International Journal of Clinical Medicine, 2013, 4, 504-509
Published Online November 2013 (
Open Access IJCM
Prevalence of Atrial Fibrillation in Systolic Heart Failure,
Pulsed and Tissue Doppler Echocardiographic
Salih H. Gabani1, Taysir S. Garadah1,2*, Adela B. Hassan1, Ahmed A. Jaradat1,
Mohamed E. Al Alawi1,2, Zuheir A. Hasan1
1College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain; 2Salmaniya Medical Complex,
Ministry of Health, Manama, Kingdom of Bahrain.
Email: *
Received September 28th, 2013; revised October 25th, 2013; accepted November 2nd, 2013
Copyright © 2013 Salih Gabani et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Heart failure (HF) is a common clinical syndrome mostly due to the impaired ability of the Left Ven-
tricle (LV) to eject blood with reduced cardiac output. Heart failure is called systolic (SHF) if left ventricle ejection
fraction on echo-cardiogram is low (LVEF of 50%). Aim: To assess the echocardiographic characteristics of patients
with SHF with Atrial Fibrillation (AF) and compare with those with Sinus Rhythm (SR) on 12 leads ECG. Furthermore,
to evaluate the clinical and biochemical markers for the prediction of AF in SHF. Method: Over two years duration,
each patient diagnosed with SHF was enrolled in the study (n = 354) based on admission code. AF or sinus rhythm on
12 leads ECG was documented on each patient. Multiple logistic regression analysis was applied to assess the risk ratio
of different clinical and Doppler derived variables for the development of AF in SHF. Results: Out of the total hospital
medical admissions of 14,674 patients, there were 354 patients with diagnosis of SHF, a prevalence of 2.4%. The
incidence of AF on ECG was 109 (31%) patients in the whole study population and 245 (69%) in SR. M Mode
echocardiogram in patients with SHF and AF compared with those in SR showed significant dilation of LV cavity in
systole with LVESD of 5.72 ± 0.63 vs. 5.23 ± 0.76 cm, P < 0.001 and in Diastole LVEDD of 6.83 ± 0.51 vs. 6.58 ±
0.63 cm, P < 0.001. Pulsed Doppler echocardiogram showed a severe restrictive-pattern with shorter Decellration Time
(DT) of 163.73 ± 7.42 vs. 214.9 ± 31.81msec, P < 0.001 and higher Pulse to Tissue Doppler ratio of E/Em of 14.26 ±
1.34 vs. 9.99 ± 1.27, P < 0.001, and the serum level of Brain Natriuretic Peptide (BNP) hormone of 723.72 ± 13.45 vs.
686.98 ± 72.57 pg/ml, P < 0.001. The predictive risks (odd ratio) of different clinical variables for the development of
AF in SHF were positive for high BNP > 500 pg/ml of 2.8, history of hypertension of 1.8, history of DM of 1.7, BMI >
28 of 1.4, LV hypertrophy on ECG of 1.3. Conclusions: The prevalence of Systolic Heart Failure in the study
population was 2.4%. The prevalence of AF in the study population was 31%. The best predictors of AF in SHF were
high BNP > 500 pg/ml, history of hypertension, Diabete Mellitus and LV Hypertrophy on ECG.
Keywords: Systolic Heart Failure; Pulse Doppler; Tissue Doppler; Prevalence
1. Introduction
Heart failure (HF) is a common clinical syndrome repre-
senting the end-stage of a number of different cardiac
diseases [1]. It can result in any structural or functional
cardiac disorder that impairs the ability of the ventricle to
fill with or eject blood [2]. There are two mechanisms by
which reduced cardiac output and HF occur: Systolic
Heart Failure (SHF) with low left ventricle ejection frac-
tion on echocardiogram (LVEF of 50%) and diastolic
heart failure (DHF) with normal LVEF of >50% [3].
