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To Study the Prevalence of Arrhythmias in Valvular Heart Disease and Their Correlation with Echocardiographic Variables

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Original Article DOI: 10.7860/JCDR/2018/36767.12300 Internal Medicine To Study the Prevalence of Arrhythmias in Section Valvular Heart Disease and their Correlation with Echocardiographic Variables SANJA SAMEER BEHRA1, AVS ANIL KUMAR2, HARKIRAT SINGH3, K SATYANAND4 ABSTRACT Results: It was found that 122 (45.5%) patients had arrhythmias, Introduction: Valvular Heart Disease (VHD) is an important out of which Atrial Fibrillation (AF) contributed the most 100 cause of arrhythmia which may manifest as syncope or (37.3%), followed by Premature Ventricular Contraction (PVC) palpitations or may be asymptomatic. VHD is very common in in 22 (8.9%) patients. There were 19 (12.5%) of the 152 India and Rheumatic Heart Disease (RHD) contributes maximally asymptomatic patients who had arrhythmias. Patients of mitral to it. There are a substantial proportion of patients in whom valve disease with AF had a mean Mitral Valvular Area (MVA) of arrhythmias go undetected due to paucity of typical symptoms. 1.20±0.39 cm2, Mean-transmitral Gradient (MG) of 14.03±3.10 The patients with arrhythmias are highly prone to Cerebro mm of Hg. The mean Left Atrial (LA) diameter for all the VHD Vascular Accidents (CVA) due to thromboembolic phenomenon. (100 cases) with AF was 48.73±3.57 mm. The mean Left Hence, it is important to detect arrhythmias early so that timely Ventricular Internal Dimension in Diastolic (LVID D) and systolic preventive measures can be put in place. (LVID S) phase was evaluated for cases of Mitral Regurgitation (MR), Aortic Regurgitation (AR) and Aortic Stenosis (AS) for Aim: Establishing the overall prevalence of arrhythmias in all the arrhythmias and were found to be 48.74±6.25 mm and VHD, proportion of asymptomatic arrhythmias, the type of 36.69±5.18mm respectively. arrhythmias occurring in this population subset and the factors which increase the risk of occurrence of arrhythmias. Conclusion: There is significant proportion of patients with VHD having asymptomatic arrhythmias; hence 24- Materials and Methods: The study included 268 consecutive hour Holter monitoring should be used to detect these early. patients of VHD enrolled between July 2015 to Jun 2016. Echocardiographic variables like LA diameter, MG, MVA, LVID S Patients were evaluated with complete history and clinical and LVID D for arrhythmias. The critical point beyond which the examination along with relevant haematological and biochemical patient is more prone to get an arrhythmia as per our study was investigations, echocardiography and 24 hour ambulatory Holter when LA diameter >43 mm, MVA <1.7 cm2, MG >09 mm Hg, monitoring. For baseline comparison of patients, chi-square (χ2) LVID D >50 mm and LVID S >39 mm. Patients with multivalvular test was used for descriptive variables. Quantitative variables involvement are more prone for arrhythmia. were compared using the independent sample t-test. Keywords: Atrial fibrillation, Holter monitoring, Mitral stenosis, Rheumatic heart disease INTRODUCTION Additionally, it is used for the analysis of the type, duration, Valvular Heart Disease is an important cause of arrhythmia. In the severity, quantification and qualification of these arrhythmias in recent years, there has been a steady decline in the prevalence this population subset [6,7]. There are various echocardiographic of VHD and the resultant arrhythmias in western countries [1]. variables, which are also associated with risk of onset of However, the prevalence still remains high in developing as well arrhythmia. If we can detect the arrhythmia early or detect as in third world countries [2]. The patients with arrhythmias the parameters which are associated with increased risk of are highly prone to Cerebro Vascular Accidents (CVA) due to arrhythmias, preventive measures can be undertaken. thromboembolic phenomenon. Early intervention can prevent and The data on the prevalence of arrhythmias, particularly asymptomatic forestall these thromboembolic events particularly, primary and arrhythmias, type of arrhythmias and echocardiographic variables recurrent CVAs [3]. Prevention of these thromboembolic events in the subset of population of VHD in South western part of the requires that the patient receives anticoagulant therapy. The most country is scanty which prompted us to undertake this study. common arrhythmia in VHD is Atrial Fibrillation (AF). A study by Wipf JE et al., reported AF prevalence rate of 75% in Rheumatic MATERIALS AND METHODS Heart Disease (RHD) [4]. Study done by Diker E et al., in 1110 This cross-sectional observational study was conducted at a tertiary patients of rheumatic VHD reported a frequency of 39% for AF [5]. care teaching hospital over a period of one year from July 2015 to AF due to VHD, particularly mitral valve