CC BY
15
Received: 25 March 2021 / Accepted: 15 June 2021 / Published online: 30 June 2021
DOI 10.34689/SH.2021.23.3.017 UDC 616.12-008.313(581)
ATRIAL FIBRILLATION PREDICTORS IN PATIENT WITH ACUTE CORONARY SYNDROME IN KABUL (AFGHANISTAN) FROM 2018 TO 2020
Ikramullah Ibrahimi1, Nasratullah Shinwari2,
Zakirullah Sarwari1, Kairat R. Karibayev3, Aida Z. Akhenbekova4
1 Department of Internal Medicine of Medical Faculty of Nangarhar University, Nangarhar Afghanistan;
2 Department of Medical Faculty of Paktia University, Paktia, Afghanistan;
3 Cardiocenter Central Clinic Hospital, Almaty c., Republic of Kazakhstan;
4 Higher School of Medicine, Faculty of Medicine and Healthcare, Al-Farabi Kazakh National University, Almaty, Republic of Kazakhstan.
Abstract
Aim: The study was aimed to find out the atrial fibrillation predictors in patient with acute coronary syndrome in Kabul, Afghanistan from 2018 to 2020.
Methodology: It was a cross-sectional descriptive study based on purposive sampling conducted in three different hospitals in Kabul. The study included 1416 both male and female patients with known ACS (148 AF) aging over 20 years.
Results: The mean age was 59±13 (22-95), the mean systolic BP was 128± 24 (60-210) mmHg, diastolic BP was 82±15 (40-125) mmHg, and mean BMI was 26.1±4.6 (16.1-37.7), CHA2DS2-VASc score was strongly associated with AF (P value < 0.001, 95% Cl: 1.36-1.99) and the cases of AF significantly increased with increasing CHA2DS2-VASc score. In addition, mean CHA2DS2-VASC score was different across AF group (2.85 ± 1.64 vs. 2.23±1.23 P value 0.001). AF was more prevalent in hypokalemia (75.10% P value < 0.001) and the mean serum potassium was significantly different across AF group (3.83±0.66 vs. 4.28±0.62 in sinus rhythm). AF prevalence was more in the elevated WBC group (P value 0.001) and there was a strong correlation between Af and WBC (pearson correlation 0.9). Moreover, mean WBC count was different across AF group (10400 ±2900 vs. 9500±3200 in sinus rhythm.
Conclusion: Atrial fibrillation is the most common heart rhythm disorder that is strongly and significantly associated with increased CHA2DS2-VASc score, elevated WBC count and low serum potassium level. Patients with these disorders should be closely monitored and serum potassium level should be kept over 3.5 mEq/L. A large cohort study is needed to propose these tests for the screening purpose of atrial fibrillation development in patients with acute coronary syndrome. Keywords: atrial fibrillation, acute coronary syndrome, AF predictors, Afghanistan.
Резюме
ПРЕДИКТОРЫ ФИБРИЛЛЯЦИИ ПРЕДСЕРДИЙ У ПАЦИЕНТОВ С ОСТРЫМ КОРОНАРНЫМ СИНДРОМОМ В КАБУЛЕ (АФГАНИСТАН)
С 2018 ПО 2020 ГОД
Икрамулла Ибрагими1, Насратулла Шинвари2,
Закирулла Сарвари1, Кайрат Р.Карибаев3, Аида Ж. Ахенбекова4
1 Кафедра внутренних болезней, Медицинский факультет, Университет Нангархар, г. Нангархар, Афганистан;
2 Кафедра внутренних болезней, Медицинский факультет Университет Пактия, г. Пактия, Афганистан;
3 Кардиологический центр, Центральная клиническая больница Алматы, г. Алматы, Республика Казахстан;
4 Высшая школа медицины, Факультет медицины и здравоохранения, Казахский Национальный Униврситет им. Аль-Фараби, г. Алматы, Республика Казахстан.
Цель. Исследование было направлено на выявление предикторов фибрилляции предсердий у пациента с острым коронарным синдромом в Кабуле, Афганистан с 2018 по 2020 год.
Методы. Было проведено перекрестное описательное исследование на основе целенаправленной выборки, проведенной в трех разных больницах г. Кабула. В исследование были включены 1416 пациентов мужского и женского пола с установленным ОКС (148 ФП) в возрасте старше 20 лет.