SHF has been classified as very mild, mild, moderate
or severe based on echocardiographic derived LVEF%
where very mild LVEF% is (<43% - 50%), mild (LVEF
of <33% - 43%), moderate (<23% - 33%) and severe
with LVEF (<22%) [4]. Systolic Heart Failure has been
recognized previously as a risk factor for the develop-
ment of Atrial Fibrillation (AF) [5]. The overall preva-
lence of new onset of AF in hospitalized patients with
*Corresponding author.
Prevalence of Atrial Fibrillation in Systolic Heart Failure, Pulsed and Tissue Doppler Echocardiographic Abnormalities 505
SHF is in the range of 8% - 36% [6]. It has been ob-
served that the incidence of AF is proportional to the
severity of HF where a higher incidence occurs in severe
SHF [7].
Previous reports showed a deleterious impact of AF on
top of SHF with poor clinical outcomes in terms of mor-
tality and hospitalization [8,9]. Randomized pathophy-
siologic studies showed important differences between
patients presented with SHF as compared with those of
DHF as it seems that the two conditions represent two
distinct syndromes rather than a continuous spectrum of
one disorder [10,11].
Earlier reports showed the high sensitivity of brain na-
triuretic peptide (BNP) as a biomarker of detecting a
symptomatic SHF with low LVEF on echo of <50% [12].
Further, a serum level of BNP was shown to have pro-
gnostic implications in patients with SHF [13]. At present,
the relationship between SHF and the development of AF
in non white population is not clear.
In this study, firstly, we assess the incidence of AF in
patients with SHF; secondly, evaluate the clinical char-
acteristics, causative agents and echocardiographic ab-
normalities in this group of patients and thirdly, correlate
the serum level of BNP with the degree of LVEF% re-
duction on echo.
2. Material and Methods
Out of the 14,674 patients admitted to the Salmaniya
Medical Complex (SMC) in the medical department with
acute medical problems. There were 354 patients diag-
nosed of systolic heart failure. SMC is a governmental
hospital with a catchment area of 900,000 populations.
All patients’ data of clinical history, physical examina-
tion, and laboratory results were obtained. The results of
echocardiogram and 12 leads electrocardiogram were
available for all patients on admission or during hospital
stay. The clinical and biochemical data were extracted
from patient’s files. The study duration for medical ad-
mission was of two years, spanning from 1 January 2010
- 31 December 2011. A constitutional ethical committee
approval was obtained prior to the data extraction and
The history of SHF class was obtained based on New
York Heart Associations (NYHA) functional classifica-
tion [14]. The clinical findings on examination of third
sound gallop, pulmonary crackles, and raised jugular ve-
nous pressure, hepatomegaly and ankle edema were all
recorded. Height and weight, goiter, murmur suggestive
of aortic or mitral or pulmonary valve disease were all
recorded. Demographic data for previous attacks of heart
failure, hypertension and diabetes mellitus (DM) prior to
admission were all recorded. History of smoking and
previous history for the development of AF were ex-
tracted from the patients’ files. Twelve leads ECG was
analyzed for voltage criteria of left ventricle hypertrophy
using Perugia score [15].
Atrial fibrillation was defined as absence of P wave on
12 leads electrocardiogram (ECG), with irregular ven-
tricular rhythm that lasting for >30 seconds [16]. The
presence of Q wave and conduction abnormality with ST
segment elevation or depression or T wave changes were
all recorded. Echocardiographic data of the M mode, 2-D
echo, Pulsed and Tissue Doppler were all tabulated re-
garding the M mode of LV cavity dimensions and LV
wall thickness. The calculated LV mass index, indices of
left ventricle diastolic fillings such as deceleration time
(DT) in msec, E wave velocity in early diastole in cm/
sand the ratio of early diastolic pulsed to Tissue Doppler
wave (E/Em) were recorded [17].
Based on LVEF% using two dimension echo formula
[18], patients were defined as those SHF with reduced
(LVREF%) of 50% and DHF with preserved
(LVPEF%). Further,those SHF patients were subgrouped
as very mild SHF (LVREF% <43 - 50%), mild (LVREF
of <33 - 43%), moderate (<23 - 33%) and severe
(<22%) [19,20].
