Medicine Department : Dr Venkanna's Narketpally cardiac arrhythmia triad of atrial fibrillation, hypertension and LV dysfunction

SUMMARY

The study included 50 patients with a mean age of 70.46 +/- 12.93 years. The age distribution showed 6% were 50–59, 32% were 60–69, 32% were 70–79, 26% were 80–89, and 4% were 90–99. Males comprised 70% and females 30%. Clinical findings included universal dyspnea (100%), pedal edema (82%), raised JVP (64%), prior heart failure admissions (36%), and a history of admissions (40%). Mean vitals were heart rate 108.14 bpm and systolic blood pressure 125.92 mmHg. Laboratory values were hemoglobin 11.25 g/dL, blood urea 62.18 mg/dL, and creatinine 3.81 mg/dL. Prevalence of comorbidities included hypertension (66%), CKD (46%), diabetes (42%), CAD (30%), and COPD (24%). Risk factors such as alcohol (28%) and smoking (22%) were present. Hypertension was significantly higher in females (p=0.005). Atrial fibrillation occurred in 94% of patients. Clinical outcomes showed 62% improved while 38% expired. The average stay was 7–10 days. Echocardiography showed 74% with LVEF <40%, RWMA (42%), TR (36%), and PAH (28%). Sepsis-related mortality was highest at 57.1%.

Thematic Analysis

1. *Demographics and Comorbidities*: The study population was predominantly male (70%), with a mean age of 70.46 years. Hypertension (66%), CKD (46%), and diabetes (42%) were common comorbidities.

2. *Clinical Presentation and Outcomes*: Dyspnea (100%), pedal edema (82%), and atrial fibrillation (94%) were prominent clinical features. The mortality rate was 38%, with sepsis being a major contributor.

3. *Treatment and Prognosis*: Patients had a prolonged hospital stay (7-10 days), with 62% showing improvement. Echocardiography revealed significant left ventricular dysfunction (LVEF <40% in 74%) and pulmonary hypertension (28%).

Narketpally Cardiac Arrhythmia Triad

Based on the themes, we propose the following triad for Narketpally:

1. *Atrial Fibrillation*: The most common arrhythmia (94%)

2. *Hypertension*: A prevalent comorbidity (66%) and significant risk factor, especially in females

3. *Left Ventricular Dysfunction*: LVEF <40% in 74% of patients, indicating significant cardiac dysfunction

This triad highlights the interplay between arrhythmia, hypertension, and cardiac dysfunction in the Narketpally population.

STUDY PERIOD: January 2024 to December 2025

STUDY DESIGN: Prospective Study, Observational study

SAMPLE SIZE: No.of cases to be studied = 50

INCLUSION CRITERIA:

Patient of any gender above or equal to 18 yrs of age at the time of presentation with arrhythmias

EXCLUSION CRITERIA:

All confirmed cases of Patients below 18 years of age

Patients not capable of giving consent (mentally-ill patients)

Patients not willing to participate in study (non-consenting patients)

Methodology

Arrhythmias are the deviation from the normal heart beat pattern . They include abnormalities of impulse formation such as heart rate rhythm or site of impulse origin and conduction disturbances ,which disturbed the normal sequence of atrial and ventricular activation

Tachyarrhythmia

Supraventricular

atrial fibrillations

atrial flutter

Ventricular

ventricular tachycardia

ventricular fibrillation

Bradyarrhythmias

Supraventricular

sinus node dysfunction

A V nodal dysfunction

heart block

Ventricular

ventricular asystole

Patients having irregular pulse and irregular heart rate in ECG are selected from cases coming to a tertiary centre in Narketpally.

Consent is taken from patient after explaining about the assessment and further follow up.

Patient examination and detailed history taken.

Necessary investigations done.

Patient Prognosis, outcomes are assessed by follow up every 3 months for 2 years.

OBSERVATIONS AND RESULTS

Previous analysis of the same 50 patient EMR data: https://pajrcasereporter.blogspot.com/2025/11/cardiac-arrhythmia-projr_26.html?m=1

Based on the detailed case discussions, thematic analyses, and management patterns documented in the provided blog post "Cardiac Arrhythmia ProJR," here is a structured paper in the standard IMRAD (Introduction, Methods, Results, and Discussion) format.

Title: Clinical Profile, Management, and Outcomes of Cardiac Arrhythmias in a Real-World Cohort: A Thematic Analysis of 50 Inpatient Cases from Rural India**

Abstract

**Background:** Cardiac arrhythmias, particularly atrial fibrillation (AF), are major causes of morbidity and mortality, especially in elderly populations with multiple comorbidities. Real-world data on their presentation and management in resource-constrained settings are limited.

Methods:** We conducted a retrospective thematic analysis of 50 inpatient electronic medical record (EMR) summaries of patients with cardiac arrhythmias admitted to a hospital in Narketpally, India. The cases were sourced from an archived database, divided into two sets of 25, and analyzed using multiple large language models (LLMs) to identify recurring themes in demographics, clinical presentation, management, and outcomes.

Results:** The cohort was predominantly elderly (ages 70-80+), with a high burden of multimorbidity. A "Cardio-Metabolic-Renal Syndrome" (hypertension, diabetes, chronic kidney disease) was nearly universal. Atrial Fibrillation was the central arrhythmia, often presenting not with palpitations but with acute decompensated heart failure. Infections (pneumonia, UTI, cellulitis) were major precipitants of hospitalization. Echocardiography revealed a high prevalence of severe LV dysfunction and valvular disease. Management followed a four-pillar approach: rate control (beta-blockers, digoxin, amiodarone), rhythm control (amiodarone), anticoagulation (predominantly DOACs), and heart failure therapy (diuretics, GDMT). Outcomes included high in-hospital mortality, often from a cascade of organ failure ("refractory shock") triggered by sepsis, and a significant rate of cardioembolic stroke.

Conclusion:** This analysis reveals that AF in this real-world setting acts as a potent destabilizing force in a fragile, multimorbid population. The high incidence of stroke and mortality underscores the critical need for early detection, consistent anticoagulation, and integrated care addressing both cardiac and non-cardiac precipitants. Thematic analysis using LLMs proved a valuable tool for rapidly synthesizing clinical patterns from unstructured EMR data.

