Chronic obstructive pulmonary disease and atrial fibrillation: an interdisciplinary perspective

Comorbidity patterns and mortality in atrial fibrillation: a latent class analysis of the EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF)

BACKGROUND

Most older patients with atrial fibrillation (AF) have comorbidities. However, it is unclear whether specific comorbidity patterns are associated with adverse outcomes. We identified comorbidity patterns and their association with mortality in multimorbid older AF patients with different multidimensional frailty.

METHODS

Hospitalised adults aged ≥65 years with non-valvular AF were followed for 12 months in the multicentre EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF). Demographic characteristics, coexisting medical conditions, use of medications including anticoagulants, and the Multidimensional Prognostic Index (MPI) were captured on discharge. We used latent class analysis (LCA) to identify comorbidity phenotypes and Cox regression to determine associations between identified phenotypes and 12-month mortality.

RESULTS

Amongst n = 2,019 AF patients (mean ± SD age 82.9 ± 7.5 years), a 3-class LCA solution was considered optimal for phenotyping. The model identified phenotype 1 (hypertensive, other circulatory conditions, metabolic diseases; 33%), phenotype 2 (digestive diseases, infection, injury, non-specific clinical and laboratory abnormalities; 26%), and phenotype 3 (heart failure, respiratory diseases; 41%). Overall, 512 patients (25%) died within 12 months. Compared to phenotype 1, after adjusting for age, sex, use of anticoagulants, cardiovascular medications, and proton pump inhibitors, and individual MPI domains, phenotype 3 had a significantly higher risk of mortality (adjusted hazard ratio = 1.27, 95% CI = 1.01 to 1.60). In contrast, the risk of mortality in phenotype 2 was not different to phenotype 1.

CONCLUSION

We observed an association between comorbidity phenotypes identified using LCA and mortality in older AF patients. Further research is warranted to identify the mechanisms underpinning such associations.

Association between catheter ablation and psychiatric disorder risk in adults with atrial fibrillation: a multi-institutional retrospective cohort study

Background

Given that atrial fibrillation (AF) s associated with a high risk of psychiatric disorders, understanding the potential benefits of catheter ablation is clinically significant. This study was conducted to examine whether catheter ablation can prevent psychiatric disorders in patients with AF.

Methods

A retrospective cohort study was conducted over two years using data from the TriNetX electronic health record network. The study included adults diagnosed with AF and treated with either antiarrhythmic or rate-control medications. Participants were divided into two groups: those who underwent catheter ablation and a control group without ablation. The primary outcome measured was a composite of anxiety, depression, and insomnia occurrence within one to three years post-treatment. Secondary outcomes included individual psychiatric disorders, suicidal ideation or attempts, dementia, cerebral infarction, and atopic dermatitis (as a negative control).

Results

We included 21,019 patients in each matched group. The ablation group demonstrated a lower risk of the primary combined outcome (hazard ratio(HR):0.873, 95% confidence interval (CI) 0.784-0.973, p<0.01), and secondary outcomes including anxiety (HR:0.822, 95% CI:0.700-0.964; p=0.016), depression (HR:0.614, 95% CI:0.508-0.743; p<0.001), suicidal ideation or attempts (HR:0.392, 95% CI:0.165-0.934; p=0.028), dementia (HR:0.569, 95% CI:0.422-0.767; p<0.001), and cerebral infarction (HR:0.704, 95% CI:0.622-0.797; p<0.001) compared to the non-ablation group.

Conclusions

In patients with atrial fibrillation, catheter ablation was associated with a reduced risk of developing psychiatric disorders, including anxiety, depression, insomnia, suicidal ideation or attempt, and dementia, in comparison to those who did not undergo ablation. Clinicians should consider incorporating psychiatric risk factors into their comprehensive patient assessment when evaluating candidates for catheter ablation.

Incidence of arrhythmias in chronic obstructive pulmonary disease, obstructive sleep apnea, and overlap syndrome: A retrospective cohort study

BACKGROUND

New-onset arrhythmias are common in patients with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA). However, scarce data exist regarding arrhythmia risk in overlap syndrome (OS), encompassing COPD and OSA.

OBJECTIVE

We compared the incidence of new-onset atrial and ventricular arrhythmias in patients with COPD, OSA, and OS.