The diastolic dysfunction of LV was regarded as se-
vere if deceleration time (DT) of E wave was <160 msec
and the early E Pulsed wave to Tissue Doppler wave
(E/Em ratio) was >12 [21]. The estimated LV mass index
on echo of >131 g/m2 for men and >113 g/m2 for women
was defined as cut off points for severe LVH [22].
The results of available serum level of brain natriuretic
peptide (BNP), uric acid, estimated glomerular filtration
rate (eGFR) and serum potassium were tabulated.
3. Statistical Analysis
The data were analyzed using the statistical package of
social sciences (SPSS) version 20. All data were pre-
sented as mean ± SD. Student’s t-test was used to test the
differences between the mean variables of M mode for
septal wall thickness, LV cavity and LV mass index in
the two groups of heart failure and Chi-square analysis
was used to test the differences between proportions of
categorical variables.
Multiple logistic regression analysis was applied to
calculate the odds ratio for different clinical and bio-
chemical variables for the development of AF in patients
with SHF. All reported p-values are two tailed and p-
value was regarded as significant at level of <0.05.
4. Results
Three hundred and fifty four patients with clinical diag-
nosis of systolic heart failure were enrolled. There were
354 defined as SHF with LVEF <50% on echocardio-
gram. Among the 354 patients with SHF, 12 leads ECG
showed AF in 109 (31%) patients and 245(69%) were in
Open Access IJCM
Prevalence of Atrial Fibrillation in Systolic Heart Failure, Pulsed and Tissue Doppler Echocardiographic Abnormalities
sinus rhythm (SR).
The mean age of patients in the study was 60.47
11.43 years. There were 191 (54.0%) female patients.
There were 30 (8.5%) patients with history of hyper-
tension, 60 (16.9%) with history of smoking, BMI was
>28 in 35(9.9%), history of hyperlipidemia was in 53
(15.0%), patients, DM in 56 (15.8%) and history of
myocardial ischemia in 40% (11.2%).
5. ECG
In the whole study, there were 109 (31%) who had AF on
admission and sinus rhythm was seen in 245 (69%).
Among those who had AF (n = 109) on 12 leads ECG
there were 34 (31%) patients with no history or docu-
ments of previous AF and they were regarded as new
onset of AF, 26 (24%) patients had history of persistent
AF and 49 (45%) patients had history of recurrent or
paroxysmal AF.
Patients with left ventricle hypertrophy based on ECG
criteria were 73 out of 354 (20.6%). Among those with
LVH there were (25.5%) patients with AF and (74.5%)
were in sinus rhythm. The overall sensitivity and speci-
ficity of ECG for detection of LVH compared with LV
mass index derived by echo as gold standard was 79%
and 63% respectively.
6. Clinical Findings
There were 141 (40%) patients with left ventricle failure
manifested with pulmonary odema, 123 (35%) patients
had both left ventricular and right ventricular failure
(biventricular) and 88 (25%) had right sided heart failure.
The history of functional (NYHA) class on admission
was as follow: 70 (20%) patients had functional class IV,
130 (37%) had class III, 152 (43%) patients had func-
tional class II and none had class I.
7. Medication Prior to Admission
There were 336 (94.9%) patients using angiotensin-
converting enzyme blocker (ACE) medication, 239
(67.5%) were on diuretics, 127 (35.9%) on beta blocker,
and 56 (16.9%) were on digoxin medication.
8. Systolic Heart Failure and Patient’s Age
Figure 1 shows the age distribution in patients with SHF.
There were 95 (26.8) patients in the young age category
of <50 years, 114 (40.6%), in age category of between 50
- 65 year and 115 (32.4%) patients in age category of
>65 year.
9. Echocardiographic and Biochemical
Table 1 shows biochemical, M mode, pulsed and tissue
age <50 year50-65age >65 year
Patients number
Figure 1. Distribution of patients according to age in patient
with systolic heart failure, n = 354.
Table 1. The mean value standard deviation (SD) of Bio-
chemical markers and echocardiographic indices in all pa-
tients presented with SHF, N = 354.
