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Steinberg BA. Atrial fibrillation and long-term cardiovascular outcomes: bringing the whole picture into focus. Eur Heart J 2024:ehae347. [PMID: 38848112 DOI: 10.1093/eurheartj/ehae347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, 30 North Mario Capecchi Drive, Salt Lake City, UT 84112, USA
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Roberts JD, Chalazan B, Andrade JG, Macle L, Nattel S, Tadros R. Clinical Genetic Testing for Atrial Fibrillation: Are We There Yet? Can J Cardiol 2024; 40:540-553. [PMID: 38551553 DOI: 10.1016/j.cjca.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/17/2023] [Accepted: 11/19/2023] [Indexed: 04/13/2024] Open
Abstract
Important progress has been made toward unravelling the complex genetics underlying atrial fibrillation (AF). Initial studies were aimed to identify monogenic causes; however, it has become increasingly clear that the most common predisposing genetic substrate for AF is polygenic. Despite intensive investigations, there is robust evidence for rare variants for only a limited number of genes and cases. Although the current yield for genetic testing in early onset AF might be modest, there is an increasing appreciation that genetic culprits for potentially life-threatening ventricular cardiomyopathies and channelopathies might initially present with AF. The potential clinical significance of this recognition is highlighted by evidence that suggests that identification of a pathogenic or likely pathogenic rare variant in a patient with early onset AF is associated with an increased risk of death. These findings suggest that it might be warranted to screen patients with early onset AF for these potentially more sinister cardiac conditions. Beyond facilitating the early identification of genetic culprits associated with potentially malignant phenotypes, insight into underlying AF genetic substrates might improve the selection of patients for existing therapies and guide the development of novel ones. Herein, we review the evidence that links genetic factors to AF, then discuss an approach to using genetic testing for early onset AF patients in the present context, and finally consider the potential value of genetic testing in the foreseeable future. Although further work might be necessary before recommending uniform integration of genetic testing in cases of early onset AF, ongoing research increasingly highlights its potential contributions to clinical care.
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Affiliation(s)
- Jason D Roberts
- Population Health Research Institute, McMaster University, and Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Brandon Chalazan
- Division of Biochemical Genetics, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason G Andrade
- Centre for Cardiovascular Innovation and Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Laurent Macle
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Stanley Nattel
- Department of Medicine and Research Center, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Rafik Tadros
- Cardiovascular Genetics Center, Montreal Heart Institute, Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada
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3
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Chevalier P, Roy P, Bessière F, Morel E, Ankou B, Morgan G, Halder I, London B, Minobe WA, Slavov D, Delinière A, Bochaton T, Paganelli F, Lesavre N, Boiteux C, Mansourati J, Maury P, Clerici G, Winum PF, Huebler SP, Carroll IA, Bristow MR. Impact of Neuroeffector Adrenergic Receptor Polymorphisms on Incident Ventricular Fibrillation During Acute Myocardial Ischemia. J Am Heart Assoc 2023; 12:e025368. [PMID: 36926933 PMCID: PMC10111522 DOI: 10.1161/jaha.122.025368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Background Cardiac adrenergic receptor gene polymorphisms have the potential to influence risk of developing ventricular fibrillation (VF) during ST-segment-elevation myocardial infarction, but no previous study has comprehensively investigated those most likely to alter norepinephrine release, signal transduction, or biased signaling. Methods and Results In a case-control study, we recruited 953 patients with ST-segment-elevation myocardial infarction without previous cardiac history, 477 with primary VF, and 476 controls without VF, and genotyped them for ADRB1 Arg389Gly and Ser49Gly, ADRB2 Gln27Glu and Gly16Arg, and ADRA2C Ins322-325Del. Within each minor allele-containing genotype, haplotype, or 2-genotype combination, patients with incident VF were compared with non-VF controls by odds ratios (OR) of variant frequencies referenced against major allele homozygotes. Of 156 investigated genetic constructs, 19 (12.2%) exhibited significantly (P<0.05) reduced association with incident VF, and none was associated with increased VF risk except for ADRB1 Gly389 homozygotes in the subset of patients not receiving β-blockers. ADRB1 Gly49 carriers (prevalence 23.0%) had an OR (95% CI) of 0.70 (0.49-0.98), and the ADRA2C 322-325 deletion (Del) carriers (prevalence 13.5%) had an OR of 0.61 (0.39-0.94). When present in genotype combinations (8 each), both ADRB1 Gly49 carriers (OR, 0.67 [0.56-0.80]) and ADRA2C Del carriers (OR, 0.57 [0.45- 0.71]) were associated with reduced VF risk. Conclusions In ST-segment-elevation myocardial infarction, the adrenergic receptor minor alleles ADRB1 Gly49, whose encoded receptor undergoes enhanced agonist-mediated internalization and β-arrestin interactions leading to cardioprotective biased signaling, and ADRA2C Del322-325, whose receptor causes disinhibition of norepinephrine release, are associated with a lower incidence of VF. Registration URL: https://clinicaltrials.gov; Unique identifier: NCT00859300.