Результаты. Средний возраст составлял 59±13 (22-95) лет, среднее систолическое АД составляло 128± 24 (60210) мм рт. ст., диастолическое АД составляло 82±15 (40-125) мм рт.ст., а средний ИМТ составлял 26,1±4,6 (16,1-
37,7), Показатель CHA2DS2-VAScq0CT0BepH0 коррелировал ФП (значение Р < 0,001, 95% ДИ: 1,36-1,99), и случаи ФП значительно увеличивались с увеличением показателя CHA2DS2-VASc. Кроме того, средний балл CHA2DS2-VASC был различным в группе с ФП (2,85 ± 1,64 против 2,23±1,23, значение Р 0,001). ФП была более распространена при гипокалиемии (75,10% Р < 0,001), а средний уровень калия в сыворотке крови значительно отличался в группе ФП (3,83±0,66 против 4,28±0,62 в синусовом ритме). Распространенность ФП была больше в группе с повышенным уровнем WBC (значение Р 0,001), и между ФП и WBC была достоверная корреляция (корреляция Пирсона 0,9). Кроме того, среднее количество WBC было различным в группе ФП (10400 ±2900 против 9500±3200 в синусовом ритме.
Заключение. Фибрилляция предсердий является наиболее распространенным нарушением сердечного ритма, которое сильно и значительно связано с повышением показателя CHA2DS2-VASc, повышением количества лейкоцитов и низким уровнем калия в сыворотке крови. Пациенты с этими нарушениями должны находиться под тщательным наблюдением, и уровень калия в сыворотке крови должен быть выше 3,5 мэкв/л. Необходимо большое когортное исследование, чтобы предложить эти тесты для скрининга развития фибрилляции предсердий у пациентов с острым коронарным синдромом.
Ключевые слова: фибрилляция предсердий, острый коронарный синдром, предикторы фебрилляции предсердий, Афганистан.
Туйшдеме
2018 ЖЫЛДАН 2020 ЖЫЛГА ДЕЙ1Н АУГАНСТАННЫН КАБУЛ КАЛАСЫНДА ЖЕДЕЛ КОРОНАРЛЫК СИНДРОМЫ БАР НАУКАСТА АТРИАЛЬДЫ ФИБРИЛЛЯЦИЯНЫ БОЛЖАУШЫЛАР
Икрамулла Ибрагими1, Насратулла Шинвари2,
Закирулла Сарвари1, Кайрат Р. Карибаев3, Аида Ж. Ахенбекова4
1 Нангархар университету Медицина факультету 1шк аурулар кафедрасы, Нангархар к-, Ауганстан.
2 Пактия университету Медицина факультету 1шк аурулар кафедрасы, Пактия к-, Ауганстан.
3 Кардиоорталыгы, Алматы Орталык клиникалык ауруханасы, Алматы к-, Казакстан Республикасы;
4 Медицина жогары мектебi, Медицина жэне денсаулык сактау факультетi, Эл-Фараби атындыгы Казак ¥лтык университетi, Алматы к-. Казакстан Республикасы.
Максаты. Зерттеу 2018 жылдан 2020 жылга дейiн Ауганстанныч Кабул каласында жедел коронарлык синдромы бар наукаста атриальды фибрилляцияны болжауга багытталган.
Эд1стеме. Бул Кабулдыч Yш тYрлi ауруханаларында жYргiзiлген максатты iрiктеуге негiзделген кросс-сипаттамалык зерттеу болды. Зерттеуге 20 жастан аскан 1416 еркек жэне эйел пациенттерi (148 ФП) фду
Нэтижелер. Орташа жасы 59±13 (22-95) жыл, орташа систолалык кан кысымы 128± 24 (60-210) мм рт.ст. болды. ст., диастолалык кан кысымы 82±15 (40-125) мм рт.ст.орташа BMI 26,1±4,6 (16,1-37,7) болды, CHA2DS2-VASc FP-мен катты байланысты болды (p < 0,001, 95% di м8нi: 1,36-1,99) жэне FP жагдайлары CHA2DS2-VASc керсетюшУч жогарылауымен айтарлыктай eстi. Сонымен катар, CHA2DS2-VASC орташа балы FP тобында эр тYрлi болды (2,85 ± 1,64 карсы 2,23±1,23, P м8нi 0,001). ФП гипокалиемияда кеч таралган (75,10% Р < 0,001), ал кан сарысуындагы калийдщ орташа дечгей ФП тобында айтарлыктай ерекшелендi (3,83±0,66 карсы Синус ыргагында 4,28±0,62). FP-ыч таралуы WBC дечгей жогары топта квбiрек болды (p м8нi 0,001) жэне FP мен WBC арасында катты корреляция болды (Пирсон корреляциясы 0,9). Сонымен катар, WBC орташа саны FP тобында эр тYрлi болды (синус ыргагында 10400 ±2900 жэне 9500±3200.