METHODS

We conducted a retrospective cohort study using the TriNetX Network, comprising >140 million patients to identify patients with COPD, OSA, and OS. Patients with pre-existing arrhythmias were excluded. Propensity score matching (PSM) was used to adjust for demographics, comorbidities, and medications. Adjusted odds ratios (aORs) were estimated to compare incidence of arrhythmias across cohorts.

RESULTS

Between 2010 and 2020, a total of 2,438,454 patients with COPD only, 1,960,845 patients with OSA only, and 440,018 patients with OS (age ≥18 years) were identified. After PSM, we included 359,496 patients per cohort for the OS vs OSA-only comparison and 399,235 patients per cohort for the OS vs COPD-only comparison. Over a mean follow-up of 5.3 years, incidence of new-onset atrial fibrillation/flutter was 10.0% in OS vs 7.0% in COPD (aOR 1.472, 95% confidence interval [CI] 1.449-1.496) and 6.4% in OSA (aOR 1.568, 95% CI 1.541-1.595). Patients with OS had higher incidence of new-onset ventricular tachycardia and cardiac arrest than those with COPD (aOR 1.442 and 1.189, respectively) and OSA (aOR 1.645 and 1.777, respectively). Patients with COPD preceding OSA diagnosis had higher odds of new-onset arrhythmias.

CONCLUSION

Patients with OS have a higher incidence of new-onset atrial fibrillation/flutter, ventricular tachycardia, and cardiac arrest compared with those with OSA and COPD alone.

Association of red cell distribution width/albumin ratio and 28-day mortality in chronic obstructive pulmonary disease patients with atrial fibrillation: a medical information mart for intensive care IV study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) complicated by atrial fibrillation (AF) in ICU patients is associated with higher risks of adverse outcomes. The red cell distribution width to albumin ratio (RAR), may predict mortality in critical illness, yet its link to 28-day mortality in ICU patients with COPD and AF remains unclear.

METHODS

This retrospective cohort study analyzed 693 ICU patients with COPD and AF from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database, grouped by RAR tertiles. The primary endpoint was 28-day mortality, with secondary endpoints including 90-day, 365-day, and ICU mortality. Multivariate cox models estimated hazard ratios (HRs) for mortality, while restricted cubic spline regression assessed the linearity of the RAR-mortality relationship. Kaplan-Meier curves compared survival across tertiles, and subgroup analyses explored RAR's impact across age, gender, race, and comorbidities.

RESULTS

Our study included 693 ICU patients with both COPD and AF, with an average age of 74.9 years. The 28-day mortality was 30.7%. Patients in the highest RAR tertile had significantly worse 28-day survival (p < 0.0001). Higher RAR was linearly associated with increased 28-day mortality (p for non-linearity > 0.05), with each 1-unit increase in RAR linked to an 18% rise in mortality risk (95% CI: 1.08-1.29). Sensitivity analyses confirmed RAR's relevance for 90-day, 365-day, and ICU mortality.

CONCLUSIONS

RAR is independently associated with 28-day mortality in COPD patients with AF. Elevated RAR levels correlate with higher 28-day mortality rates in this population.

CLINICAL TRIAL NUMBER

Not applicable.

Non-traditional risk factors for atrial fibrillation: epidemiology, mechanisms, and strategies

Atrial fibrillation (AF) has become the pre-dominant arrhythmia worldwide and is associated with high morbidity and mortality. Its pathogenesis is intricately linked to the deleterious impact of cardiovascular risk factors, emphasizing the pivotal imperative for early detection and mitigation strategies targeting these factors for the prevention of primary AF. While traditional risk factors are well recognized, an increasing number of novel risk factors have been identified in recent decades. This review explores the emerging non-traditional risk factors for the primary prevention of AF, including unhealthy lifestyle factors in current society (sleep, night shift work, and diet), biomarkers (gut microbiota, hyperuricaemia, and homocysteine), adverse conditions or diseases (depression, epilepsy, clonal haematopoiesis of indeterminate potential, infections, and asthma), and environmental factors (acoustic pollution and other environmental factors). Unlike traditional risk factors, individuals have limited control over many of these non-traditional risk factors, posing challenges to conventional prevention strategies. The purpose of this review is to outline the current evidence on the associations of non-traditional risk factors with new-onset AF and the potential mechanisms related to these risk factors. Furthermore, this review aims to explore potential interventions targeting these risk factors at both the individual and societal levels to mitigate the growing burden of AF, suggesting guideline updates for primary AF prevention.

