European Journal of Cardiovascular Medicine

Atrial fibrillation (AF) is the most frequently encountered sustained cardiac arrhythmia in clinical practice and remains a major cause of cardiovascular-related hospital admissions. [1,2] Its clinical significance is emphasized by its strong association with adverse outcomes, including an approximately fivefold increase in the risk of ischemic stroke and nearly a twofold rise in all-cause mortality. AF is a supraventricular arrhythmia characterized electrocardiographically by the absence of organized atrial activity, low-amplitude fibrillatory waves, and an irregularly irregular ventricular rhythm. These fibrillatory waves typically occur at rates of 300–600 beats per minute and exhibit marked variability in amplitude, morphology, and timing. [2,3]

AF is the most common persistent cardiac rhythm disorder and presents significant challenges in long-term management. Patients with chronic AF often require prolonged use of antiarrhythmic and anticoagulant medications, which may lead to important drug interactions and adverse effects, especially in elderly patients with multiple comorbidities. Management strategies differ between paroxysmal and chronic AF and among related supraventricular tachyarrhythmias such as atrial flutter, emphasizing the need for accurate clinical classification. With advancing age, the prevalence of AF continues to rise, making it increasingly common in aging populations. [2]

The etiology of AF is multifactorial and involves a complex interplay of demographic, clinical, and lifestyle-related factors. Well-established risk factors include advancing age, male sex, systemic hypertension, valvular heart disease, left ventricular systolic dysfunction, obesity, and chronic alcohol consumption. [4] The Framingham Heart Study identified hypertension, cardiac failure, and rheumatic heart disease as the most common precursors of AF, underscoring the strong association between structural heart disease and atrial arrhythmogenesis. [1] In addition, emerging risk factors such as prehypertension, increased pulse pressure, obstructive sleep apnea, high-intensity physical training, diastolic dysfunction, genetic susceptibility, hypertrophic cardiomyopathy, and congenital heart disease have been increasingly recognized. AF has also been associated with coronary artery disease, chronic kidney disease, systemic inflammation, excess pericardial fat, and tobacco use, contributing to its heterogeneous clinical presentation. [5,6]

From a pathophysiological perspective, AF is sustained by abnormalities that promote ectopic impulse formation and reentrant circuits. Four principal mechanisms are involved: ion channel dysfunction, disturbances in intracellular calcium handling, structural remodeling of the atria, and autonomic nervous system imbalance. Among these, atrial fibrosis has emerged as a key substrate by disrupting myocardial architecture, creating conduction barriers, and increasing electrical heterogeneity through abnormal electrical interactions between cardiomyocytes and fibroblasts. [7,8]

Epidemiological studies indicate that while the incidence of AF has remained relatively stable, its prevalence continues to rise due to population aging, improved survival, and better detection and treatment of associated conditions such as hypertension, CAD, and HF. [9,10] In India, particularly in Rajasthan, data on the clinical profile of AF patients remain limited. Evaluating regional patterns of presentation, comorbidities, and complications in a university hospital setting is therefore essential. This study aims to describe the clinical profile of patients with atrial fibrillation admitted to a university hospital in Rajasthan.

This was a hospital-based, descriptive observational study conducted in the Department of Medicine at a tertiary care university hospital in Madhya Pradesh, India. The study was carried out over a one-year period. A total of 100 adult patients diagnosed with atrial fibrillation were included in the study. All consecutive patients admitted to the inpatient wards during the study period and fulfilling the eligibility criteria were enrolled. Inclusion and Exclusion Criteria All patients aged 18 years and above presenting with atrial fibrillation in any clinical form, including paroxysmal, persistent, long-standing persistent, or permanent AF, were eligible for inclusion. Patients were included irrespective of the duration of atrial fibrillation or underlying etiology. Patients with incomplete clinical records, those unwilling to provide informed consent, and those in whom atrial fibrillation could not be confirmed on electrocardiography were excluded from the study. Data Collection and Diagnostic Evaluation The diagnosis of atrial fibrillation was established based on a detailed clinical history, thorough physical examination, and electrocardiographic confirmation. A standard 12-lead electrocardiogram was performed in all patients to confirm atrial fibrillation, defined by the absence of discrete P waves and the presence of an irregularly irregular ventricular rhythm. Baseline demographic data, clinical presentation, duration of symptoms, and associated comorbidities such as hypertension, diabetes mellitus, coronary artery disease, and heart failure were recorded using a predesigned and structured proforma. Relevant laboratory investigations were obtained from patient records as part of routine clinical evaluation. Echocardiographic Assessment All patients underwent transthoracic echocardiography with color Doppler imaging to assess underlying structural heart disease. Echocardiographic parameters included evaluation of left atrial size, left ventricular systolic function, presence of valvular heart disease, and features suggestive of rheumatic or non-rheumatic cardiac pathology. Color Doppler assessment was used to determine the presence and severity of valvular lesions. Statistical Analysis Data were compiled and analyzed using appropriate descriptive statistical methods. Continuous variables were expressed as mean and standard deviation, while categorical variables were presented as frequencies and percentages. Ethical Considerations The study was conducted after obtaining approval from the Institutional Ethics Committee. Written informed consent was obtained from all participants prior to inclusion in the study, and patient confidentiality was maintained throughout the research process.