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Affiliation(s)
- Philippe Chevalier
- Rhythmology Department Hospital Louis Pradel Lyon France
- Université Claude Bernard Lyon 1 Université de Lyon Lyon France
| | - Pascal Roy
- Hospices Civils de Lyon, Services Biostatistiques Lyon France
| | | | - Elodie Morel
- Rhythmology Department Hospital Louis Pradel Lyon France
| | | | - Gina Morgan
- Division of Cardiovascular Medicine University of Iowa Iowa City IA
| | - Indrani Halder
- Division of Cardiovascular Medicine University of Iowa Iowa City IA
| | - Barry London
- Division of Cardiovascular Medicine University of Iowa Iowa City IA
| | - Wayne A Minobe
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
| | - Dobromir Slavov
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
| | | | - Thomas Bochaton
- Department of Intensive Cardiac Care Hospital Louis Pradel Lyon France
| | | | | | | | - Jacques Mansourati
- Cardiology Department Hôpital de La Cavale Blanche, Brest University Hospital Brest France
| | - Philippe Maury
- Cardiology Department University Hospital Rangueil Toulouse France
| | - Gaël Clerici
- Cardiology Department Saint Pierre University Hospital La Réunion France
| | | | | | - Ian A Carroll
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
- ARCA Biopharma Westminster CO
| | - Michael R Bristow
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
- ARCA Biopharma Westminster CO
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4
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Sessions AJ, May HT, Crandall BG, Day JD, Cutler MJ, Groh CA, Navaravong L, Ranjan R, Steinberg BA, J Bunch T. Increasing time between first diagnosis of atrial fibrillation and catheter ablation adversely affects long-term outcomes in patients with and without structural heart disease. J Cardiovasc Electrophysiol 2023; 34:507-515. [PMID: 36640433 DOI: 10.1111/jce.15810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Atrial Fibrillation (AF) is a common arrhythmia often comorbid with systolic or diastolic heart failure (HF). Catheter ablation is a more effective treatment for AF with concurrent left ventricular dysfunction, however, the optimal timing of use in these patients is unknown. METHODS All patients that received a catheter ablation for AF(n = 9979) with 1 year of follow-up within the Intermountain Healthcare system were included. Patients with were identified by the presence of structural disease by ejection fraction (EF): EF ≤ 35% (n = 1024) and EF > 35% (n = 8955). Recursive partitioning categories were used to separate patients into clinically meaningful strata based upon time from initial AF diagnosis until ablation: 30-180(n = 2689), 2:181-545(n = 1747), 3:546-1825(n = 2941), and 4:>1825(n = 2602) days. RESULTS The mean days from AF diagnosis to first ablation was 3.5 ± 3.8 years (EF > 35%: 3.5 ± 3.8 years, EF ≤ 35%: 3.4 ± 3.8 years, p = .66). In the EF > 35% group, delays in treatment (181-545 vs. 30-180, 546-1825 vs. 30-180, >1825 vs. 30-180 days) increased the risk of death with a hazard ratio (HR) of 2.02(p < .0001), 2.62(p < .0001), and 4.39(p < .0001) respectively with significant risks for HF hospitalization (HR:1.44-3.69), stroke (HR:1.11-2.14), and AF recurrence (HR:1.42-1.81). In patients with an EF ≤ 35%, treatment delays also significantly increased risk of death (HR 2.07-3.77) with similar trends in HF hospitalization (HR:1.63-1.09) and AF recurrence (HR:0.79-1.24). CONCLUSION Delays in catheter ablation for AF resulted in increased all-cause mortality in all patients with differential impact observed on HF hospitalization, stroke, and AF recurrence risks by baseline EF. These data favor earlier use of ablation for AF in patients with and without structural heart disease.