Корытынды. атриальды фибрилляция-бул жYрек ыргагыныч еч квп кездесетiн бузылуы, ол CHA2DS2-VASc дечгейУч жогарылауымен, ак кан клеткаларыныч квбеюiмен жэне кан сарысуындагы калийдiч темен дечгейiмен байланысты. Бул бузылулары бар наукастар мукият бакылауда болуы керек жэне кан сарысуындагы калий дечгей 3,5 мэкв/л-ден жогары болуы керек.Жедел коронарлык синдромы бар наукастарда атриальды фибрилляцияны ч дамуын тексеру Yшiн осы сынактарды усыну Yшiн Yлкен когорттык зерттеу кажет.
TYÜiHdi свздер: атриальды фибрилляция, жедел коронарлык синдром, ФП предикторлары, Ауганстан.
Bibliographic citation:
Ibrahimi I., Shinwari N., Sarwari Z., Karibayev K.R., Akhenbekova A.Z. Atrial fibrillation predictors in patient with acute coronary syndrome in Kabul (Afghanistan) from 2018 to 2020 // Nauka i Zdravookhranenie [Science & Healthcare]. 2021, (Vol.23) 3, pp. 146-152. doi 10.34689/SH.2021.23.3.017
Икрамулла И., Шинвари Н., Сарвари З., Карибаев К.Р., Ахенбекова А.Ж. Предикторы фибрилляции предсердий у пациентов с острым коронарным синдромом в Кабуле (Афганистан) с 2018 по 2020 год // Наука и Здравоохранение. 2021. 3(Т.23). С. 146-152. doi 10.34689/SH.2021.23.3.017
Икрамулла И., Шинвари Н., Сарвари З., Карибаев К.Р., Ахенбекова А.Ж. 2018 жылдан 2020 жылга дейЫ Ауганстанныч Кабул каласында жедел коронарлык синдромы бар наукаста атриальды фибрилляцияны болжаушылар // Гылым жэне Денсаулык сактау. 2021. 3 (Т.23). Б. 146-152. doi 10.34689/SH.2021.23.3.017
Introduction.
Atrial fibrillation is a common heart rhythm disorder that complicates acute coronary syndrome in about 10-15% casesresulting in deleterious outcomes such as heart failure, thromboembolic events and mortality [1, 2].Pulmonary veins which have their distinctive architecture and electrical properties, contribute to the reentry and ectopic firing which are the two leading mechanisms of atrial fibrillation initiation such that autopsy examinations revealed the presence of purkinje fibers, transitional and pacemaker cells [3].Moreover, An appraisal of the data from the healthcare system of the United States showed that the lyear direct cost for a patient with AF was $20,670 compared to $11,965 for a patient with a similar co-morbidity profile without AF from 2004 through 2006 in which inpatient services posed the most important cause of the cost difference followed respectively by OPD and emergency department visits [4].Atrial fibrillation and acute coronary syndrome share almost the same risk factors including advancing age, diabetes mellitus, hypertension, smoking, dyslipidemia, heart failure, obesity, physical inactivity, and alcohol all of which in fact cause electrical and structural remodeling which are counted as necessary substrates for reentry and ectopic firing [5-10]. AF markedly increases mortality in patients suffering from ACS [11], moreover, 17. 9% deaths in women and 14% deaths in men in the year 2010 were from cardiovascular diseases in Afghanistan [12]. CHA2DS2-VASc score was designed as a clinical rule for stroke risk stratification in non-valvular AF and to judge whether treatment with anticoagulant is needed to avoid future stroke episodes due to thromboemblism caused by AF [13].
Besides the advances in the diagnosis and treatment of the comorbid ACS-AF condition over the last two decades, there are not any inexpensive, non-invasive, easy and accessible tests and scores to predict the onset of atrial fibrillation in patient suffering from acute coronary syndrome for a low income country like Afghanistan where most people cannot afford expensive and invasive tests, so we aimed to reveal whether low serum potassium level,
Demographic Characteristics.
Demographic Characteristic
elevated WBC count and increased CHA2DS2-VASc score could really predict or alarm the AF development in ACS patients or not in the local hospitals in Kabul, Afghanistan.