Introduction

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a leading cause of stroke, heart failure, and death worldwide. Its prevalence increases with age, and it rarely occurs in isolation, frequently coexisting with hypertension, diabetes, coronary artery disease, and chronic kidney disease [1]. While clinical guidelines for AF management are well-established [2], their application in real-world, resource-limited settings and the true clinical journey of these complex patients are often poorly documented.

Traditional retrospective studies often rely on structured data extraction, which can miss the nuanced interplay of comorbidities, acute precipitants, and clinical decision-making captured in detailed medical records. The "Patient Journey Recorder" (PaJR) project archives such detailed EMR summaries, offering a unique opportunity to study these complexities. The primary aim of this study was to perform a thematic analysis of 50 consecutive cardiac arrhythmia inpatient cases from this archive to characterize the real-world clinical profile, management strategies, and outcomes, thereby identifying key themes and areas for improving care.

Methods

**Study Design and Data Source:** This was a retrospective, thematic analysis of existing, anonymized patient data. The data source was a publicly accessible blog ("PaJR Case Reports") containing 50 archived inpatient EMR summaries of patients with cardiac arrhythmias from Narketpally, India (linked from the primary analysis blog post) [3].

**Data Processing and Analysis:** The analysis was conducted in a multi-step process to manage the data volume and leverage analytical capabilities:

1. **Data Stratification:** The complete set of 50 cases was manually divided into two equal cohorts of 25 cases each to facilitate processing.

2. **Thematic Analysis:** Each cohort's text data was input into multiple large language models (LLMs) with a standardized prompt requesting a thematic analysis. The prompt asked for emerging themes related to patient demographics, clinical presentation, diagnostic patterns, pharmacological management, and outcomes.

3. **Synthesis:** The thematic analyses from both cohorts were then synthesized by the lead analyst (hu2) into a comprehensive final report. This synthesis identified overarching themes, recurring patient "archetypes," and key management patterns across all 50 cases. The process was guided and validated by clinical experts within the PaJR collaborative (e.g., cm, hu4).

4. **Complementary Quantitative Analysis (Post-hoc):** Following the thematic analysis, a manual, quantitative analysis of the same 50 cases was performed to extract specific demographic and outcome statistics (mean age, gender ratio, length of stay, mortality by etiology) for comparison [4].

Results

The thematic analysis of the 50 cases revealed consistent patterns across six major domains.

**1. Patient Demographics and Comorbidity Profile**

The cohort was overwhelmingly geriatric, with most patients in their 70s and 80s. Isolated AF was virtually non-existent. Instead, the cases were characterized by a complex interplay of multiple chronic conditions.

* **Universal Cardiovascular Comorbidities:** Hypertension, coronary artery disease (CAD), and heart failure (HF) were nearly universal. HF with reduced Ejection Fraction (HFrEF) appeared more common than HF with preserved EF (HFpEF).

* **High Prevalence of Renal Dysfunction:** A significant number of patients presented with Acute Kidney Injury (AKI) on a background of Chronic Kidney Disease (CKD), highlighting the recurrent theme of "cardio-renal syndrome."

* **Metabolic and Other Conditions:**

Type 2 Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), and hypothyroidism were frequently noted.

**2. Clinical Presentation and Precipitating Factors**

* **Dominant Mode of Presentation:**

The most common reason for admission was not palpitations, but symptoms of **acute decompensated heart failure**, including shortness of breath (SOB), orthopnea, paroxysmal nocturnal dyspnea (PND), and bilateral pedal edema.

* **AF as Both Cause and Consequence:** AF often acted as the trigger for acute decompensation in a chronically failing heart (tachycardiomyopathy). Conversely, critical illness, particularly infection, frequently precipitated new-onset AF.

* **The Role of Acute Precipitants:** **Infection** (pneumonia, urinary tract infections, cellulitis) emerged as the single most common acute event leading to hospitalization and clinical deterioration. Non-compliance with medications was also implied in several cases.

**3. Diagnostic and Investigative Patterns**

* **Echocardiography:** 2D Echo was central to management. Findings consistently showed severe LV dysfunction (EF often <30-35%), significant valvular dysfunction (moderate to severe Mitral Regurgitation (MR) and Tricuspid Regurgitation (TR)), and markers of fluid overload (dilated chambers, non-collapsing IVC).

* **Biochemical Hallmarks:** Metabolic acidosis and worsening renal function (rising urea and creatinine) were consistent features in deteriorating patients and correlated with poor outcomes.

**4. Pharmacological Management Strategies (The "Four Pillars")**

The treatment approach followed a remarkably consistent pattern:

* **Pillar 1: Rate and Rhythm Control:** **Beta-blockers** (Metoprolol) were the most common agents for rate control. **Amiodarone** was used extensively for both acute rate and rhythm control, especially in patients with structural heart disease. **Digoxin** was a frequent add-on for rate control in HFrEF.

* **Pillar 2: Anticoagulation and Antiplatelet Therapy:** **Direct Oral Anticoagulants (DOACs)** —Dabigatran, Rivaroxaban, and Apixaban—were the predominant choice for stroke prevention, reflecting a shift from warfarin. "Triple therapy" (aspirin, clopidogrel, and an anticoagulant) was used in patients with concomitant CAD and AF.

* **Pillar 3: Heart Failure Management:** Loop diuretics (Furosemide) were a cornerstone for volume overload. There was consistent use of Guideline-Directed Medical Therapy (GDMT) for HFrEF, including ARNI (Sacubitril/Valsartan), MRAs (Spironolactone), and SGLT2 inhibitors (Dapagliflozin) in later cases.

* **Pillar 4: Comorbidity and Precipitant Management:** This involved aggressive antibiotic use for infections and standard management of hypertension and diabetes.

**5. Outcomes and End-of-Life Care**

* **High In-Hospital Mortality:** A significant proportion of cases resulted in death, underscoring the high-risk nature of the cohort.

* **Mode of Death:** Death was rarely due to a single cause but was typically the result of a **cascade of organ failures—"refractory shock"** in the setting of sepsis with multi-organ dysfunction syndrome (MODS) or cardiogenic shock.

* **Major Complication - Cardioembolic Stroke:** The most devastating complication of AF was ischemic stroke, often large and disabling (e.g., MCA territory infarcts). These cases represented a "preventable tragedy," highlighting critical gaps in anticoagulation.

**6. Systemic and Documentation Themes**

* Discharge summaries were remarkably detailed, indicating a structured approach to patient education.

