The History of Atrial Fibrillation: The Last 100 Years

Eric N. Prystowsky, M.D.

Disclosures

J Cardiovasc Electrophysiol. 2008;19(6):575-582. 

In This Article

Abstract and Introduction

Abstract

Atrial fibrillation (AF) has had a rich history that has touched the careers of many of the great clinicians and investigators of the 20th century. More recently, there has been an explosion of research into various aspects of the mechanisms and therapy for AF, as evidenced by over 8,000 publications on AF from 2000 to 2007. A century of research and clinical observations, coupled with modern investigative technologies, has enabled modern investigators to have their own "fantastic voyage" as they travel beyond the cell borders into the ionic mechanisms responsible for AF and its many atrial perturbations. One can only imagine the satisfaction of Wenckebach, MacKenzie, and Lewis if they could see how their seeds of wisdom have grown into such sturdy ideas, or how delighted Scherf would be to learn that his ectopic focus theory for AF has been given new life.

This paper on 100 years of AF was initially prepared for presentation as the Plenary Lecture at the AFib Summit for Heart Rhythm 2007 in Denver, Colorado. I have tried to provide the reader with some of the most important observations on AF, realizing that it would be impossible to include all or even most of the major research done during this time frame. I apologize to my many colleagues whose research has helped us to understand better the clinical and basic aspects of AF, yet who could not be cited for lack of space.

Introduction

Physicians have been fascinated by the pulse of patients for centuries. Moses Maimonides in approximately 1,187 wrote aphorisms that pertained to the human pulse.[1] He described in some of his writings a totally irregular pulse that was most likely atrial fibrillation. Other notable physicians who described an irregular pulse that was most likely atrial fibrillation were William Stokes and Wenckebach.[2,3] MacKenzie[4] made an in-depth study of pulse tracings. He recorded simultaneous tracings of jugular and radial pulses in a patient that had a continuing irregular pulse, and one can see that there are absent a-waves. The development of the electrocardiogram by Einthoven and the many studies both he and Sir Thomas Lewis did clearly put atrial fibrillation "on the map." The more recent explosion of literature on atrial fibrillation is impressive (Fig. 1). Note from this Medline search using atrial or auricular fibrillation as search words that there were 19,405 references, and these are only from the time that Medline came into use. Most importantly, observe that the last seven years have counted for nearly one half of all recorded publications. It would be an impossible task to comment on all the many important observations on atrial fibrillation over the past 100 years, and this review will try to highlight what this writer feels are some of the key observations.

Figure 1.

Medline search for publications on the topic of atrial or auricular fibrillation.

Professor Einthoven had an ongoing communication with Sir Thomas Lewis.[5] In one such letter he states, "Dear Professor Einthoven, by this post I am sending you some curves, experimental and clinical. Please treat the curves I send you as if they were your own."[5] If one analyzes the tracings, it is clear that this patient has atrial fibrillation. The mechanism of atrial fibrillation was evaluated by Garrey.[6] In one of his experiments performed on mammal auricules, he applied faradic current to the tip of the auricular appendix until there were sustained fibrillatory contractions. He then separated the fibrillating auricles and the appendix stopped its fibrillation; however, the auricles continued to fibrillate. He hypothesized that there needed to be a critical tissue mass to allow fibrillation to continue. Sir Thomas Lewis made many important observations on atrial fibrillation in humans and performed a variety of experiments trying to understand the mechanism of atrial fibrillation.[7–10] He defined it as "conspicuous and continuous oscillations of varying form and dimensions, and of auricular origin."[9] He further stated that atrial fibrillation affects the whole auricular surface with the excitation wave or its offshoots, and it has a varying path of excitation.

In a study by Yater[11] in 1929, 145 patients underwent autopsy. The most common etiologies of these patients with atrial fibrillation were chronic endocarditis (19%), exophthalmic goiter (25%), adenomatous goiter (19%), and hypertension (8%). Note that these etiologies from this early pathology study on atrial fibrillation are in marked contrast to the main cause of atrial fibrillation today, namely, hypertension. Yater further stated that no distinctive lesion for atrial fibrillation was found and that the lesions themselves were not considered of sufficient importance to explain the arrhythmia.

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