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Affiliation(s)
| | - Heidi T May
- Department of Cardiology, Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah, USA
| | - Brian G Crandall
- Department of Cardiology, Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah, USA
| | - John D Day
- St. Marks Hospital, Salt Lake City, Utah, USA
| | - Michael J Cutler
- Department of Cardiology, Intermountain Medical Center, Intermountain Heart Institute, Salt Lake City, Utah, USA
| | - Christopher A Groh
- Department of Internal Medicine, Division of Cardiology, University Hospital, Salt Lake City, Utah, USA
| | - Leenapong Navaravong
- Department of Internal Medicine, Division of Cardiology, University Hospital, Salt Lake City, Utah, USA
| | - Ravi Ranjan
- Department of Internal Medicine, Division of Cardiology, University Hospital, Salt Lake City, Utah, USA
| | - Benjamin A Steinberg
- Department of Internal Medicine, Division of Cardiology, University Hospital, Salt Lake City, Utah, USA
| | - Thomas J Bunch
- Department of Internal Medicine, Division of Cardiology, University Hospital, Salt Lake City, Utah, USA
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Van Deutekom C, Van Gelder IC, Rienstra M. Atrial fibrillation and heart failure temporality: does it matter? Europace 2022; 25:247-248. [PMID: 36576343 PMCID: PMC9935021 DOI: 10.1093/europace/euac255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Colinda Van Deutekom
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - Michiel Rienstra
- Corresponding author. Tel: +31 50 3611327; fax: +31 50 3614391. E-mail address:
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Dose-limiting, adverse event–associated bradycardia with β-blocker treatment of atrial fibrillation in the GENETIC-AF trial. Heart Rhythm O2 2022; 3:40-49. [PMID: 35243434 PMCID: PMC8859785 DOI: 10.1016/j.hroo.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Heart failure (HF) patients with atrial fibrillation (AF) often have conduction system disorders, which may be worsened by β-blocker therapy. Objective In a post hoc analysis we examined the prevalence of bradycardia and its association with adverse events (AEs) and failure to achieve target dose in the GENETIC-AF trial. Methods Patients randomized to metoprolol (n = 125) or bucindolol (n = 131) entering 24-week efficacy follow-up and receiving study medication were evaluated. Bradycardia was defined as an electrocardiogram (ECG) heart rate (HR) <60 beats per minute (bpm) and severe bradycardia <50 bpm. Results Mean HR in sinus rhythm (SR) was 62.6 ± 12.5 bpm for metoprolol and 68.3 ± 11.1 bpm for bucindolol (P < .0001), but in AF HRs were not different (87.5 bpm vs 89.7 bpm, respectively). Episodes per patient for bucindolol vs metoprolol were 0.82 vs 2.08 (P < .001) for bradycardia and 0.24 vs 0.57 for severe bradycardia (P < .001), with 98.9% of the episodes occurring in SR. Patients experiencing bradycardia had a 4.15-fold higher prevalence of study medication dose reduction (P <.0001) compared to patients without bradycardia. Fewer patients receiving metoprolol were at target dose (61.7% vs 74.9% for bucindolol, P < .0001) at ECG recordings, and bradycardia AEs were more prevalent in the metoprolol group (13 vs 1 for bucindolol, P = .001). On multivariate analysis of 21 candidate bradycardia predictors including presence of a device with pacing capability, bucindolol treatment was associated with the greatest degree of prevention (Zodds ratio -4.24, P < .0001). Conclusion In AF-prone HF patients bradycardia may limit the effectiveness of β blockers, and this property is agent-dependent.
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Roston TM, Islam S, Hawkins NM, Laksman ZW, Sanatani S, Krahn AD, Sandhu R, Kaul P. A Population-Based Study of Unexplained/Lone Atrial Fibrillation: Temporal Trends, Management, and Outcomes. CJC Open 2022; 4:65-74. [PMID: 35072029 PMCID: PMC8767123 DOI: 10.1016/j.cjco.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/06/2021] [Indexed: 11/28/2022] Open
Abstract
Background Previous studies on lone/unexplained atrial fibrillation and atrial flutter (AF) did not exclude patients with contemporary secondary AF triggers. We characterized unexplained AF using a strict definition, and compared it to secondary AF. Methods In this population-based study, unexplained AF was defined by the lack of any identifiable triggering medical/surgical diagnosis. Comparisons by AF type (unexplained vs secondary), age-of-onset (≤ / > 65 years), and sex were undertaken. Data were acquired by linking 6 population databases maintained by the Alberta Ministry of Health over a 9-year period (April 2006 to March 2015). The primary composite outcome of stroke, transient ischemic attack, thromboembolism, and/or death was assessed. Results There were 33,150 incident AF diagnoses identified, including 1145 patients (3.5%) with unexplained AF, 931 (81.2%) of whom were aged ≤ 65 years (2.8% of diagnoses, and 79% male). Patients with unexplained AF less often received rate/rhythm-control drugs (P < 0.0001), but they more often underwent electrical cardioversion (P < 0.0001) vs secondary AF patients. Men were younger at unexplained AF diagnosis (45 [interquartile range: 34-59] vs 58 [interquartile range: 40-69] years; P < 0.001). After adjusting for age at diagnosis, there were no sex-based differences in the primary outcome. Event-free survival in young unexplained AF (age ≤ 65 years) was 99.4% at 1 year and 98.3% at 3 years. At 3 years, hospitalization(s)/emergency visit(s) for noncardiovascular reasons and for AF occurred in 56.6% and 23.8% of these patients, respectively. Conclusions Using a strict contemporary definition of unexplained AF, this study shows that the condition is rare, predominantly male, and has excellent event-free survival. However, the high rate of acute hospital utilization after diagnosis is concerning.