* Clear referrals to other specialties demonstrated an interdisciplinary care approach.

* "LAMA" (Leave Against Medical Advice) was a documented outcome, highlighting challenges in patient adherence.

**Comparison with Quantitative Analysis**

A subsequent manual quantitative analysis provided statistical validation for these themes [4]:

* **Demographics:** Mean age 71.9 ± 9.7 years; 70% Male, 30% Female.

* **Etiology-based Mortality:** Ischemic heart disease was the most common underlying etiology and carried the highest mortality (29.6%). In contrast, patients with a primary etiology of hypertensive heart disease had 0% in-hospital mortality.

* **Length of Stay:** Mean hospitalization was 4.4 days.

### **Discussion**

This thematic analysis of 50 real-world cases provides a granular and clinically rich picture of cardiac arrhythmia management in a comorbid, elderly Indian population. The central finding is that **Atrial Fibrillation acts as a potent destabilizing force on a fragile physiological baseline**, where the clinical course is often dictated as much by non-cardiac factors (infection, renal failure) as by the arrhythmia itself.

The study's findings have several important implications. First, the high frequency of cardioembolic stroke reinforces the critical public health priority of identifying AF and implementing guideline-adherent anticoagulation. The predominant use of DOACs in the management summaries suggests an awareness of current guidelines, yet the occurrence of these strokes points to significant gaps in screening, initiation, and perhaps adherence to therapy in the community.

Second, the dominance of heart failure symptoms at presentation and the identification of infection as a major precipitant highlight the need for an integrated, holistic care model. Effective management extends beyond rhythm or rate control to include aggressive management of volume status, optimization of GDMT for HF, and prompt recognition and treatment of infections. This aligns with the concept of managing AF as part of a broader "Cardio-Metabolic-Renal" syndrome rather than an isolated electrical disorder.

Third, the outcomes, particularly the high mortality and the "cascade of organ failure" observed in deceased patients, illustrate the grim prognosis for this population once they cross a certain threshold of acute-on-chronic illness. The 0% mortality in the hypertensive heart disease subgroup, compared to the high mortality in the ischemic group, suggests that the underlying myocardial substrate is a key determinant of short-term outcomes, a nuance captured by the subsequent quantitative analysis.

This study has several limitations. As a retrospective analysis of EMR summaries, it is subject to the completeness and accuracy of the original documentation. The use of LLMs for thematic analysis, while efficient, may introduce a degree of interpretive variability, although the synthesis by clinical experts mitigates this. Finally, the findings from a single center may not be generalizable to all settings.

**Conclusion:** This real-world analysis demonstrates that AF in elderly, multimorbid patients is a complex condition where outcomes are determined by the interplay of cardiac dysfunction, comorbidities, and acute precipitants like infection. The high incidence of stroke and death underscores an urgent need for improved primary prevention through systematic AF screening and anticoagulation, coupled with integrated care models that address the full spectrum of patient vulnerability. The combined use of LLM-driven thematic analysis and traditional quantitative methods proved a powerful approach for extracting actionable insights from unstructured clinical data.

### **References**

1. Benjamin, E. J., et al. (2019). Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association. *Circulation*.

2. Hindricks, G., et al. (2020). 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation. *European Heart Journal*.

3. PaJR Case Reports. (2025, November 26). Cardiac Arrhythmia ProJR. Retrieved from [Provided Blog Link]

4. (Assumed reference for the manual analysis results shared in the conversation on 12/12/2025). Dr. Venkanna's Narketpally Cardiac ProJR Analysis. *Internal PaJR Document*.

TABLE 1: AGE DISTRIBUTION

Age in years

Count (n=50)

Percentage

50–59

6.0%

60–69

32.0%

70–79

32.0%

80–89

26.0%

90–99

4.0%

Total

100%

Mean ± SD

70.46 ± 12.93 years

The cohort predominantly comprised elderly individuals, with the highest concentration between 60–79 years. The mean age of approximately 70 years reflects an aging cardiovascular population vulnerable to arrhythmias and heart failure. Very advanced age groups were fewer, indicating progressive mortality or reduced hospital presentation beyond the ninth decade.

TABLE 2: SEX DISTRIBUTION

Sex

Count (n=50)

Percentage

Male

70.0%

Female

30.0%

Males constituted the majority of admissions, representing about two-thirds of the study population. This male predominance aligns with known epidemiological trends in cardiovascular disease and arrhythmias. However, the presence of a substantial female subgroup enables meaningful gender-based comparisons in comorbidities, risk factors, and clinical outcomes within the cohort.

TABLE 3: CLINICAL PRESENTATION ON ADMISSION

Symptom / Sign

Count (n=50)

Percentage

Dyspnea (NYHA III–IV)

100%

Pedal edema

82.0%

Raised JVP

64.0%

Prior heart failure admission

36.0%

History of admissions

40.0%

Dyspnea was universal, confirming acute cardiac decompensation as the principal presentation. High frequencies of pedal edema and raised jugular venous pressure further support congestive heart failure physiology. Prior admissions and recurrent symptoms indicate chronic disease burden, emphasizing the relapsing nature of advanced cardiac dysfunction in elderly hospitalized patients.

TABLE 4: VITAL SIGNS ON ADMISSION

Parameter

Mean

Heart Rate (bpm)

108.14

24.85

Systolic BP (mmHg)

125.92

26.99

Elevated mean heart rate with wide variability reflects tachyarrhythmia-driven hemodynamic stress. Systolic blood pressure remained relatively preserved overall, suggesting compensated or mixed shock states rather than profound hypotension. These findings are consistent with atrial fibrillation-related rapid ventricular response occurring in structurally compromised yet partially perfused cardiovascular systems.

TABLE 5: LABORATORY PARAMETERS

Parameter

Mean

Hemoglobin (g/dL)

11.25

2.10

Blood Urea (mg/dL)

62.18

41.07

Serum Creatinine (mg/dL)

3.81

14.67

Serum Sodium (mEq/L)

136.63

3.53

Serum Potassium (mEq/L)

4.13

0.57

Laboratory evaluation demonstrated mild anemia, significant azotemia, and marked variability in renal function, indicating frequent cardiorenal involvement. Electrolyte levels were largely maintained within near-normal ranges. Overall, the biochemical profile reflects chronic systemic illness with superimposed acute decompensation, commonly observed in elderly patients with advanced cardiovascular disease.

