Elsevier

American Heart Journal

Volume 146, Issue 5, November 2003, Pages 902-907
American Heart Journal

Clinical investigation
Circadian variation of arrhythmia onset patterns in patients with persistent atrial fibrillation

https://doi.org/10.1016/S0002-8703(03)00405-8Get rights and content

Abstract

Background

The circadian onset patterns and cycle lengths of atrial tachyarrhythmias (AT) were determined in a group of patients with persistent atrial fibrillation.

Methods

Fifteen patients, mean age 63 ± 14 years and 80% male, were implanted with the Jewel AF atrial defibrillator (Medtronic, Minneapolis, Minn) for persistent atrial fibrillation only. Onset times of AT and median onset atrial cycle lengths were determined from device memory.

Results

Over a follow-up period of 23.3 ± 7 months, 227 episodes of persistent AT were treated by patient-activated atrial defibrillation. The peak onset of persistent AT was nocturnal, with 74% of episodes initiating between 8 pm and 8 am. Eighty-seven percent of the patients experienced an additional 403 paroxysmal AT episodes. These episodes showed a “double-peaked” pattern with the least number of episodes occurring between midnight and 8 am. The mean onset atrial cycle length of persistent AT was significantly shorter than the paroxysmal AT episodes (200 ± 37 ms vs 240 ± 39 ms, P < .005). The atrial cycle lengths at arrhythmia onset of both paroxysmal and persistent AT episodes also demonstrated circadian variation.

Conclusion

There is a circadian distribution of onsets for persistent AT with predominance at night. Patients with persistent AF have >1 type of atrial arrhythmia with differences in the onset patterns and atrial cycle lengths, suggesting different triggers and onset mechanisms.

Section snippets

Patients

Fifteen consecutive patients (mean age 63 ± 14 years, 80% male) implanted with the Medtronic (Minneapolis, Minn) Jewel AF atrial defibrillator (model 7250) were studied. All patients gave written informed consent approved by the local Research Ethical Committee. Patient demographics, underlying etiology, and antiarrhythmic drug use are shown in Table I. None of the patients had a preimplant history of paroxysmal episodes. A minimum of 2 preimplant ambulatory 24-hour tapes were obtained and a

Results

Patients were followed-up for a mean of 23 ± 7 months. There were 227 episodes of persistent AT treated by patient-activated defibrillation (median 9 per patient). Table I shows the number of arrhythmia episodes for each patient. The onset time distribution during the 24-hour period was nonuniform (P < .0001) with a single harmonic circadian pattern peaking at midnight (Figure 2). Seventy-four percent of persistent episodes initiated between 8 pm and 8 am. The median duration of persistent AT

Discussion

It is well recognized that a large number of cardiac conditions exhibit a circadian pattern. Myocardial infarction has a peak incidence between 6 am and midday, sudden cardiac death and malignant ventricular arrhythmias are more common in the morning, and there are circadian patterns for supraventricular arrhythmias and stroke.1, 2, 3, 12, 13, 14 There are also diurnal variations in a number of electrophysiological parameters such as heart rate, QT interval, sinus node recovery time, atrial

Acknowledgements

We are extremely grateful for the statistical assistance and advice provided by Dr Derek Robinson from the University of Sussex, Brighton, UK.

References (46)

  • Z.C. Wen et al.

    Role of autonomic tone in facilitating spontaneous onset of typical atrial flutter

    J Am Coll Cardiol

    (1998)
  • J.L. Huang et al.

    Changes of autonomic tone before the onset of paroxysmal atrial fibrillation

    Int J Cardiol

    (1998)
  • E.N. Prystowsky et al.

    Enhanced parasympathetic tone shortens atrial refractoriness in man

    Am J Cardiol

    (1983)
  • M. Kupari et al.

    Double-peaking circadian variation in the occurrence of sustained supraventricular tachyarrhythmias

    Am Heart J

    (1990)
  • H.J. Sih et al.