Methodology. Design & setting: This is a descriptive cross-sectional study based on purposive sampling including patients from three leading hospitals (Ibne Sina chest hospital, Amiri medical complex and Wazir Akbar Khan hospital) in Kabul from 2018-2020.
Study subjects: The study includes 1416 both male and female ACS patients aging over 20 years of whom 148 patients had atrial fibrillation. Patients with other diagnoses mimicking ACS or causing AF other than ACS such as valvular disease, COPD, thyrotoxicosis, myocarditis, cardiomyopathies, pulmonary embolism and etc. were excluded from the study.
Data collection and Ethics: Data was collected from the medical record files in medical record rooms of the aforementioned hospitals after receiving an official permission from the authorities. Patients' information and variables of interest were collected and entered to the excel database sheet but the patients' identity was intentionally hidden for ethical purpose and serial numbers were used instead.
Data analysis: Data was analyzed in SPSS version 26 using mean ± standard deviation for continuous variables and frequencies & percentages for categorical variables. Logistic regression was run to see the effect of continuous variables on AF and Chi square test was applied to see the difference between categorical variables, furthermore, the difference in medians of continuous variables were analyzed between AF and sinus rhythm using independent samples test. Statistical significance was set at P value less than 0.05.
Results
Demographics and baseline characteristics: The study included 1416 known ACS patients (148 AF); 585 of whom were male and 831 were female. Most patients in the study were greater than 60 years of age and 53.3% patients had elevated BMI (52.3%). Most patients came from the Kabul city (55.9%) and low- income families (69.2%). Further patient demographic characteristics are described in table 1.
Table 1.
Frequency Percentage
Gender Male 585 41.3%
Female 831 58.7%
20-39 88 6.2%
Age Group 40-59 587 41.5%
60 and up 741 52.3%
Underweight 15 1.1%
BMI Group Normal weight 646 45.6%
Overweight 280 19.8%
Obese 475 33.5%
Poor 981 69.2%
Income Status Fair 351 24.8%
Good 84 5.9%
Marital Status Married 1325 93.6%
Unmarried 91 6.4%
Religion Islam 1386 97.9%
Others 30 2.1%
Kabul City 792 55.9%
Region Kabul Districts 486 34.3%
Other Provinces 138 9.8%
The mean age was 59±13 (22-95), the mean systolic BP was 128± 24 (60-210) mmHg, diastolic BP was 82±15 (40-125) mmHg, height was 1.7±0.08 (1.5-1.84) m, weight was 75.5±14.8 (40-110)kg BMI was 26.1±4.6 (16.1-37.7), CHA2DS2-VASc score was 2.3±1.3 (0-8), potassium was 4.2±0.64 (3-7.5) mEq/L, creatinine was 1.17±0.74 (0.4-5.8) mg/dl, Hb was 13± 2 (6.7-19.6) g/dl and the mean WBC was 9600 ± 3200 (3700-22900) /|_iL
AF predictors: With the increasing CHA2DS2-VASc Score, the prevalence of AF significantly increased
CHA2DS2-VASc score & AF.
CHA2DS2- VASc Score Sinus Rhythm AF
0 91.2% 8.8%
1 93.1% 6.9%
2 91.1% 8.9%
3 91.7% 8.3%
4
5
6 7
specifically with CHA2DS2-VASc Score of 4 and up i.e. atrial fibrillation prevalence being the least at CHA2DS2-VASc Score 1 (6.9%) and the most at CHA2DS2-VASc Score 8 (100%) in comparison to sinus rhythm (P <0.001, 95% CI 1.36-1.99). For more clarification the prevalence of atrial fibrillation across different CHA2DS2-VASc Score is shown in table 2. In fact, with CHA2DS2-VASc Score of 8 there was no sinus rhythm acute coronary syndrome case and the prevalence of atrial fibrillation was 100% with the mentioned score.
Table 2.
95%Confidence interval
Total P value
Lower upper
100% 100% 100% 100%
84.4% 72.9% 50.0% 0.0%
15.6% 27.1% 50.0% 100%
100% 100% 100% 100%
< 0.001
1.36
1.99
For more clear visualization, figure 1 shows the association between AF and CHA2DS2-VASc score.
AF
100%
01234567
CHA2DS2-VASC SCORE
Figure 1 Association between AF & CHA2DS2-VASc score
Figure 1 reveals that with the increasing CHA2DS2- The prevalence of AF across serum potassium groups VASc score considerably from 4 and on the prevalence of is shown in figure 2. AF steeps.