TABLE 6: PREVALENCE OF COMORBIDITIES

Comorbidity

Present

Absent

Prevalence

Hypertension

66.0%

CKD

46.0%

Diabetes Mellitus

42.0%

CAD

30.0%

COPD

24.0%

Dyslipidemia

6.0%

Hypertension emerged as the most prevalent comorbidity, followed by chronic kidney disease and diabetes. Coronary disease and pulmonary pathology were moderately represented, while dyslipidemia was relatively uncommon. This distribution underscores the clustering of cardiometabolic and renal disorders that collectively amplify arrhythmia susceptibility and worsen hospitalization outcomes.

TABLE 7: PERSONAL HISTORY

Risk Factor

Present

Prevalence

Alcohol

28.0%

Smoking

22.0%

Alcohol use and smoking were present in notable minorities, representing modifiable cardiovascular risk exposures. Although not universal, their contribution to myocardial injury, arrhythmogenesis, and disease progression remains clinically meaningful. These findings reinforce the importance of lifestyle modification strategies alongside pharmacologic and interventional cardiac management in elderly populations.

TABLE 8: GENDER DIFFERENCES IN RISK FACTORS

Risk Factor

Total

Male

Female

P-value

Smoking

0.139

Hypertension

0.005

Hypertension showed a statistically significant female predominance, suggesting differing vascular risk profiles between sexes in late life. Smoking was more frequent among males but without statistical significance. These gender-specific patterns highlight the need for tailored preventive strategies and may partially explain variation in disease expression and outcomes.

TABLE 9: ETIOLOGICAL PROFILE OF ARRHYTHMIAS

Etiology(Grouped etiologies)

Count (n=50)

Percentage

Ischemic heart disease

54%

Hypertensive heart disease

22%

Sepsis / infection

14%

Valvular

Others

Ischemic heart disease was the leading precipitant, acCount (n=50)ing for over half of arrhythmia cases. Hypertensive, infectious, and valvular causes were less frequent. This hierarchy emphasizes myocardial ischemia as the dominant pathological substrate driving electrical instability and supports aggressive ischemia prevention and management in high-risk elderly patients.

TABLE 10: ECG PATTERNS

Arrhythmia

Count (n=50)

Percentage

Atrial fibrillation

94%

Other rhythms

Atrial fibrillation overwhelmingly dominated electrocardiographic findings, confirming it as the principal rhythm disturbance responsible for acute admissions. Only a small minority exhibited alternative rhythms. This pattern reflects the strong association between structural heart disease, aging myocardium, and atrial electrical remodeling leading to sustained fibrillatory activity.

TABLE 11: CLINICAL OUTCOMES

Outcome

Count (n=50)

Percentage

Improved

62%

Expired

38%

Most patients improved with treatment, though mortality remained substantial. The observed death proportion reflects severe baseline cardiac dysfunction and advanced age. These outcomes highlight both the effectiveness of acute management in many patients and the persistent high-risk nature of arrhythmia-associated hospitalizations in elderly cardiovascular populations.

TABLE 12: LENGTH OF STAY

Statistic

Value

Mean duration

~7–10 days

Range

1–14 days

Hospitalization duration averaged approximately one week, consistent with stabilization and rhythm control management timelines. The observed range indicates variability in clinical severity, complications, and recovery speed. Length of stay therefore indirectly reflects heterogeneity in disease burden and treatment response among elderly cardiac admissions.

TABLE 13: ETIOLOGY VS MORTALITY

Etiology

Total

Deaths

Mortality

Ischemic

40.7%

Sepsis

57.1%

Hypertensive

27.3%

Valvular

33.3%

P-value

0.122 (NS)

Higher mortality within ischemic and sepsis-related arrhythmias suggests greater systemic and myocardial injury in these groups. However, the absence of statistical significance indicates overlapping risk across etiologies. Mortality therefore appears multifactorial, influenced by age, comorbidities, and cardiac dysfunction rather than etiology alone.

TABLE 14: HYPERTENSION VS OUTCOME

Status

Improved

Expired

Hypertensive (n=33)

Non-hypertensive (n=17)

P-value

>0.05 (NS)

Deaths occurred in both hypertensive and non-hypertensive patients, though numerically greater among hypertensives due to higher prevalence. Lack of statistical significance suggests hypertension contributes to overall disease burden without independently determining survival. Outcomes likely depend on combined effects of cardiac function, renal status, and acute illness severity.

TABLE 15: AGE VS OUTCOME

Outcome

Mean Age

Expired

73 years

Improved

69 years

Expired patients were modestly older than survivors, indicating age-related physiological decline contributes to vulnerability. However, the difference was limited, implying chronological age alone is insufficient to predict mortality. Functional reserve, comorbidity load, and cardiac dysfunction likely exert stronger influence on clinical outcomes.

TABLE 16: 2D ECHO FINDINGS

Parameter

Finding

Count (n=50)

Percentage

LVEF

Preserved ≥50%

Mildly reduced 40–49%

18%

Reduced <40%

74%

RWMA

Present

42%

Present

36%

Present

12%

Present

10%

PAH

Present

28%

Pericardial effusion

Present

LV aneurysm

Present

Most patients demonstrated reduced ejection fraction with frequent regional wall motion abnormalities and valvular lesions, confirming advanced structural heart disease. Pulmonary hypertension and pericardial involvement were less common. Overall, echocardiography depicts a population with severe myocardial compromise predisposing to arrhythmia and adverse prognosis.

DISCUSSION

Age Distribution

In the present study, the age distribution of the 50 patients presenting with cardiac arrhythmias revealed a predominantly elderly population, with a mean age of 70.46 ± 12.93 years. The highest frequency of patients fell within the 60–79 years age bracket, accounting for 64% of the total cohort. These findings indicated that the incidence of arrhythmias and associated cardiac decompensation rose significantly with advancing age, likely due to the cumulative burden of degenerative myocardial changes and prolonged exposure to cardiovascular risk factors. The relatively smaller proportion of patients in the very advanced age group (90–99 years) potentially reflected a "survivor effect" or reduced hospitalization rates in this demographic.

