QTc interval predicts outcome of catheter ablation in paroxysmal atrial fibrillation patients with type 2 diabetes mellitus

Abstract

Catheter ablation has been recommended as a treatment option for paroxysmal atrial fibrillation (PAF) patients complicated with type 2 diabetes mellitus (T2DM). PAF patients with T2DM have a higher recurrence rate after catheter ablation. Prolongation of corrected QT (QTc) interval has been linked to poor outcomes in T2DM patients. Whether the abnormal QTc interval is associated with the ablation outcome in the PAF patients with T2DM remains unknown. In this study, 134 PAF patients with T2DM undergoing primary catheter ablation were retrospectively enrolled. Pre-procedural QTc interval was corrected by using the Bazett’s formula. Cox proportional hazards models were constructed to assess the relationship between QTc interval and the recurrence of AF. After a 29.1-month follow-up period, 61 patients experienced atrial tachyarrhythmia recurrence. Recurrent patients had a longer QTc interval than non-recurrent patients (425.2±21.5 ms vs. 414.1±13.4 ms, P=0.002). Multivariate Cox regression analysis revealed that QTc interval [hazard ratio (HR)=1.026, 95% confidence interval (CI) 1.012–1.040, P=0.005] and left atrial diameter (LAD) (HR=1.125, 95% CI 1.062–1.192, P=0.003) were independent predictors of recurrent atrial tachyarrhythmia. Receiver operating characteristic analysis demonstrated that the cut-off value of QTc (418 ms) predicted arrhythmia recurrence with a sensitivity of 55.7% and a specificity of 69.9%. A combination of LAD and QTc was more effective than LAD alone (P<0.001) in predicting arrhythmia recurrence after the procedure. QTc interval could be used as an independent predictor of arrhythmia recurrence in T2DM patients undergoing AF ablation, thus providing a simple method to identify those patients who likely have a better outcome following the procedure.

Keywords

QTc interval / type 2 diabetes mellitus / catheter ablation / paroxysmal atrial fibrillation / recurrence

References

[1] JohansenOE, BrustadE, EngerS, et al. . Prevalence of abnormal glucose metabolism in atrial fibrillation: a case control study in 75-year old subjects. Cardiovasc Diabetol, 2008, 7(1): 1179-1199

[2] DuX, NinomiyaT, de GalanB, et al. . Risks of cardiovascular events and effects of routine blood pressure lowering among patients with type 2 diabetes and atrial fibrillation: results of the ADVANCE study. Eur Heart J, 2009, 30(9): 1128-1135 PMID: 19282274

[3] CammAJ, LipGY, De CaterinaR, 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(21): 2719-2747 PMID: 22922413

[4] JanuaryCT, WannLS, AlpertJS, et al. . 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation, 2014, 130(23): 2071-2104 PMID: 24682348

[5] TangRB, DongJZ, LiuXP, et al. . Safety and efficacy of catheter ablation of atrial fibrillation in patients with diabetes mellitus—single center experience. J Interv Card Electrophysiol, 2006, 17(1): 41-46 PMID: 17235682

[6] ForleoGB, ManticaM, De LucaL, et al. . Catheter ablation of atrial fibrillation in patients with diabetes mellitus type 2: results from a randomized study comparing pulmonary vein isolation versus antiarrhythmic drug therapy. J Cardiovasc Electrophysiol, 2008, 20(1): 22-28 PMID: 18775050

[7] GuJ, LiuX, WangX, et al. . Beneficial effect of pioglitazone on the outcome of catheter ablation in patients with paroxysmal atrial fibrillation and type 2 diabetes mellitus. Europace, 2011, 13(9): 1256-1261 PMID: 21551479

[8] LuZH, LiuN, BaiR, et al. . HbA1c levels as predictors of ablation outcome in type 2 diabetes mellitus and paroxysmal atrial fibrillation. Herz, 2015, 40: 130-136 PMID: 25336239

[9] GreenlandP, AlpertJS, BellerGA, et al. . 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 2010, 122(25): 584

[10] VeglioM, BrunoG, BorraM, et al. . Prevalence of increased QT interval duration and dispersion in type 2 diabetic patients and its relationship with coronary heart disease: a population-based cohort. J Intern Med, 2002, 251(4): 317-324 PMID: 11952882

[11] LiX, RenH, XuZR, et al. . Prevalence and risk factors of prolonged QTc interval among Chinese patients with type 2 diabetes. Exp Diabetes Res, 2012, 2012: 234084 PMID: 23319939 PMCID: 3540769

[12] CoxAJ, AzeemA, YeboahJ, et al. . Heart rate-corrected QT interval is an independent predictor of all-cause and cardiovascular mortality in individuals with Type 2 diabetes: the diabetes heart study. Diabetes Care, 2014, 37(5): 1454-1461 PMID: 24574343 PMCID: 4182905

[13] MandyamMC, SolimanEZ, AlonsoA, et al. . The QT interval and risk of incident atrial fibrillation. Heart Rhythm, 2013, 10(10): 1562-1568 PMID: 23872693 PMCID: 3787974

[14] NielsenJB, GraffC, PietersenA, et al. . J-shaped association between QTc interval duration and the risk of atrial fibrillation: Results from the Copenhagen ECG study. J Am Coll Cardiol, 2013, 61(25): 2557-2564 PMID: 23583581

[15] WenSN, LiuN, LiSN, et al. . QTc Interval prolongation predicts arrhythmia recurrence after catheter ablation of atrial fibrillation in patients With hypertrophic cardiomyopathy. Circ J, 2015, 79(5): 1024-1030 PMID: 25739859