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Affiliation(s)
- Thomas M. Roston
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Centre for Cardiovascular Innovation, Division of Cardiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sunjidatul Islam
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Nathaniel M. Hawkins
- Centre for Cardiovascular Innovation, Division of Cardiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Zachary W. Laksman
- Centre for Cardiovascular Innovation, Division of Cardiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Shubhayan Sanatani
- Division of Cardiology, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew D. Krahn
- Centre for Cardiovascular Innovation, Division of Cardiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Roopinder Sandhu
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Corresponding author: Dr Padma Kaul, 4-120 Katz Group Centre for Pharmacy and Health Research, University of Alberta, Edmonton, Alberta T6G 2E1, Canada. Tel.: +1-780-492-1140 ; fax: +1-780-492-0613.
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Heijman J, Hohnloser SH, Camm AJ. Antiarrhythmic drugs for atrial fibrillation: lessons from the past and opportunities for the future. Europace 2021; 23:ii14-ii22. [PMID: 33837753 DOI: 10.1093/europace/euaa426] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/29/2020] [Indexed: 12/16/2022] Open
Abstract
Atrial fibrillation (AF) remains a highly prevalent and troublesome cardiac arrhythmia, associated with substantial morbidity and mortality. Restoration and maintenance of sinus rhythm (rhythm-control therapy) is an important element of AF management in symptomatic patients. Despite significant advances and increasing importance of catheter ablation, antiarrhythmic drugs (AADs) remain a cornerstone of rhythm-control therapy. During the past 50 years, experimental and clinical research has greatly increased our understanding of AADs. As part of the special issue on paradigm shifts in AF, this review summarizes important milestones in AAD research that have shaped their current role in AF management, including (i) awareness of the proarrhythmic potential of AADs; (ii) increasing understanding of the pleiotropic effects of AADs; (iii) the development of dronedarone; and (iv) the search for AF-specific AADs. Finally, we discuss short- and long-term opportunities for better AF management through advances in AAD therapy, including personalization of AAD therapy based on individual AF mechanisms.
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Affiliation(s)
- Jordi Heijman
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, PO Box 616, Maastricht 6200, The Netherlands
| | - Stefan H Hohnloser
- Department of Cardiology, J. W. Goethe-Universität Frankfurt am Main, Frankfurt/Main, Germany
| | - A John Camm
- Cardiovascular and Cell Sciences Research Institute, Cardiology Clinical Academic Group, St George's, University of London, London, UK
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Piccini JP, Dufton C, Carroll IA, Healey JS, Abraham WT, Khaykin Y, Aleong R, Krueger SK, Sauer WH, Wilton SB, Rienstra M, van Veldhuisen DJ, Anand IS, White M, Camm AJ, Ziegler PD, Marshall D, Bristow MR, Connolly SJ. Bucindolol Decreases Atrial Fibrillation Burden in Patients With Heart Failure and the ADRB1 Arg389Arg Genotype. Circ Arrhythm Electrophysiol 2021; 14:e009591. [PMID: 34270905 DOI: 10.1161/circep.120.009591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Jonathan P Piccini
- Duke Clinical Research Institute & Duke University Medical Center, Durham, NC (J.P.P.)
| | | | - Ian A Carroll
- ARCA biopharma, Inc, Westminster, CO (C.D., I.A.C., D.M., M.R.B.)
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., S.J.C.)
| | | | | | - Ryan Aleong
- University of Colorado, Aurora (R.A., M.R.B.)
| | | | - William H Sauer
- Brigham and Women's Hospital & Harvard Medical School, Boston, MA (W.H.S.)
| | - Stephen B Wilton
- Libin Cardiovascular Institute of Alberta, University of Calgary (S.B.W.)
| | - Michiel Rienstra
- University of Groningen & University Medical Center Groningen, the Netherlands (M.R., D.J.v.V.)
| | - Dirk J van Veldhuisen
- University of Groningen & University Medical Center Groningen, the Netherlands (M.R., D.J.v.V.)
| | | | | | - A John Camm
- St. George's University of London, United Kingdom (A.J.C.)
| | | | - Debra Marshall
- ARCA biopharma, Inc, Westminster, CO (C.D., I.A.C., D.M., M.R.B.)
| | - Michael R Bristow
- ARCA biopharma, Inc, Westminster, CO (C.D., I.A.C., D.M., M.R.B.).,University of Colorado, Aurora (R.A., M.R.B.)