When comparing these results with contemporary literature, a distinct variation in age profiles across different geographical and clinical settings was observed. Our cohort was notably older than the populations described in studies from developing regions or emergency settings. For instance, Dudhrejia et al. (2025) reported a much younger mean age of 43.52 years in their emergency department study, and Kiyeng et al. (2023) found a median age of 46 years in a Kenyan cardiac care unit. In contrast, our findings aligned more closely with large-scale registries focusing on atrial fibrillation in developed or specific high-risk populations. Naser et al. (2017) reported a mean age of 68 ± 13 years, which was statistically comparable to our data. Similarly, Zhao et al. (2025) identified a median age of 73.0 years in their high-complexity cluster, supporting the observation that complex arrhythmia presentations are characteristic of the seventh and eighth decades of life.

Table 17: Comparison of Age Distribution with Other Studies

Author (Year)

Study Population

Age Statistic (Years)

Present Study

n=50

Mean 70.46

Dudhrejia et al. (2025)

Emergency Dept (India)

Mean 43.52

Kiyeng et al. (2023)

Cardiac Care Unit (Kenya)

Median 46

Yinadsawaphan et al. (2025)

PAH Patients (USA)

Mean 56.1

Naser et al. (2017)

AF Patients (Bosnia)

Mean 68 ± 13

Zhao et al. (2025)

AF Registries (Europe/Asia)

Median 73.0

Sex Distribution

The current study demonstrated a marked male preponderance, with 70% of the admitted patients being male and 30% female. This 2.3:1 male-to-female ratio suggested a higher susceptibility or earlier presentation of severe arrhythmia-related complications in men within this study population. The dominance of males in cardiovascular cohorts is a well-documented phenomenon, often attributed to differences in hormonal protection, lifestyle risk factors such as smoking and alcohol consumption, and the earlier onset of coronary artery disease in men. The female cohort, while smaller, represented a significant subgroup with distinct clinical characteristics, particularly regarding hypertension prevalence.

The male dominance observed in our study was consistent with findings from several other researchers but contrasted with specific disease-focused cohorts. Dudhrejia et al. (2025) reported a similar trend, with 75.4% of their emergency arrhythmia patients being male.

Conversely, Kiyeng et al. (2023) observed a female majority (59.4%) in their study, likely driven by the high prevalence of rheumatic heart disease in that specific region, which disproportionately affects females. Similarly, Yinadsawaphan et al. (2025) reported an 81.8% female preponderance, but this was expected given their focus on Pulmonary Arterial Hypertension (PAH), a condition known to be more prevalent in women. Naser et al. (2017) reported a more balanced but still male-predominant distribution (52%), further validating that general atrial fibrillation cohorts tend to skew towards males.

Table 18: Comparison of Sex Distribution with Other Studies

Author (Year)

Male Percentage

Female Percentage

Dominant Sex

Present Study

70.0%

30.0%

Male

Dudhrejia et al. (2025)

75.4%

24.6%

Male

Kiyeng et al. (2023)

40.6%

59.4%

Female

Yinadsawaphan et al. (2025)

18.2%

81.8%

Female

Naser et al. (2017)

52.0%

48.0%

Male

Zhao et al. (2025)

63.4% (High complexity)

36.6%

Male

Clinical Presentation on Admission

In this study, the clinical presentation was dominated by signs of acute cardiac decompensation. Dyspnea (NYHA class III–IV) was a universal finding, present in 100% of the patients, indicating that respiratory distress was the primary driver for hospital admission. Pedal edema was observed in 82% of cases, and raised jugular venous pressure (JVP) in 64%, confirming that the majority of patients presented with congestive heart failure precipitating or complicating their arrhythmia. The high rate of prior heart failure admissions (36%) further highlighted the chronic, progressive nature of the disease in this elderly cohort.

Comparing these findings with the literature revealed that while symptoms were similar, the severity and frequency in our cohort were notably higher. Dudhrejia et al. (2025) reported shortness of breath in 44.6% and cough in 44.6% of their patients. The lower frequency of dyspnea in their study compared to our 100% prevalence suggests that our cohort likely suffered from more advanced structural heart disease or presented at a later stage of decompensation. The universal presence of dyspnea in our study aligns with the pathophysiology of atrial fibrillation with rapid ventricular response, where the loss of atrial kick and reduced diastolic filling time precipitates failure in non-compliant ventricles. This comparison suggests our study population represented a "sicker" subset of patients requiring urgent hospitalization for heart failure management

Table 19: Comparison of Clinical Presentation with Other Studies

Author (Year)

Dyspnea / SOB

Chest Pain

Present Study

100%

Dudhrejia et al. (2025)

44.6%

28.5%

Vital Signs on Admission

The hemodynamic profile of patients in our study was characterized by tachycardia and preserved systolic blood pressure. The mean heart rate was 108.14 ± 24.85 bpm, reflecting the prevalence of tachyarrhythmias such as atrial fibrillation with rapid ventricular response. The mean systolic blood pressure was 125.92 ± 26.99 mmHg, indicating that despite the arrhythmia and heart failure, most patients maintained systemic perfusion pressure on admission, although a wide standard deviation suggested a subset of patients presented with hypotension or hypertensive urgency.

Our findings were consistent with other studies examining acute arrhythmias. Dudhrejia et al. (2025) reported a slightly higher mean heart rate of 117.78 bpm and a lower mean systolic blood pressure of 111.93 mmHg. This difference might be attributed to the younger age of their cohort, who could perhaps mount a more robust adrenergic rate response. Kiyeng et al. (2023) observed a mean heart rate of 113 bpm in their arrhythmia group, which is very close to our finding of 108 bpm. Yinadsawaphan et al. (2025) reported a much lower mean heart rate of 82.6 bpm, likely because their study involved chronic management of PAH patients rather than solely acute emergency admissions. The tachycardia observed across the acute studies underscores the hemodynamic stress imposed by the arrhythmia.

Table 20: Comparison of Vital Signs with Other Studies

Author (Year)

Mean Heart Rate (bpm)

Mean Systolic BP (mmHg)

Present Study

108.14 ± 24.85

125.92 ± 26.99

Dudhrejia et al. (2025)

117.78 ± 49.87

111.93 ± 27.02

Kiyeng et al. (2023)

113 (Median)

100 (Median)

Yinadsawaphan et al. (2025)

82.6

124.5

Laboratory Parameters

The laboratory profile of our cohort indicated significant renal impairment and mild anemia. The mean serum creatinine was remarkably high at 3.81 ± 14.67 mg/dL, with a mean blood urea of 62.18 mg/dL. This suggested a high prevalence of acute-on-chronic kidney disease, likely exacerbated by poor renal perfusion due to reduced cardiac output (cardiorenal syndrome). The large standard deviation in creatinine indicated a skewed distribution with some patients suffering from profound renal failure. The mean hemoglobin was 11.25 g/dL, reflecting mild anemia which is a common comorbidity in elderly heart failure patients.