A total of 100 patients diagnosed with atrial fibrillation (AF) were included in the present study. The study population demonstrated a clear female predominance, with females constituting 72% of cases and males accounting for 28%. The age distribution showed a progressive increase in the prevalence of AF with advancing age. The highest proportion of patients belonged to the 60–69 year age group (30%), followed by the 50–59 year group (26%). Younger age groups contributed comparatively fewer cases, indicating that AF was predominantly a disease of middle-aged and elderly individuals in the study population (Table 1).

On clinical classification, permanent AF was the most frequently observed subtype, seen in 46% of patients. Persistent AF accounted for 34% of cases, while paroxysmal AF was observed in 20% of patients. The predominance of permanent AF reflects the chronic nature of the disease in a substantial proportion of patients presenting to a tertiary care center (Table 2).

Table 1. Age and sex distribution of patients with atrial fibrillation (n = 100)

On clinical classification, permanent AF was the most frequently observed subtype, seen in 46% of patients. Persistent AF accounted for 34% of cases, while paroxysmal AF was observed in 20% of patients. The predominance of permanent AF reflects the chronic nature of the disease in a substantial proportion of patients presenting to a tertiary care center (Table 2).

Table 2. Distribution of atrial fibrillation by clinical type

With regard to etiology, valvular heart disease emerged as the most common cause of AF, accounting for 42% of cases. Among non-valvular etiologies, hypertensive heart disease was the leading contributor (26%), followed by ischemic heart disease (14%) and dilated cardiomyopathy (9%). Less frequent causes included hyperthyroidism, congenital heart disease, and cor pulmonale (Graph 1). Among patients with valvular AF, rheumatic heart disease was the predominant underlying pathology. Mitral valve involvement, either isolated or in combination with other valvular lesions, was the most frequently encountered structural abnormality (Table 3).

Figure 1. Etiological distribution of atrial fibrillation.

Table 3. Pattern of valvular lesions in valvular atrial fibrillation (n = 42)

Palpitation was the most common presenting symptom, reported by 56% of patients. Dyspnea was the next most frequent symptom, present in 45% of cases. Other symptoms included dizziness (20%), fatigue (19%), and chest pain (11%). Many patients reported more than one symptom at the time of presentation, highlighting the variable clinical manifestations of AF (Table 4).

Table 4. Clinical presentation of atrial fibrillation

AF-related complications were observed in a considerable proportion of patients. Heart failure was the most common complication, occurring in 22% of cases. Cerebrovascular accident was documented in 8% of patients, while left atrial thrombus was detected in 6% on echocardiographic evaluation (Figure 2). These findings emphasize the significant morbidity associated with AF.

Figure 2: Complications observed in patients with atrial fibrillation

Echocardiographic assessment revealed left atrial enlargement in the majority of patients. Mild to moderate left atrial dilation (4–5 cm) was the most common finding, observed in 58% of cases. Severe enlargement (>5 cm) was present in 17% of patients, while 25% had a left atrial size within normal limits (<4 cm) (Table 5). The high prevalence of left atrial enlargement reflects chronic atrial remodeling in patients with sustained AF.

Table 5. Left atrial size on echocardiography

The present study evaluated the clinical profile, etiological factors, and complications of atrial fibrillation (AF) among patients presenting to a tertiary care center, thereby reflecting disease patterns relevant to the Indian population. AF is characterized by chaotic atrial electrical activity resulting in ineffective atrial contraction and loss of atrioventricular synchrony. As described in standard cardiology texts by Braunwald, the electrocardiographic hallmark of AF includes absent P waves replaced by irregular fibrillatory waves with an irregular ventricular response [11].

