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Estimation of atrial fibrillation recency of onset and safety of cardioversion using NTproBNP levels in patients with unknown time of onset
  1. Spyridon Deftereos1,
  2. Georgios Giannopoulos1,
  3. Charalampos Kossyvakis1,
  4. Konstantinos Raisakis1,
  5. Andreas Kaoukis1,
  6. Constadina Aggeli2,
  7. Konstantina Toli3,
  8. Andreas Theodorakis4,
  9. Vasiliki Panagopoulou1,
  10. Metaxia Driva1,
  11. Ioannis Mantas2,
  12. Vlasios Pyrgakis1,
  13. Ilias Rentoukas5,
  14. Christodoulos Stefanadis2
  1. 1Department of Cardiology, Athens General Hospital “G Gennimatas”, Athens, Greece
  2. 21st Cardiology Department, University of Athens Medical School, Athens, Greece
  3. 3Department of Cardiology, Chalkida General Hospital, Chalkida, Greece
  4. 4Department of Cardiology, Mesologgi General Hospital, Mesologgi, Greece
  5. 52nd Cardiology Department, “A Fleming” General Hospital, Melissia, Greece
  1. Correspondence to Georgios Giannopoulos, Cardiology Department, Athens General Hospital “G. Gennimatas”, 154 Mesogeion Ave, 11527 Athens, Greece; ggiann{at}


Objective As shown previously in patients with new-onset atrial fibrillation (AF) without symptoms or signs of heart failure, N-terminal pro-brain natriuretic peptide (NTproBNP) increases rapidly, reaching a maximum within 24–36 h, and then decreases even if AF persists. A study was undertaken to use NTproBNP measurements in patients with AF of unknown time of onset to identify patients with presumed recent onset of the arrhythmia.

Design Two-group open cross-sectional study.

Setting Hospitalised patients in cardiology departments of four hospitals.

Patients Patients presenting with AF of unknown onset and no signs or symptoms of heart failure were separated into two groups: group A with NTproBNP above the cut-off level and group B with a low NTproBNP level.

Interventions No therapeutic intervention. All patients underwent transoesophageal echocardiography (TEE).

Main outcome measures Presence of left atrial thrombus on TEE.

Results In group A (N=43) only two patients (4.7%) were found to have an atrial thrombus on TEE (negative predictive value of raised NTproBNP levels 95.3%) compared with 13 of 43 patients in group B (30.2%; p=0.002). Patients with a higher CHA2DS2VASc score (p=0.002) and a larger left atrium (p<0.001) were more likely to have an atrial thrombus. In the multivariate analysis, NTproBNP below the cut-off level was the most powerful predictor of the presence of thrombus (OR 25.0; p=0.016).

Conclusion The reported strong correlation between raised NTproBNP levels and the absence of atrial thrombi on TEE suggests that the short-term increase in NTproBNP levels after AF onset might be used to assess the age of the arrhythmia and thus the safety of cardioversion in patients with AF of unknown onset and no heart failure.

  • Atrial fibrillation
  • transesophageal echocardiography
  • amino-terminal pro-B natriuretic peptide
  • thromboembolic risk

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  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval This study was conducted with the approval of the review boards of the participating hospitals.

  • Provenance and peer review Not commissioned; externally peer reviewed.