Comparatively, our cohort appeared to have worse renal function than those in the reference studies. Dudhrejia et al. (2025) reported a mean creatinine of 2.56 mg/dL, which is also elevated but lower than our mean. Kiyeng et al. (2023) reported a mean creatinine of 133 µmol/L (approximately 1.5 mg/dL), indicating much better renal preservation in their population compared to ours. The hemoglobin levels were lower in Dudhrejia et al. (9.24 g/dL) compared to our study (11.25 g/dL). The elevated creatinine in our study emphasizes the complexity of managing these patients, as renal dysfunction limits the use of certain anticoagulants and antiarrhythmic agents, thereby complicating therapeutic strategies.

Table 21: Comparison of Laboratory Parameters with Other Studies

Author (Year)

Hemoglobin (g/dL)

Serum Creatinine (mg/dL)

Blood Urea (mg/dL)

Present Study

11.25

3.81

62.18

Dudhrejia et al. (2025)

9.24

2.56

87.47

Kiyeng et al. (2023)

14.5

~1.5 (133 µmol/L)

~35 (12.7 mmol/L)

Yinadsawaphan et al. (2025)

eGFR <60 in 55.6%

Echocardiographic Profile

Echocardiographic assessment in our study revealed severe myocardial compromise. The estimated mean left ventricular ejection fraction (LVEF) was approximately 30%, with 74% of patients classified as having reduced ejection fraction (<40%). Regional wall motion abnormalities (RWMA) were present in 42% of patients, strongly pointing towards an ischemic etiology. This profile depicted a population where arrhythmia was a consequence of advanced structural heart disease rather than a primary electrical disorder.

Our cohort exhibited significantly worse systolic function compared to the literature. Dudhrejia et al. (2025) reported a mean LVEF of 49.13%, suggesting a population with better preserved pump function. Similarly, Naser et al. (2017) reported a mean LVEF of 54%, with only 7% of their patients having severely reduced function (<30%), a stark contrast to our 74%. Kiyeng et al. (2023) found that 50% of their non-arrhythmia patients and 24% of their arrhythmia patients had preserved EF (≥50%). The profound systolic dysfunction in our study likely explains the high rates of dyspnea and mortality, identifying our patients as a particularly high-risk group with end-stage cardiac pathology.

Table 22: Comparison of Echocardiographic Findings with Other Studies

Author (Year)

Mean LVEF / Status

Prevalence of Reduced EF

Present Study

~30%

74% (<40%)

Dudhrejia et al. (2025)

49.13%

Kiyeng et al. (2023)

24.2% (≥50%) in arrhythmia group

25.7% (≤40%)

Yinadsawaphan et al. (2025)

60.8%

Naser et al. (2017)

54%

7% (<30%)

Prevalence of Comorbidities

Comorbidities were highly prevalent in our study, with hypertension being the most common, affecting 66% of patients. This was followed by chronic kidney disease (CKD) at 46%, diabetes mellitus at 42%, and coronary artery disease (CAD) at 30%. This clustering of cardiometabolic conditions creates a substrate for atrial fibrillation and complicates management. The high rate of CKD (46%) was particularly notable and aligned with the elevated serum creatinine levels observed, reinforcing the strong link between renal and cardiac dysfunction in this elderly cohort.

The prevalence of hypertension in our study (66%) was comparable to Naser et al. (2017), who reported 76%, but much higher than Dudhrejia et al. (2025), who found hypertension in only 28.5% of their younger cohort. Similarly, diabetes was twice as common in our study (42%) compared to Dudhrejia et al. (19.2%) and Naser et al. (22%). However, our rate of CAD (30%) was lower than the 39% reported by Naser et al., but higher than the 10.8% reported by Dudhrejia et al. The high burden of CKD in our study (46%) far exceeded the 10% reported by Naser et al., highlighting the fragility of our specific patient population.

Table 23: Comparison of Comorbidities with Other Studies

Author (Year)

Hypertension

Diabetes Mellitus

CAD

CKD

Present Study

66.0%

42.0%

30.0%

46.0%

Dudhrejia et al. (2025)

28.5%

19.2%

10.8%

10.0%

Kiyeng et al. (2023)

18.9%

2.9%

0.0%

1.4%

Yinadsawaphan et al. (2025)

46.3%

25.9%

5.6%

55.6%

Naser et al. (2017)

76.0%

22.0%

39.0%

10.0%

Personal History

Analysis of personal habits revealed that alcohol consumption was present in 28% of patients and smoking in 22%. These modifiable risk factors are known precipitants for arrhythmias, particularly atrial fibrillation ("holiday heart syndrome") and contribute to the progression of ischemic heart disease. While not the majority, the presence of these factors in over a quarter of the patients suggests that lifestyle modification remains a crucial component of secondary prevention, even in an elderly population.

The prevalence of these risk factors varied across the comparison studies. Our smoking rate (22%) was significantly lower than that reported by Naser et al. (2017), where 57% of patients were current or past smokers. However, our alcohol consumption rate (28%) was remarkably similar to Naser et al. (27%) and Kiyeng et al. (2023), who reported 33.3%. This consistency across different populations reinforces alcohol as a stable and significant contributor to arrhythmia risk globally. The lower smoking rate in our study compared to Naser et al. might reflect regional differences in tobacco use or a survival bias where heavy smokers may have succumbed to other diseases earlier.

Table 24: Comparison of Risk Factors with Other Studies

Author (Year)

Smoking History

Alcohol Consumption

Present Study

22.0%

28.0%

Dudhrejia et al. (2025)

10.0%

Kiyeng et al. (2023)

11.4%

33.3%

Naser et al. (2017)

57.0%

27.0%

Gender Differences in Risk Factors

Our study explored gender differences in risk factor profiles and found a statistically significant association between female sex and hypertension (p=0.005). While males comprised the majority of the study, a higher proportion of the female patients were hypertensive compared to their male counterparts. Conversely, smoking was predominantly observed in males (10 males vs. 1 female), although this difference did not reach statistical significance (p=0.139) likely due to the small sample size. This suggests that the pathophysiology driving arrhythmias may differ slightly between sexes, with hypertension playing a more central role in women and lifestyle factors like smoking in men.