A key observation in this study was the predominance of female patients. Large epidemiological analyses by Miyasaka and colleagues have demonstrated that although the incidence of AF becomes similar in men and women with advancing age, the lifetime risk of developing AF at 40 years is nearly identical for both sexes [12]. Heeringa et al., in the Rotterdam Study, further emphasized that the higher prevalence of AF among elderly women is largely attributable to greater longevity [14]. Indian data summarized by Chopra and coworkers also suggest a slight female predominance, in contrast to Western cohorts where non-valvular AF related to obesity, hypertension, and metabolic risk factors is more common [13]. These observations underline the influence of regional and etiological differences on sex distribution in AF.

Rheumatic heart disease continues to be a dominant etiological factor for AF in India. In the present study, valvular heart disease constituted a substantial proportion of AF cases, with rheumatic mitral valve involvement being the most frequent lesion. Rheumatic pathology leads to chronic pressure overload, progressive left atrial dilatation, and structural remodeling, all of which provide a favorable substrate for AF. Since rheumatic heart disease disproportionately affects women, this may partly explain the higher prevalence of AF among females in developing countries.

With regard to clinical presentation, palpitation was the most common symptom, followed by dyspnea and chest pain. Similar symptom patterns have been described in guideline-based reviews by Fuster and colleagues, who highlighted the variable but often symptomatic nature of AF [15]. Permanent AF was the predominant clinical subtype in this study, reflecting delayed diagnosis or long-standing disease. Comparable findings have been reported in large real-world registries analyzed by Chiang et al. and observational studies by Albina et al., where permanent AF accounted for a major proportion of cases [16,17].

The classification of AF into paroxysmal, persistent, permanent, and lone AF has important therapeutic and prognostic implications. Davidson’s Principles and Practice of Medicine outlines these categories based on duration and reversibility of arrhythmia [18]. Lazar emphasized the role of cardioversion in persistent AF, while Waktare described permanent AF as a stage where rhythm control is either unsuccessful or not pursued [19,20]. Krahn and colleagues, in the Manitoba Follow-Up Study, demonstrated that lone AF in younger individuals is associated with a relatively favorable prognosis [21], a concept also supported in Kumar and Clark’s Clinical Medicine [22].

Prevention of thromboembolic complications remains central to AF management. In this study, anticoagulation was initiated in patients with valvular AF and in those with non-valvular AF who had elevated CHA₂DS₂-VASc scores, in accordance with established recommendations. The ASSERT study by Healey et al. highlighted the association between subclinical AF and increased stroke risk [23], while Hansen et al. demonstrated the importance of adequate anticoagulation around cardioversion to reduce thromboembolic events [24]. However, maintenance of anticoagulation within the therapeutic range was achieved in only a proportion of patients in the present study, reflecting real-world challenges related to monitoring and adherence.

Left atrial enlargement was a frequent echocardiographic finding and served as a marker of disease chronicity and increased thromboembolic risk. The ACC/AHA/ESC guidelines emphasize the pivotal role of echocardiography in assessing atrial size, valvular pathology, ventricular function, and intracardiac thrombus [25]. Persistent atrial dilatation has been associated with increased stroke risk and higher recurrence rates following cardioversion or ablation. Giménez-García and colleagues further demonstrated that patients with sustained AF experience worse outcomes compared with those with paroxysmal AF [26].

The present study has certain limitations. Being a single-center, hospital-based observational study with a modest sample size, the findings may not be fully generalizable. Additionally, long-term outcomes were not evaluated, and the absence of continuous rhythm monitoring may have led to underestimation of paroxysmal AF.

Atrial fibrillation remains a common and clinically significant arrhythmia in the Indian population, with substantial morbidity related to heart failure and thromboembolic complications. This study highlights a female predominance and a strong association with rheumatic valvular heart disease, particularly mitral valve involvement, reflecting the continued burden of rheumatic heart disease in developing regions. Permanent atrial fibrillation was the most frequent clinical subtype, suggesting delayed presentation and chronic disease in a significant proportion of patients. Palpitation and dyspnea were the most common presenting symptoms, while left atrial enlargement was a frequent echocardiographic finding, indicating advanced structural remodeling. The study underscores the importance of early diagnosis, appropriate etiological evaluation, timely risk stratification, and optimal anticoagulation to reduce atrial fibrillation–related morbidity and improve clinical outcomes.

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