N = 109
N = 245 P value
IVS cm 0.98 ± 0.22 0.97 ± 0.94 0.083
PW cm 0.89 ± 0.12 0.88 ± 0.12 0.071
ESD cm 5.72 ± 0.63 5.23 ± 0.76 0.001
EDD cm 6.83 ± 0.51 6.58 ± 0.63 0.001
LV Mass Index 111.58 ± 2.81 112.20 ± 3.050.063
DT msc 163.73 ± 7.42 214.90 ± 31.810.001
E/Em ratio 14.26 ± 1.34 9.99 ± 1.27 0.001
BNP in (pg/ml) 723.72 ± 13.45 686.98 ± 72.570.001
Uric acid (mmol/L)472.25 ± 34.14 397.62 ± 92.080.001
eGFR 56.21 ± 12.59 76.65 ± 10.570.001
Potassium (mmol/L)3.43 ± 0.27 3.78 ± 0.24 0.001
Abbreviations: SHF: Systolic heart failure; IVS Interventricular septum;
PW: posterior wall; ESD: end systolic Dimension; EDD: end diastolic di-
mension; DT: Deceleration time; eGFR: estimated glomerular filtration rate;
AF: Atrial fibrillation; SR: Sinus rhythm; E/Em: ratio of E velocity to Tissue
Doppler velocity of septum; BNP: Brain Natriuretic Peptide.
Doppler echocardiogram results in patients with SHF.
In patients with SHF and AF compared with SR on 12
leads ECG. Echocardiographic M mode measurement
showed no significant difference in LV wall thickness or
LV mass index of P = 0.083 and P = 0.063 respectively.
However LV cavity showed significant dilation in both
systole and diastole. Pulse and tissue Doppler showed
significantly shorter DT of E wave of 163.7 ± 7.4 vs.
214.9 ± 31 msec, P < 0.001, higher E/Em ratio of 14.26 ±
1.34 vs. 9.99.1 ± 1.27, P < 0.05.
10. Biochemical Markers
In SHF patients with AF compared with those in SR,
there was significantly higher level of uric acid, BNP
level but a lower eGFR and low serum potassium. Fur-
thermore, Two D segmental wall motion abnormallities
suggesting ischemia were detected in 38 (11.9%) in pa-
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Prevalence of Atrial Fibrillation in Systolic Heart Failure, Pulsed and Tissue Doppler Echocardiographic Abnormalities 507
tients with AF patients versus 22 (6.7%) in those with SR.
11. Etiological Diagnosis
In patients with SHF (n = 354) there were 113 (31.9%)
patients with dilated cardiomyopathy with global hy-
pokinesia, 31 (8.7%) had hypertension heart failure, 74
(20.9%) had ischemic heart disease with old myocardial
infarction in 36(10.1%) patients, 67 (18.9%) had signifi-
cant valve disease with 28(7.9%) of severe mitral valve
regurgitation and 18(5.0%) had severe aortic regurgita-
tion, 17 (4.8%) patients had thyroid disease and 35 (9.9%)
were of unknown etiology.
12. The Odds Ratio for Risk of AF in SHF
Table 2 shows the hazard ratio of clinical and bio-
chemical variables in the study for the developing of AF
in patients with SHF. After adjusting for age and sex
multiple logistic regression analysis showed positive pre-
dictive value for: history of hypertension of 1.8, history
of DM of 1.7, for BMI >28 of 1.4, LVH on ECG of 2.4.
The positive predictors biomarker were hyperuricemia
>420 mmol/l of 2.1 higher BNP >500 pg/ml of 2.8 and
low estimated glomerular filtration rate (eGFR) <50 of
2.1, LVH of 1.3 and hypokalemia of <3.4 mmol/l of 1.2.
13. Discussion
Patients with heart failure in this study were evaluated
with echocardiogram and ECG for the development of
AF. Patients who had systolic heart failure on echo had
reduced EF 50%. SHF patients had high female distri-
bution and mostly age of between 50 - 65 years. This
finding is in keeping with previous report, where 49% of
patients with systolic heart failure were below the age of
70 year [10].