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., S.J.C.)
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Kany S, Reissmann B, Metzner A, Kirchhof P, Darbar D, Schnabel RB. Genetics of atrial fibrillation-practical applications for clinical management: if not now, when and how? Cardiovasc Res 2021; 117:1718-1731. [PMID: 33982075 PMCID: PMC8208749 DOI: 10.1093/cvr/cvab153] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Indexed: 12/12/2022] Open
Abstract
The prevalence and economic burden of atrial fibrillation (AF) are predicted to more than double over the next few decades. In addition to anticoagulation and treatment of concomitant cardiovascular conditions, early and standardized rhythm control therapy reduces cardiovascular outcomes as compared with a rate control approach, favouring the restoration, and maintenance of sinus rhythm safely. Current therapies for rhythm control of AF include antiarrhythmic drugs (AADs) and catheter ablation (CA). However, response in an individual patient is highly variable with some remaining free of AF for long periods on antiarrhythmic therapy, while others require repeat AF ablation within weeks. The limited success of rhythm control therapy for AF is in part related to incomplete understanding of the pathophysiological mechanisms and our inability to predict responses in individual patients. Thus, a major knowledge gap is predicting which patients with AF are likely to respond to rhythm control approach. Over the last decade, tremendous progress has been made in defining the genetic architecture of AF with the identification of rare mutations in cardiac ion channels, signalling molecules, and myocardial structural proteins associated with familial (early-onset) AF. Conversely, genome-wide association studies have identified common variants at over 100 genetic loci and the development of polygenic risk scores has identified high-risk individuals. Although retrospective studies suggest that response to AADs and CA is modulated in part by common genetic variation, the development of a comprehensive clinical and genetic risk score may enable the translation of genetic data to the bedside care of AF patients. Given the economic impact of the AF epidemic, even small changes in therapeutic efficacy may lead to substantial improvements for patients and health care systems.
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Affiliation(s)
- Shinwan Kany
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Martinistraße 52, 20251 Hamburg, Hamburg, Germany
| | - Bruno Reissmann
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Martinistraße 52, 20251 Hamburg, Hamburg, Germany.,The Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston Birmingham B15 2TT, UK
| | - Dawood Darbar
- Division of Cardiology, Departments of Medicine, University of Illinois at Chicago and Jesse Brown Veterans Administration, 840 South Wood Street, Suite 928 M/C 715, Chicago, IL 60612, USA
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Martinistraße 52, 20251 Hamburg, Hamburg, Germany
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11
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Steinberg BA, Li Z, O'Brien EC, Pritchard J, Chew DS, Bunch TJ, Mark DB, Nabutovsky Y, Greiner MA, Piccini JP. Atrial fibrillation burden and heart failure: Data from 39,710 individuals with cardiac implanted electronic devices. Heart Rhythm 2021; 18:709-716. [PMID: 33508517 PMCID: PMC8096675 DOI: 10.1016/j.hrthm.2021.01.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/11/2021] [Accepted: 01/16/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) and heart failure (HF) often accompany one another, and each is independently associated with poor outcomes. However, the association between AF burden and outcomes is poorly understood. OBJECTIVE The purpose of this study was to describe the association between device-based AF burden and HF clinical outcomes. METHODS We used a nationwide, remote monitoring database of cardiac implantable electronic devices (CIEDs) linked to Medicare claims. We included patients with nonpermanent AF, undergoing new CIED implant, stratified by baseline HF. The outcomes were new-onset HF, HF hospitalization, and all-cause mortality at 1 and 3 years. RESULTS We identified 39,710 patients who met inclusion criteria (25,054 with HF; 14,656 without HF). Patients with HF were younger (mean age 76.3 vs 78.5 years; P <.001), more often male (65% vs 54%; P <.001), and had higher mean CHA2DS2-VASc scores (5.4 vs 4.1; P <.001). Among those without HF, increasing device-based AF burden was significantly associated with increased risk of new-onset HF (adjusted hazard ratio [HR] 1.09 per 10% AF burden; 95% confidence interval [CI] 1.06-1.12; P <.001) and all-cause mortality (adjusted HR 1.05 per 10% AF burden; 95% CI 1.01-1.10; P = .012). Among patients with HF, increasing AF burden was significantly associated with increased risk of HF hospitalization (adjusted HR 1.05 per 10% AF burden; 95% CI 1.04-1.06; P <.001) and all-cause mortality (adjusted HR 1.06 per 10% AF burden; 95% CI 1.05-1.08; P <.001). CONCLUSION Among older patients with AF receiving a CIED, increasing AF burden is significantly associated with increasing risk of adverse HF outcomes and all-cause mortality.