These findings resonate with broader epidemiological data. Naser et al. (2017) noted that while AF is more common in men, risk factors accumulate differently. The significant link between females and hypertension in our study aligns with global trends where older women often have higher rates of uncontrolled hypertension. While direct statistical comparisons of gender subgroups were limited in the provided PDF summaries, the general trend of male dominance in smoking incidence reported in our study is a universally recognized pattern in cardiovascular epidemiology, as reflected in the male-dominated cohorts of Dudhrejia et al. (2025) and Naser et al. (2017).

Table 25: Comparison of Gender-Specific Findings

Author (Year)

Male Dominance in Cohort

Present Study

Yes (70%)

Dudhrejia et al. (2025)

Yes (75.4%)

Kiyeng et al. (2023)

No (Female 59%)

Naser et al. (2017)

Yes (52%)

Etiological Profile of Arrhythmias

Ischemic heart disease (IHD) was identified as the leading etiology in our study, accounting for 54% of cases. This was followed by hypertensive heart disease (22%) and sepsis/infection (14%). The dominance of ischemia underscores that in this elderly population, arrhythmias are largely a secondary manifestation of coronary atherosclerosis and myocardial infarction. The presence of sepsis as a precipitant in 14% of cases highlights the vulnerability of this frailer population to systemic stress, which can trigger arrhythmias in a predisposed heart.

The etiological landscape differed significantly from the reference studies. Dudhrejia et al. (2025) reported coronary artery disease in only 10.8% of their patients, a much lower figure than our 54%. This discrepancy is likely due to the age difference; their younger cohort (mean age 43) is less likely to have advanced atherosclerosis compared to our elderly cohort (mean age 70). Similarly, Kiyeng et al. (2023) found rheumatic heart disease (34.3%) to be a major driver in their Kenyan cohort, whereas valvular etiology was rare in our study (6%). Naser et al. (2017) reported CAD/Angina in 39% of patients, which is closer to our findings and reflects a similar demographic profile.

Table 26: Comparison of Etiology with Other Studies

Author (Year)

Ischemic / CAD

Hypertensive

Other Major Etiologies

Present Study

54.0%

22.0%

Sepsis (14%)

Dudhrejia et al. (2025)

10.8%

28.5%

COAD (21%)

Kiyeng et al. (2023)

2.9%

18.9%

Rheumatic Heart Disease (34.3%)

Naser et al. (2017)

39.0%

76.0%

Heart Failure (27%)

ECG Patterns

Electrocardiographic analysis revealed that Atrial Fibrillation (AF) was the overwhelming arrhythmia, present in 94% of the patients. Only 6% of patients presented with other rhythms. This near-universal prevalence of AF is consistent with the advanced age and high burden of structural heart disease (dilated atria, heart failure) observed in our cohort. AF is the end-stage electrical consequence of atrial remodeling caused by long-standing hypertension and ischemia, both of which were prevalent in our study subjects.

Our AF prevalence was significantly higher than that reported in general emergency settings but matched specialized AF cohorts. Dudhrejia et al. (2025) found AF in 32.3% of their emergency patients, with a wider variety of other rhythms like SVT (10.8%) and heart block (13.1%). Kiyeng et al. (2023) reported AF in 82.3% of their arrhythmia patients, which is comparable to our 94%. Naser et al. (2017) focused exclusively on AF, reporting distributions of paroxysmal (15%), persistent (31%), and permanent (46%) AF. Our study aligns with Naser’s findings that in elderly, comorbid populations, AF becomes the dominant sustained arrhythmia.

Table 27: Comparison of ECG Patterns with Other Studies

Author (Year)

Atrial Fibrillation Prevalence

Other Arrhythmias

Present Study

94.0%

6.0%

Dudhrejia et al. (2025)

32.3%

SVT (10.8%), Heart Block (13.1%)

Kiyeng et al. (2023)

82.3% (of arrhythmia group)

Atrial Flutter (6.5%)

Yinadsawaphan et al. (2025)

19.3% (Total cohort)

Atrial Flutter (8.2%)

Naser et al. (2017)

100% (Study inclusion criteria)

Clinical Outcomes

The clinical outcomes in our study were sobering, with a mortality rate of 38%. While 62% of patients improved and were discharged, the high death rate reflected the severity of illness in this cohort. The combination of advanced age, severe systolic dysfunction (LVEF ~30%), and renal failure (mean creatinine 3.81 mg/dL) created a poor prognostic profile. This mortality rate is indicative of a population with limited physiological reserve facing acute cardiac decompensation.

Our mortality rate was higher than most comparison studies. Dudhrejia et al. (2025) reported a mortality rate of 15.4%, less than half of ours, likely due to their younger and less comorbid population. Kiyeng et al. (2023) reported a 30-day mortality of 32.9% in their arrhythmia group, which is close to our 38% in-hospital mortality, suggesting similar severity in acute cardiac care settings. Yinadsawaphan et al. (2025) reported a very high mortality of 53.7% in their pre-existing arrhythmia group, but this was over a 10-year follow-up period in patients with Pulmonary Hypertension, a different context. Our outcomes emphasize that in elderly patients with AF and heart failure, in-hospital mortality remains a significant challenge.

Table 28: Comparison of Clinical Outcomes with Other Studies

Author (Year)

Mortality Rate

Context

Present Study

38.0%

In-hospital

Dudhrejia et al. (2025)

15.4%

Emergency Dept Outcome

Kiyeng et al. (2023)

32.9%

30-day Mortality

Yinadsawaphan et al. (2025)

53.7%

10-year Mortality (Group 1)

Length of Stay

The mean length of hospital stay (LOS) in our study ranged between 7 and 10 days, with a range of 1 to 14 days. This duration is typical for the stabilization of acute heart failure and rate/rhythm control of atrial fibrillation. It reflects the time required for diuresis, optimization of electrolytes, and initiation or adjustment of antiarrhythmic and anticoagulant medications. The upper limit of 14 days likely represents patients with complications such as infection or refractory failure.

