurrence compared to LA-diameter (AP-Lad). Therefore, combination of AP-Lad with LAVI may provide more reliable results. Although AP-Lad inaccurately represents true LA size, it was shown that AP-Lad can predict AF recurrence in various studies (4, 5). It was also found to be relevant with AF recurrence in the present study. In addition, we aimed to predict AF recurrence using parameters that easily applied in daily clinical practice. We therefore preferred AP-Lad that is routinely used in daily electrocardiographic evaluations and more practical than LAVI.

Interatrial conduction delays have been implicated in initiating and maintaining AF (6). P-wave dispersion (PWD) shows the prolonged interatrial conduction and can be used to predict the recurrence of AF We agree with the opinion that PWD can be used as a practical predictor of AF. It could be exciting and interesting study in which NLR and PWD are evaluated together and these parameters are compared.

We are in absolutely agreement with authors about the improving effects of antiarrhythmic drug therapy on prognosis in AF. Therefore, amiodarone was given to all patients before cardioversion (CV) and was continued for 1 month following CV in this study. Antihypertensive agents such as angiotensin converting enzyme inhibitors and angiotensin receptor blockers have antifibrillatory and antifibrotic actions via inhibition of angiotensin II. Also, statins have anti-inflammatory and antioxidant action. However, according to the ESC 2012 AF guideline, there is only little reason to consider the use of such therapy for the prevention of AF recurrence in patients with little or no underlying heart disease (7).

We agree with authors that bacterial or viral infections, chronic inflammatory disease and drug treatments might affect neutrophil and lymphocyte counts and so the ratio of these parameters might be changed. Therefore, we excluded the patients with chronic obstructive pulmonary disease, malignity and acute infectious disease. It could be considered to evaluate together with other serum inflammatory markers. However, these inflammation markers are not used in daily practice and are only assayed with commercially available kits. Another limitation of commercial kits is those shelf lives are generally short after first use. However, our aim was to find a basic parameter analysis of which is quick, economical and labor free for predicting AF following electrical cardioversion (ECV). For this reason, other serum inflammatory markers were not evaluated.

Finally, we support the comments of authors that future large-scale prospective clinical studies are needed to clarify the essential pathophysiological mechanisms in the recurrence of AF after ECV in patients with non-valvular AF.

Alpay Aribas, Hakan Akilli, Mehmet Kayrak

Department of Cardiology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya-Turkey

References

(1.) Aribas A, Akilli H, Gul EE, Kayrak M, Demir K, Duman C, et al. Can neutrophil/lymphocyte ratio predict recurrence after electrical cardioversion in non-valvular atrial fibrillation? Anadolu Kardiyol Derg 2013; 13: 123-30.

(2.) Maddukuri PV, Vieira ML, DeCastro S, Maron MS, Kuvin JT, Patel AR, et al. What is the best approach for the assessment of left atrial size? Comparison of various unidimensional and two-dimensional parameters with three-dimensional echocardiographically determined left atrial volume. J Am Soc Echocardiogr 2006; 19: 1026-32. [CrossRef]

(3.) Marchese P Bursi F Delle Donne G, Malavasi V, Casali E, Barbieri A, et al. Indexed left atrial volume predicts the recurrence of non-valvular atrial fibrillation after successful cardioversion. Eur J Echocardiogr 2011; 12: 214-21. [CrossRef]

(4.) Olshansky B, Heller EN, Mitchell LB, Chandler M, Slater W, Green M, et al. Are transthoracic echocardiographic parameters associated with atrial fibrillation recurrence or stroke? Results from the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study. J Am Coll Cardiol 2005; 45: 2026-33. [CrossRef]

(5.) Chang SL, Tsao HM, Lin YJ, Lo LW, Hu YF Tuan TC, et al. Characteristics and significance of very early recurrence of atrial fibrillation after catheter ablation. J Cardiovasc Electrophysiol 2011; 22: 1193-8. [CrossRef]

(6.) Xia Y, Hertervig E, Kongstad O, Ljungstrom E, Platonov P Holm M, et al. Deterioration of interatrial conduction in patients with paroxysmal atrial fibrillation: electroanatomic mapping of the right atrium and coronary sinus. Heart Rhythm 2004; 1: 548-53. [CrossRef]

(7.) Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 33: 2719-47. [CrossRef]

Address for Correspondence/Yazisma Adresi: Dr. Alpay Aribas

Necmettin Erbakan Universitesi, Meram Tip Fakultesi, Kardiyoloji Anabilim Dali Meram, Konya-Turkiye

Phone: +90 332 223 78 50

E-mail: draribas@hotmail.com
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Article Details
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Author:Balta, Sevket; Unlu, Murat; Demirkol, Sait; Celik, Turgay
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Letter to the editor
Date:Jun 1, 2013
Words:1972
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