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Affiliation(s)
| | - Zhen Li
- Department of Population Health, Duke University, Durham, North Carolina
| | - Emily C O'Brien
- Department of Population Health, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Jessica Pritchard
- Department of Population Health, Duke University, Durham, North Carolina
| | - Derek S Chew
- Department of Population Health, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - T Jared Bunch
- Division of Cardiovascular medicine, University of Utah, Salt Lake City, Utah
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | | | - Melissa A Greiner
- Department of Population Health, Duke University, Durham, North Carolina
| | - Jonathan P Piccini
- Department of Population Health, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
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12
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Abstract
PURPOSE OF REVIEW Atrial fibrillation is the most common sustained cardiac arrhythmia. In addition to traditional risk factors, it is increasingly recognized that a genetic component underlies atrial fibrillation development. This review aims to provide an overview of the genetic cause of atrial fibrillation and clinical applications, with a focus on recent developments. RECENT FINDINGS Genome-wide association studies have now identified around 140 genetic loci associated with atrial fibrillation. Studies into the effects of several loci and their tentative gene targets have identified novel pathways associated with atrial fibrillation development. However, further validations of causality are still needed for many implicated genes. Genetic variants at identified loci also help predict individual atrial fibrillation risk and response to different therapies. SUMMARY Continued advances in the field of genetics and molecular biology have led to significant insight into the genetic underpinnings of atrial fibrillation. Potential clinical applications of these studies include the identification of new therapeutic targets and development of genetic risk scores to optimize management of this common cardiac arrhythmia.
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Affiliation(s)
- Jitae A. Kim
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mihail G. Chelu
- Department of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Na Li
- Department of Medicine (Section of Cardiovascular Research), Baylor College of Medicine, Houston, TX
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX
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13
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Alkhatib N, Sweitzer NK, Lee CS, Erstad B, Slack M, Gharaibeh M, Karnes J, Klimecki W, Ramos K, Abraham I. Ex Ante Economic Evaluation of Arg389 Genetically Targeted Treatment with Bucindolol versus Empirical Treatment with Carvedilol in NYHA III/IV Heart Failure. Am J Cardiovasc Drugs 2021; 21:205-217. [PMID: 32710439 DOI: 10.1007/s40256-020-00425-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The Beta-Blocker Evaluation Survival Trial showed no survival benefit for bucindolol in New York Heart Association (NYHA) class III/IV heart failure (HF) with reduced ejection fraction, but subanalyses suggested survival benefits for non-Black subjects and Arg389 homozygotes. We conducted an ex ante economic evaluation of Arg389 targeted treatment with bucindolol versus carvidolol, complementing a previous ex ante economic evaluation of bucindolol preceded by genetic testing for the Arg389 polymorphism, in which genetic testing prevailed economically over no testing. METHODS A decision tree analysis with an 18-month time horizon was performed to estimate the cost effectiveness/cost utility of trajectories of 100%, 50%, and 0% of patients genetically tested for Arg389 and comparing bucindolol with empirical carvedilol treatment as per prior BEST subanalyses. Incremental cost-effectiveness/cost-utility ratios (ICERs/ICURs) were estimated. RESULTS Race-based analyses for non-White subjects at 100% testing showed a loss of (0.04) life-years and (0.03) quality-adjusted life-years (QALYs) at an incremental cost of $2185, yielding a negative ICER of ($54,625)/life-year and ICUR of ($72,833)/QALY lost; at 50%, the analyses showed a loss of (0.27) life-years and (0.16) QALYs at an incremental cost of $1843, yielding a negative ICER of ($6826)/life-year and ICUR of ($11,519)/QALY lost; at 0%, the analyses showed a loss of (0.33) life-years and (0.30) QALYs at an incremental cost of $1459, yielding a negative ICER of ($4421)/life-year and ICUR of ($4863)/QALY lost. Arg389 homozygote analyses at 100% testing showed incremental gains of 0.02 life-years and 0.02 QALYs at an incremental cost of $378, yielding an ICER of 18,900/life-year and ICUR of $18,900/QALY gained; at 50%, the analyses showed a loss of (0.24) life-years and (0.09) QALYs at an incremental cost of $1039, yielding a negative ICER of ($4329)/life-year and ICUR of ($9336)/QALY lost; at 0%, the analyses showed a loss of (0.33) life-years and (0.30) QALYs at an incremental cost of $1459, yielding a negative ICER of ($4421)/life-year and ICUR of ($4863)/QALY lost. CONCLUSION This independent ex ante economic evaluation suggests that genetically targeted treatment with bucindolol is unlikely to yield clinicoeconomic benefits over empirical treatment with carvedilol in NYHA III/IV HF.