AF
hyperkalemia
13,70%
normal potassium
11,20%
hypokalemia
75,10%
0% 10% 20% 30% 40% 50% 60% 70% 80%
Figure 2. AF & serum potassium levels.
As shown in figure 2, most AF cases occurred in patient with hypokalemia (75.1% 2P value <0.001) followed by hyperkalemia (13.7%) and normal potassium level (11.2%).
AF prevalence was higher in WBC count between 10000-11900 (46%) followed respectively by WBC count 6000-7900 (21%), 12000-13900 (14%), 8000-9900 (11%), and 4000-5900 (2%) i.e. AF had strong correlation with WBC count (pearson correlation 0.9, 2P value <0.001).
The means of CHA2DS2-VASc score, serum potassium level and WBC count were different across AF and sinus
The prevalence of AF increased at higher WBC counts as shown in figure 3.
rhythm. In fact, mean CHA2DS2-VASc score and WBC count were higher in the atrial fibrillation group compared to sinus rhythm but the mean potassium level was lower in the atrial fibrillation group compared to the sinus rhythm and the differences were statistically significant (P value 0.001) as shown in table 3.
Figure 3. AF across WBC counts.
Table 3.
Comparison of means between AF & sinus rhythm.
CHA2DS2-VASc score 2.85±1.64 2.23±1.23 0 8 0.001
Serum potassium 3.83±0.66 4.28±0.62 3 7.5 0.001
WBC count 10400±2900 9500±3200 3700 22900 0.001
Discussion
This was the first study conducted in the local hospitals of Kabul city in Afghanistan on the predictors of atrial fibrillation in patients with acute coronary syndrome.
The major finding of the study included the strong and significant association between the three predictors such as CHA2DS2-VASc score, serum potassium level and WBC count with the prevalence or development of atrial fibrillation in patients with underlying acute coronary syndrome disease. As the CHA2DS2-VASc score increased, the prevalence of AF increased accordingly and the difference was significant at P value less than 0.001. Our finding is supported by the finding of Aksoy et al. demonstrating that higher CHA2DS2-VASc score predicted AF in ACS patients [14]. The components of CHA2DS2- VASc Score [15] are associated with elevated inflammatory response in patients [164], and the mechanism and association of inflammation are well known in the development of atrial fibrillation [16].
The reason why serum potassium is lower in patients with myocardial ischemia is that Na-K ATPase pump is activated by adrenergic stimulus in myocardial ischemia resulting in hypokalemia [17]. And serum potassium level was strongly correlated with Af i.e. the prevalence of atrial fibrillation was high in the hypokalemic ACS patients which is consistent with many studies in the literature [18-20].
WBC count was strongly correlated with the AF i.e. AF prevalence was higher in higher counts of WBC and lower in the lower WBC counts; which is in fact, consistent with the finding of Framingham Heart Study and the Atherosclerosis Risk in Community [21-22] and Boyrne et al [23]. Moreover, in a study by Tran et al. high wBc count later in the acute hospital stay is associated with increase in the risk of AF development, and they claim that every 109 cells/L increase in WBC caused about 14% higher risk of AF development. However, it is controversial with the finding of a study conducted in Japan [24]. in fact, his idea is supported by Byrne et al. who found a positive correlation between a raised WBC count and elevated C- reactive protein level [23] which is elevated in inflammatory conditions.
Conclusion
Atrial fibrillation is the most common heart rhythm disorder that is strongly and significantly associated with increased CHA2DS2-VASc score, elevated WBC count and low serum potassium level. Patients with these disorders should be closely monitored and serum potassium level should be kept over 3.5 mEq/L. A large cohort study is needed to propose these tests for the screening purpose of atrial fibrillation development in patients with acute coronary syndrome.
Limitation
The study has a few limitations, first of which is the design being cross-sectional in which the results may have been affected
by confounders. Second, the unavailability of holter monitoring may have caused the under estimation of atrial fibrillation cases and finally the unavailability of the C-reactive protein test through which we could make decision on linking the elevated WBC count with the inflammatory process which is a mechanism of the atrial fibrillation onset.
Conflict of interest
The authors declare that they do not have any competing interests.
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Coresponding Author
Ibrahimi Ikramullah - Lecturer at Department of Internal Medicine of Medical Faculty of Nangarhar University, Nangarhar Afghanistan, Nangarhar Afghanistan Email: ikr.ibrahimi@gmail.com Phone: +93777165716