disease has a substantially June 2016. Prior clearance was taken from the institutional ethical higher risk for CVAs than with AF with non-valvular heart disease. committee. Informed written consent was taken from the patients. Also there is a greater CVA risk in patients with permanent AF than Consecutive patients of all functional classes as defined by the New in patients with paroxysmal AF and the risk of stroke is highest in York Heart Association (NYHA) were included (Total 280). Patients the year of onset of the arrhythmia [4]. with concurrent other heart diseases and patients below 18 years Arrhythmias can result in symptoms like palpitations and of age were excluded from the study. Coronary heart disease was syncope. But there are a substantial number of patients with excluded by ECG findings, echocardiography and wherever clinically VHD in whom arrhythmias may go undetected due to a paucity suspected stress Myocardial Perfusion Imaging (MPI) was done. of clinical symptoms and in whom Holter monitoring has proved Total six patients were suspected to have CAD and were excluded. to be invaluable tool in identifying any underlying arrhythmias. Two had dilated cardiomyopathy and were also excluded. Four 12 Journal of Clinical and Diagnostic Research, 2018, Nov, Vol-12(11): OC12-OC19 www.jcdr.net Sanja Sameer Behra et al., Prevalence of Arrhythmias in Valvular Heart Disease and Their Correlation with Echocardiographic Variables patients were lost to follow-up. Rest of the patients (total of 268) Arrhythmia were all included in the study [Table/Fig-1]. Total Present Absent ≤20 1 5 6 21-30 13 69 82 31-40 40 42 82 Age group 41-50 38 23 61 51-60 18 3 21 >60 12 4 16 Total 122 146 268 [Table/Fig-2]: Arrhythmia in different age groups. 43(16%), Aortic Regurgitation (AR) in 45 (17%) of patients (total isolated as well as in combination) [Table/Fig-3]. Overall involvement of mitral valve was 243 (90.6%) and aortic valve was 48 (18%). The pulmonary valve involvement {both stenosis (PS) and regurgitation (PR)} was 0.7% and that of tricuspid valve involvement {both stenosis (TS) and regurgitation (TR)} was 14 (5.2%). Our study showed the various valvular involvements in decreasing frequency as follows: MS in 98(36.5%) >MS+MR in 64 (24%) >MR in 48 (17.9%) > AS in 10 (3.73%) >AR in 10 (3.73%) >MS+MR+AS+AR in 9 (3.36%) > MS+MR+AS in 7(2.61%) >MR+TR >AS+AR >MR+AS >MR+AR > [Table/Fig-1]: Showing patient participation. MS+MR+TR [Table/Fig-3]. A detailed history was taken to find out any symptoms related to the AF Total (%), valvular lesions arrhythmias (unexplained syncope and palpitation that were non- Present (%) In whole cohort exertional), history of alcohol intake or medication that can provoke arrhythmias. They underwent detailed physical examination, routine AR 0 0.0 5 1.9 haemogram, biochemistry, Erythrocyte Sedimentation Rate (ESR), AS 0 0.0 10 3.7 C-Reactive Protein (CRP), chest radiography (X-Ray), thyroid BAV 0 0.0 5 1.9 profile and Electrocardiogram (ECG). All patients underwent an MS 31 42.5 73 27.2 echocardiography (iE33 PHILIPS serial no-4158990) to affirm the MR 11 25.6 43 16.0 presence of VHD, to study the various echocardiographic variables of Mitral Valve Area (MVA), Mitral Gradient (MG), Left Ventricular MVP 0 0.0 5 1.9 Internal Dimensions (LVID) and Left Atrial Diameter (LA dia) and PS 0 0.0 1 0.4 to ascertain the current cardiac status. Consequent to which the AS+AR 0 0.0 3 1.1 patient underwent 24 hour ambulatory Holter monitoring (Holter MR+MS 33 50.8 65 24.3 medilog FD 12 Holter recorder with serial no 92345 made by Schiller). MR+AR 0 0.0 2 0.7 The patients’ Holter recordings were reviewed in our OPD and documented and were advised to promptly report if they developed MR+AS 0 0.0 4 1.4 any new symptoms when again ambulatory Holter monitoring for MR+TR 1 20.0 5 1.9 24 hours was done. MS+BAV 1 100 1 0.4 MS+AR 1 25.0 4 1.4 STATISTICAL ANALYSIS MS+TR 1 100 1 0.4 For baseline comparison of patients, chi-square (χ2) test was used MS+AS 3 60 5 1.9 for descriptive variables. Quantitative variables were compared using the independent sample t-test. PS+TR 0 0.0 1 0.4 MS+AS+AR 0 0.0 3 1.1 Sample size estimation: AF is the dominant arrhythmia in the patients with VHD. By considering the prevalence of AF in VHD in MR +AS+AR 0 0.0 1 0.4 previous studies being 39% [3], we calculated the sample size (N) MR+AS+TR 1 100.0 1 0.4 using the following formula: MR+ AR+TR 0 0.0 1 0.4 • N= 4xPxQ/L2 MS+MR+AS 2 28.5 7 2.6 • Where P=prevalence of disease=40% MS+MR+TR 3 100.0 3 1.1 • Q=100-P=60% MS+MR+AR 2 25.0 8 2.9 • L=experimental error-15% of P=6% MS+MR+AS+ AR 9 100.00 9 3.4 • N=264.33=264(minimum sample required) MS+MR+AR+TR 1 50 2 0.7 100 268 RESULTS [Table/Fig-3]: Frequency of various valvular lesions in the study group and presence of atrial fibrillation with relation to different valvular lesions; (%) denotes There were 268 patients with mean age of 37±12 years in our study.
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