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14
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Magavern EF, Kaski JC, Turner RM, Drexel H, Janmohamed A, Scourfield A, Burrage D, Floyd CN, Adeyeye E, Tamargo J, Lewis BS, Kjeldsen KP, Niessner A, Wassmann S, Sulzgruber P, Borry P, Agewall S, Semb AG, Savarese G, Pirmohamed M, Caulfield MJ. The Role of Pharmacogenomics in Contemporary Cardiovascular Therapy: A position statement from the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:85-99. [PMID: 33638977 DOI: 10.1093/ehjcvp/pvab018] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/05/2021] [Accepted: 02/24/2021] [Indexed: 12/14/2022]
Abstract
There is a strong and ever-growing body of evidence regarding the use of pharmacogenomics to inform cardiovascular pharmacology. However, there is no common position taken by international cardiovascular societies to unite diverse availability, interpretation and application of such data, nor is there recognition of the challenges of variation in clinical practice between countries within Europe. Aside from the considerable barriers to implementing pharmacogenomic testing and the complexities of clinically actioning results, there are differences in the availability of resources and expertise internationally within Europe. Diverse legal and ethical approaches to genomic testing and clinical therapeutic application also require serious thought. As direct-to-consumer genomic testing becomes more common, it can be anticipated that data may be brought in by patients themselves, which will require critical assessment by the clinical cardiovascular prescriber. In a modern, pluralistic and multi-ethnic Europe, self-identified race/ethnicity may not be concordant with genetically detected ancestry and thus may not accurately convey polymorphism prevalence. Given the broad relevance of pharmacogenomics to areas such as thrombosis and coagulation, interventional cardiology, heart failure, arrhythmias, clinical trials, and policy/regulatory activity within cardiovascular medicine, as well as to genomic and pharmacology subspecialists, this position statement attempts to address these issues at a wide-ranging level.
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Affiliation(s)
- E F Magavern
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Department of Clinical Pharmacology, Cardiovascular Medicine, Barts Health NHS Trust, London, UK
| | - J C Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, United Kingdom
| | - R M Turner
- The Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - H Drexel
- Vorarlberg Institute for Vascular Investigation & Treatment (VIVIT), Feldkirch, A Private University of the Principality of Liechtenstein, Triesen, FL.,Drexel University College of Medicine, Philadelphia, USA
| | - A Janmohamed
- Department of Clinical Pharmacology, St George's, University of London, United Kingdom
| | - A Scourfield
- Department of Clinical Pharmacology, University College London Hospital Foundation Trust, UK
| | - D Burrage
- Whittington Health NHS Trust, London, UK
| | - C N Floyd
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, London, UK.,Department of Clinical Pharmacology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - E Adeyeye
- Department of Clinical Pharmacology, Cardiovascular Medicine, Barts Health NHS Trust, London, UK
| | - J Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Madrid, Spain
| | - B S Lewis
- Cardiovascular Clinical Research Institute, Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Keld Per Kjeldsen
- Department of Cardiology, Copenhagen University Hospital (Amager-Hvidovre), Copenhagen, Denmark.,Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - A Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna
| | - S Wassmann
- Cardiology Pasing, Munich, Germany and University of the Saarland, Homburg/Saar, Germany
| | - P Sulzgruber
- Medical University of Vienna, Department of Medicine II, Division of Cardiology
| | - P Borry
- Center for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Leuven Institute for Human Genetics and Society, Leuven, Belgium
| | - S Agewall
- Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - A G Semb
- Preventive Cardio-Rheuma clinic, department of rheumatology, innovation and research, Diakonhjemmet hospital, Oslo, Norway
| | - G Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - M Pirmohamed
- The Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Liverpool Health Partners, Liverpool, UK
| | - M J Caulfield
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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15
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Magavern EF, Kaski JC, Turner RM, Janmohamed A, Borry P, Pirmohamed M. The Interface of Therapeutics and Genomics in Cardiovascular Medicine. Cardiovasc Drugs Ther 2021; 35:663-676. [PMID: 33528719 PMCID: PMC7851637 DOI: 10.1007/s10557-021-07149-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 01/31/2023]
Abstract
Pharmacogenomics has a burgeoning role in cardiovascular medicine, from warfarin dosing to antiplatelet choice, with recent developments in sequencing bringing the promise of personalised medicine ever closer to the bedside. Further scientific evidence, real-world clinical trials, and economic modelling are needed to fully realise this potential. Additionally, tools such as polygenic risk scores, and results from Mendelian randomisation analyses, are only in the early stages of clinical translation and merit further investigation. Genetically targeted rational drug design has a strong evidence base and, due to the nature of genetic data, academia, direct-to-consumer companies, healthcare systems, and industry may meet in an unprecedented manner. Data sharing navigation may prove problematic. The present manuscript addresses these issues and concludes a need for further guidance to be provided to prescribers by professional bodies to aid in the consideration of such complexities and guide translation of scientific knowledge to personalised clinical action, thereby striving to improve patient care. Additionally, technologic infrastructure equipped to handle such large complex data must be adapted to pharmacogenomics and made user friendly for prescribers and patients alike.