    Differences in organization between acute and chronic atrial fibrillation in dogs

    J Am Coll Cardiol

    (2000)
  • F. Gaita et al.

    Different patterns of atrial activation in idiopathic atrial fibrillationsimultaneous multisite atrial mapping in patients with paroxysmal and chronic atrial fibrillation

    J Am Coll Cardiol

    (2001)
  • J.E. Muller et al.

    Circadian variation in the frequency of onset of acute myocardial infarction

    N Engl J Med

    (1985)
  • J.E. Muller et al.

    Circadian variation in the frequency of sudden cardiac death

    Circulation

    (1987)
  • M. Peckova et al.

    Circadian variations in the occurrence of cardiac arrestsinitial and repeat episodes

    Circulation

    (1998)
  • W.K. Clair et al.

    Spontaneous occurrence of symptomatic paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia in untreated patients

    Circulation

    (1993)
  • S. Viskin et al.

    Circadian variation of symptomatic paroxysmal atrial fibrillationdata from almost 10 000 episodes

    Eur Heart J

    (1999)
  • L.A. Shehadeh et al.

    Temporal patterns of atrial arrhythmia recurrences in patients with implantable defibrillatorsimplications for assessing antiarrhythmic therapies

    J Cardiovasc Electrophysiol

    (2002)
  • C.D. Swerdlow et al.

    Detection of atrial fibrillation and flutter by a dual-chamber implantable cardioverter-defibrillatorfor the Worldwide Jewel AF Investigators

    Circulation

    (2000)
  • Cited by (50)

    • Circadian rhythms and cardiovascular health

      2012, Sleep Medicine Reviews
      Citation Excerpt :

      In contrast, the adrenergically mediated type is opposite to the vagal type in all respects. Persistent AF, as studied with implanted atrial defibrillators, shows circadian distribution of onsets, i.e., predominant during the day.225 Pritchett et al.226 documented paroxysmal supraventricular tachycardia (PSVT) by telephone transmission of the ECG of 14 apparently diurnally active patients treated with the calcium channel blocker medications of verapamil or diltiazem.

    • Cardiovascular Consequences of Obese and Nonobese Obstructive Sleep Apnea

      2010, Medical Clinics of North America
      Citation Excerpt :

      Mounting data strengthen the association between OSA and AF, 2 disorders that often coexist.64 Continuous cardiac monitoring with an atrial defibrillator showed that the onset of nearly 75% of episodes of persistent atrial fibrillation in OSA patients occurred in the overnight hours (8 pm to 8 am).65 Retrospective analysis shows that, within 12 months of successful therapeutic electrical cardioversion for atrial fibrillation, untreated sleep apneics were found to have an arrhythmia recurrence rate double that of patients treated with CPAP.66

    • Continuous heart rhythm monitoring using mobile photoplethysmography in ambulatory patients

      2020, Journal of Electrocardiology
      Citation Excerpt :

      Yet, because participants were active in only a part of the trial period, we cannot verify the accuracy of measurements done specifically during activity. Nevertheless, assuming measurement's reliability only at rest would not preclude its value for detecting asymptomatic AF, as a substantial percentage of such events begins during night sleep [18,19]. A second limitation is that, although the CardiacSense PPG technology has shown promise in AF detection at rest, the present trial did not address the rhythm question directly and therefore cannot conclude regarding the PPG device ability to detect AF in ambulatory patients.

    • Continuous heart rate monitoring for automatic detection of atrial fibrillation with novel bio-sensing technology

      2019, Journal of Electrocardiology
      Citation Excerpt :

      Obviously, the technological challenges needed for reliable detection of atrial fibrillation in active, ambulatory patients, are formidable and it remains to be seen if the present device will reliably detect AF in ambulatory patients. Nevertheless, even if PPG technology is ultimately used only for heart rate monitoring at rest, it would still be of value for detecting asymptomatic AF because a substantial percentage of such events begin during sleep at night [18,19]. Another possible limitation is over-detection of irregular rhythms other than AF.

    View all citing articles on Scopus
    View full text