[16] FusterV, RydénLE, CannomDS, et al. . ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation, 2006, 114(7): 257-e354

[17] American Diabetes Association.. Executive summary: standards of medical care in diabetes—2011. Diabetes Care, 2011, 34: S11-61 PMCID: 3006050

[18] GageBF, WatermanAD, ShannonW, et al. . Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA, 2001, 285(22): 2864-2870 PMID: 11401607

[19] MediC, SparksPB, MortonJB, et al. . Pulmonary vein antral isolation for paroxysmal atrial fibrillation: results from long-term follow-up. J Cardiovasc Electrophysiol, 2011, 22(2): 137-141 PMID: 20812937

[20] WeerasooriyaR, KhairyP, LitalienJ, et al. . Catheter ablation for atrial fibrillation: are results maintained at 5 years of follow-up?. J Am Coll Cardiol, 2011, 57(2): 160-166 PMID: 21211687

[21] CaiL, YinY, LingZ, et al. . Predictors of late recurrence of atrial fibrillation after catheter ablation. Int J Cardiol, 2013, 164(1): 82-87 PMID: 21737164

[22] SoranH, YounisN, CurrieP, et al. . Influence of diabetes on the maintenance of sinus rhythm after a successful direct current cardioversion in patients with atrial fibrillation. Q J Med, 2008, 101(3): 181-187

[23] ChaoTF, SuenariK, ChangSL, et al. . Atrial substrate properties and outcome of catheter ablation in patients with paroxysmal atrial fibrillation associated with diabetes mellitus or impaired fasting glucose. Am J Cardiol, 2010, 106(11): 1615-1620 PMID: 21094363

[24] RautaharjuPM, SurawiczB, GettesLS, et al. . AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part IV: the ST segment, T and U waves, and the QT interval: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol, 2009, 53(11): 982-991 PMID: 19281931

[25] ChristensenPK, GallMA, Major-PedersenA, et al. . QTc interval length and QT dispersion as predictors of mortality in patients with non-insulin-dependent diabetes. Scand J Clin Lab Invest, 2000, 60(4): 323-332 PMID: 10943602

[26] HashimotoY, TanakaM, SenmaruT, et al. . Heart rate-corrected QT interval is a novel risk marker for the progression of albuminuria in people with type 2 diabetes. Diabet Med, 2015, 32(9): 1221-1226 PMID: 25683576

[27] StrausSM, KorsJ D, BruinML, et al. . Prolonged QTc interval and risk of sudden cardiac death in a population of older adults. J Am Coll Cardiol, 2006, 47(2): 362-367 PMID: 16412861

[28] ZhangY, PostWS, Blasco-ColmenaresE, et al. . Electrocardiographic QT interval and mortality: a meta-analysis. Epidemiology, 2011, 22(5): 660-670 PMID: 21709561 PMCID: 3150395

[29] OkinPM, DevereuxRB, LeeET, et al. . Electrocardiographic repolarization complexity and abnormality predict all-cause and cardiovascular mortality in diabetes: the strong heart study. Diabetes, 2004, 53(2): 434-440 PMID: 14747295

[30] ZieglerD, ZentaiCP, PerzS, et al. . Prediction of mortality using measures of cardiac autonomic dysfunction in the diabetic and nondiabetic population: the MONICA/KORA Augsburg Cohort Study. Diabetes Care, 2008, 31(3): 556-561 PMID: 18086873

[31] OtakeH, SuzukiH, HondaT, et al. . Influences of autonomic nervous system on atrial arrhythmogenic substrates and the incidence of atrial fibrillation in diabetic heart. Int Heart J, 2009, 50(5): 627-641 PMID: 19809211

[32] MagnanoAR, HolleranS, RamakrishnanR, et al. . Autonomic nervous system influences on QT interval in normal subjects. J Am Coll Cardiol, 2002, 39(11): 1820-1826 PMID: 12039498

[33] MagnanoAR, TalathotiN, HallurR, et al. . Sympathomimetic infusion and cardiac repolarization: the normative effects of epinephrine and isoproterenol in healthy subjects. J Cardiovasc Electrophysiol, 2006, 17(9): 983-989 PMID: 16879629

[34] CoudercJP. Measurement and regulation of cardiac ventricular repolarization: from the QT interval to repolarization morphology. Philos Trans R Soc A, 2009, 367(1892): 1283-1299

[35] NerbonneJM, KassRS. Molecular physiology of cardiac repolarization. Physiol Rev, 2005, 85(4): 1205-1253 PMID: 16183911

[36] ByrdGD, PrasadSM, RipplingerCM, et al. . Importance of geometry and refractory period in sustaining atrial fibrillation: testing the critical mass hypothesis. Circulation, 2005, 112: I7-13 PMID: 16159868

[37] XuGJ, GanTY, TangBP, et al. . Age-related changes in cellular electrophysiology and calcium handling for atrial fibrillation. J Cell Mol Med, 2013, 17(9): 1109-1118 PMID: 23837844 PMCID: 4118170

[38] KirchhofP, EckardtL, FranzMR, et al. . Prolonged atrial action potential durations and polymorphic atrial tachyarrhythmias in patients with long QT syndrome. J Cardiovasc Electrophysiol, 2003, 14(10): 1027-1033 PMID: 14521653

[39] ZhuangJ, WangY, TangK, et al. . Association between left atrial size and atrial fibrillation recurrence after single circumferential pulmonary vein isolation: a systematic review and meta-analysis of observational studies. Europace, 2012, 14(5): 638-645 PMID: 22117033