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Affiliation(s)
- E F Magavern
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Clinical Pharmacology, Cardiovascular Medicine, Barts Health NHS Trust, London, UK
| | - J C Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.
| | - R M Turner
- The Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - A Janmohamed
- Department of Clinical Pharmacology, St George's, University of London, London, UK
| | - P Borry
- Center for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Leuven Institute for Human Genetics and Society, Leuven, Belgium
| | - M Pirmohamed
- The Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Liverpool Health Partners, Liverpool, UK
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16
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Abstract
Susceptibility to atrial fibrillation (AF) is determined by well-recognized risk factors such as diabetes mellitus or hypertension, emerging risk factors such as sleep apnea or inflammation, and increasingly well-defined genetic variants. As discussed in detail in a companion article in this series, studies in families and in large populations have identified multiple genetic loci, specific genes, and specific variants increasing susceptibility to AF. Since it is becoming increasingly inexpensive to obtain genotype data and indeed whole genome sequence data, the question then becomes to define whether using emerging new genetics knowledge can improve care for patients both before and after development of AF. Examples of improvements in care could include identifying patients at increased risk for AF (and thus deploying increased surveillance or even low-risk preventive therapies should these be available), identifying patient subsets in whom specific therapies are likely to be effective or ineffective or in whom the driving biology could motivate the development of new mechanism-based therapies or identifying an underlying susceptibility to comorbid cardiovascular disease. While current guidelines for the care of patients with AF do not recommend routine genetic testing, this rapidly increasing knowledge base suggests that testing may now or soon have a place in the management of select patients. The opportunity is to generate, validate, and deploy clinical predictors (including family history) of AF risk, to assess the utility of incorporating genomic variants into those predictors, and to identify and validate interventions such as wearable or implantable device-based monitoring ultimately to intervene in patients with AF before they present with catastrophic complications like heart failure or stroke.
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Affiliation(s)
- M. Benjamin Shoemaker
- Department of Medicine (Cardiovascular Medicine), Vanderbilt University Medical Center, Nashville, TN
| | - Rajan L. Shah
- Department of Medicine (Cardiovascular Medicine), Stanford University Medical Center, Palo Alto, CA
| | - Dan M. Roden
- Departments of Medicine (Cardiovascular Medicine and Clinical Pharmacology), Pharmacology, and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Marco V. Perez
- Stanford Center for Inherited Cardiovascular Diseases, Stanford University, Palo Alto, CA
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17
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Grubb A, Mentz RJ. Pharmacological management of atrial fibrillation in patients with heart failure with reduced ejection fraction: review of current knowledge and future directions. Expert Rev Cardiovasc Ther 2020; 18:85-101. [PMID: 32066285 DOI: 10.1080/14779072.2020.1732210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Both heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation (AF) independently cause significant morbidity and mortality. The two conditions commonly coexist and AF in the setting of HFrEF is associated with worse mortality, hospitalizations, and quality of life compared to HFrEF without AF. Despite the large burden of these conditions, there is no clear optimal management strategy for when they occur together.Areas covered: This review focuses on the pharmacological management of AF in HFrEF. Studies were identified through PubMed search of relevant keywords. The authors review key clinical trials that have influenced management strategies and guidelines. The authors focus on the classes of drugs used to treat AF for both rate and rhythm control strategies including beta-blockers, digoxin, amiodarone, and dofetilide. Additionally, the authors discuss select non-antiarrhythmic medications that affect AF in HFrEF. The authors highlight the strengths and weakness of the data supporting the use of these medications and suggest future directions.Expert opinion: The pharmacological treatment of AF in HFrEF will need further refinement alongside the emerging role of catheter ablation. Novel HF medications and antiarrhythmics offer new tools to prevent the development of AF, as well as for rate and rhythm control strategies.
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Affiliation(s)
- Alex Grubb
- Department of Medicine, Duke University Hospital, Durham, NC, USA
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Hospital, Durham NC, USA.,Duke Clinical Research Institute, Durham NC, USA
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