The overall prevalence of systolic heart failure in the
Table 2. The hazard ratio for the development of AF in
patients presented with systolic heart failure using multiple
logistic regression analysis in patients presented with sys-
tolic heart failure, n = 354.
Variable Odds ratio
95% Confidence
interval P value
History of hypertension 1.8 (1.2 - 2.4) 0.036
History of DM 1.7 (1.2 - 2.2) 0.037
BMI > 28 1.4 (0.9 - 1.9) 0.028
LV hypertrophy on ECG 1.3 (1.0 - 1.6) 0.021
K < 3.4 mmol/L 1.2 (0.9 - 1.5) 0.043
Uric acid > 420 mmol/L 2.1 (1.7 - 2.4) 0.021
eGFR < 50 2.1 (1.5 - 2.8) 0.013
BNP > 500 pg/ml = pg/L 2.8 (2.1 - 3.5) 0.001
Abbreviations: BNP: Brain Natriuretic Peptide; eGFR: estimated Glo-
merular Filtration Rate; K: Potassium; BMS: Body Mass Index.
study in two years was 2.4%. This was lower than other
studies with prevalence of 4.1% and 4.2 respectively
[23,24]. The prevalence in of SHF was 2.4% is similar to
one study by Mureddu GF et al. [25].
The rate of occurrence of AF patients with HF in
whole the study was of 31% which was higher than pre-
vious report found in occurrence of 25% [26].
In different clinical trials, the use of different diagnos-
tic criteria and different age groups leads to variation of
prevalence of HF. In one study by Grewal J, et al., the
prevalence of HF was 1.9% [27] and in another study by
Phillips SJ et al., [28] as the prevalence of HF was of
1.7%. In both studies the prevalence was lower compared
with this study although the prevalence was increasing as
the patient’s age increased.
In this study the percentage of female gender was high
in SHF. In previous studies female gender in SHF ac-
counting to 25% - 35% of systolic heart failure [29]. In
another report male gender had doubled the risk of devel-
oping blood-pumping problems (SHF) compared with
female [30].
The age distribution in SHF showed increment in the
rate of SHF mostly between 50 and 65 year. In one study
the estimated prevalence of systolic dysfunction among
patients was different where 15%, were at ages <50 year,
33% at age of 50 - 70 year, and 50% > 70 years, [31]. In
one report, a higher incidence of SHF was observed in
patients aged <65 years due to ischemia and hypertension
The level of BNP was significantly higher in SHF with
AF. This finding had been shown previously, where BNP
was significantly high in dilated SHF [27]. In one report
higher level of BNP >100 pg/ml was shown as an inde-
pendent predictor of adverse cardiovascular outcome in
patients with DHF [33].
The serum level of potassium in AF patients in pa-
tients with SHF was lower than those with Sinus rhythm.
Previous studies showed the incidence of AF compared
with SR is inversely related with level of serum Potas-
sium [34].
In this study a higher rate of segmental wall motion
abnormality on echo was detected in patients with AF.
The causative agents of SHF were mainly idiopathic di-
lated myopathy followed by valvular heart disease. In
one report by Topol et al., hypertension and ischemia
were the main etiology of DHF [35].
Patients in SHF with dilation of LV on echo, tachycar-
dia-mediated cardiomyopathy were presumed to be the
causative agent in 29% of patients with HF however. In
this subset of patients improvement of LV function is ex-
pected to improve as patient revert to sinus rhythm [36, 37].
14. Conclusion
The prevalence of SHF was 2.4% in the study population,
Open Access IJCM
Prevalence of Atrial Fibrillation in Systolic Heart Failure, Pulsed and Tissue Doppler Echocardiographic Abnormalities
with the incidence of AF being 31% in the whole study.
The best predictors of AF in HF were high BNP >500
pg/ml, left ventricle hypertrophy on ECG followed by
history of hypertension and DM.
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