Our LOS findings were consistent with the literature. Dudhrejia et al. (2025) reported an average hospital stay of 6.45 days, slightly shorter than ours, which aligns with their population being younger and potentially recovering faster. Kiyeng et al. (2023) reported a median LOS of 8 days for their arrhythmia group, which is almost identical to our average. This consistency across different healthcare settings suggests that the clinical trajectory for stabilizing acute arrhythmias requiring admission is relatively uniform, typically requiring about one week of inpatient care.

Table 29: Comparison of Length of Stay with Other Studies

Author (Year)

Length of Stay (Days)

Statistic

Present Study

7 – 10

Mean estimate

Dudhrejia et al. (2025)

6.45 ± 6.01

Mean

Kiyeng et al. (2023)

8 (IQR 4-12)

Median

Yinadsawaphan et al. (2025)

Etiology vs Mortality

An analysis of mortality by etiology in our study showed that patients with sepsis/infection had the highest mortality rate (57.1%), followed by those with ischemic heart disease (40.7%). While the p-value (0.122) indicated no statistical significance due to sample size, the trend highlights the lethality of septic cardiomyopathy and superimposed infection in cardiac patients. Ischemia also carried a poor prognosis, consistent with the extensive myocardial damage typically present. Hypertensive etiology had a comparatively lower mortality (27.3%), suggesting that arrhythmias driven primarily by afterload issues might be more amenable to acute medical management than those driven by sepsis or infarction.

While direct mortality-by-etiology comparisons in the PDFs were limited, the trends align with general clinical knowledge. Dudhrejia et al. (2025) noted that refractory ventricular fibrillation and sepsis (2.3% of deaths) were causes of mortality, supporting the high risk of infection we observed. The high mortality in our ischemic group parallels the findings in Yinadsawaphan et al. (2025), where comorbidities and structural disease drove poor survival. The lack of statistical significance in our breakdown suggests that mortality is likely multifactorial, driven by the overall burden of disease rather than a single etiological factor.

Table 30: Comparison of Etiology-Specific Mortality trends

Author (Year)

High Risk Etiologies

Observations

Present Study

Sepsis (57.1%), Ischemic (40.7%)

Trend only (p>0.05)

Dudhrejia et al. (2025)

Refractory VF, Sepsis

Sepsis noted as cause of death

Kiyeng et al. (2023)

Mortality high in HF patients

Hypertension vs Outcome

Our study examined the relationship between hypertension and clinical outcome. Among the 33 hypertensive patients, 14 (42%) expired, whereas among the 17 non-hypertensive patients, 5 (29%) expired. Although the mortality rate was numerically higher in the hypertensive group, the difference was not statistically significant (p>0.05). This suggests that while hypertension is a major risk factor for developing the disease, it may not be the sole determinant of acute in-hospital survival once severe decompensation has occurred. Other factors like renal function and infection likely play more immediate roles in short-term survival.

This finding contrasts slightly with long-term prognostic data but aligns with acute care realities where immediate hemodynamic stability matters most. Naser et al. (2017) identified hypertension as a key driver for AF (Hazard Ratio 1.352) but did not explicitly link it to immediate in-hospital death. In Yinadsawaphan et al. (2025), comorbidities like hypertension were associated with arrhythmia development, which in turn worsened survival (Hazard Ratio 2.06). Our data reflects that in the acute setting, the presence of hypertension is part of the overall disease burden but does not independently predict immediate death in a small cohort.

Table 31: Comparison of Hypertension Impact with Other Studies

Author (Year)

Hypertension Prevalence

Impact on Outcome

Present Study

66%

NS difference in mortality

Naser et al. (2017)

76%

Risk factor for AF (HR 1.35)

Yinadsawaphan et al. (2025)

46.3% (Group 1)

Associated with arrhythmia presence

Age vs Outcome

We observed a modest difference in age between patients who expired (mean ~73 years) and those who improved (mean ~69 years). While survivors were slightly younger, the overlapping age ranges and small difference indicate that chronological age alone was not a definitive predictor of mortality in this study. This supports the concept that biological age and physiological reserve—influenced by comorbidities like CKD and heart failure—are more critical than age in years. The elderly patients in our study were all high-risk, regardless of whether they were 65 or 75.

This aligns with findings from Dudhrejia et al. (2025), who noted that age is a critical risk factor, and Yinadsawaphan et al. (2025), who found that older age was associated with arrhythmias which in turn increased mortality. However, Naser et al. (2017) found a hazard ratio of only 1.028 for age, suggesting a small incremental risk per year. Our data supports this nuanced view: advanced age sets the stage for frailty, but specific acute insults determine the immediate outcome.

Table 32: Comparison of Age Impact with Other Studies

Author (Year)

Age Effect

Statistic

Present Study

Expired patients older (~73 vs 69)

Modest difference

Naser et al. (2017)

HR 1.028 for Age

Significant but small magnitude

Yinadsawaphan et al. (2025)

Older age linked to arrhythmia

Arrhythmia increases mortality

CONCLUSION

The study concluded that hospitalized patients presenting with arrhythmias were predominantly elderly, with a mean age of 70.46 years, which highlighted the vulnerability of an aging population to cardiovascular decompensation. It was established that atrial fibrillation was the nearly universal rhythm disturbance, occurring in 94% of the cohort. Ischemic heart disease was identified as the leading etiological factor, accounting for over half of the cases. The clinical profile was characterized by significant myocardial compromise, as 74% of patients exhibited a severely reduced ejection fraction of less than 40%. Furthermore, the prevalence of hypertension and chronic kidney disease was high, contributing to the complexity of the cases. While 62% of the patients improved through acute management, a substantial mortality rate of 38% was observed. This mortality was particularly high in sepsis-related cases and was modestly associated with more advanced age. Gender-based differences were notable, particularly the significant female predominance in hypertension. Laboratory parameters often revealed significant azotemia and mild anemia, reflecting a state of chronic systemic illness. Ultimately, the study demonstrated that hospital outcomes were driven by a multifactorial interplay between structural heart disease, severe systolic dysfunction, and a high burden of comorbid metabolic and renal disorders.

SUMMARY

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Medicine Department

Friday, February 13, 2026

Dr Venkanna's Narketpally cardiac arrhythmia triad of atrial fibrillation, hypertension and LV dysfunction

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