[Update COPD and cardiovascular events]

Chronic Obstructive Pulmonary Disease (COPD) is closely linked to cardiovascular disease (CVD), with up to 70% of COPD patients experiencing cardiovascular comorbidities. The coexistence of COPD and CVD significantly increases hospitalization rates, symptom burden, and mortality, particularly during acute exacerbations of COPD (AECOPD), which impose an increased risk of cardiovascular events - both during and shortly after these episodes. Mechanistic links between COPD and CVD include systemic inflammation, oxidative stress, endothelial dysfunction, and hypoxemia, all of which contribute to the progression of both conditions.Current management guidelines stress the importance of early screening and risk factor control for cardiovascular comorbidities in COPD patients. Different COPD therapies can affect cardiovascular outcomes in distinct ways. Recent research suggests that inhaled corticosteroids (ICS), either alone or as part of triple therapy (long-acting muscarinic antagonist [LAMA], long-acting beta-agonist [LABA], and ICS), may help reduce mortality and morbidity, particularly for those at higher risk. Furthermore, beta-blockers and statins have shown potential benefits for COPD patients with CVD, although their exact role is not entirely clear. Newer antidiabetic agents, such as SGLT-2 inhibitors, have also demonstrated promise in reducing exacerbation rates.This review emphasizes the need for an integrated care approach, highlighting the importance of personalized, guideline-driven therapies to enhance quality of life and clinical outcomes for COPD patients with cardiovascular comorbidities.

Super-Enhancer Target Gene CBP/p300-Interacting Transactivator With Glu/Asp-Rich C-Terminal Domain, 2 Cooperates With Transcription Factor Forkhead Box J3 to Inhibit Pulmonary Vascular Remodeling

The function of super-enhancers (SEs) in pulmonary hypertension (PH), especially in the proliferation of pulmonary artery smooth muscle cells (PASMCs), is currently unknown. We identified SEs-targeted genes in PASMCs with chromatin immunoprecipitation (ChIP)-sequence by H3K27ac antibody and proved that CBP/p300-interacting transactivator with Glu/Asp-rich C-terminal domain, 2 (CITED2) is an SEs-targeted gene through bioinformatics prediction, ChIP-PCR, dual-luciferase reporter gene assays and other experimental methods. We also found that the expression of CITED2 and the transcription factor Forkhead Box J3 (FOXJ3) was reduced in hypoxic mouse PASMCs. In addition, the expression of CITED2 and FOXJ3 also decreased in both the patients with idiopathic pulmonary arterial hypertension (iPAH) and the human PASMCs exposed to hypoxia. The decreased expression of CITED2 was reversed by co-transfection of FOXJ3 and SEs plasmids. Overexpressing of CITED2 attenuated the PASMCs proliferation induced by hypoxia. Lentiviral overexpression of CITED2 also reversed hypoxia-induced pulmonary hypertension mice model. Mechanically, the expression of CITED2 by affecting by FOXJ3, which binding with three SEs located in the about 2000 bp of TSS. In conclusion, we first identified that CITED2 is a kind of SEs-targeted gene, modulated by FOXJ3. The FOXJ3/SEs/CITED2 axis may become a new therapeutic target of PH.

A New Functional Threshold for Minimally Invasive Lobectomy

OBJECTIVE

To assess the performance of a lower predicted postoperative (ppo) forced expiratory volume in 1 second (FEV 1 ) or diffusion capacity of the lung for carbon monoxide (DLCO) (ppoFEV 1 /ppoDLCO) threshold to predict cardiopulmonary complications after minimally invasive surgery (MIS) lobectomy.

BACKGROUND

Although MIS is associated with better postoperative outcomes than open surgery, MIS uses risk-assessment algorithms developed for open surgery. Moreover, several different definitions of cardiopulmonary complications are used for assessment.

METHODS

All patients who underwent MIS lobectomy for clinical stage I to II lung cancer from 2018 to 2022 at our institution were considered. The performance of a ppoFEV 1 /ppoDLCO threshold of <45% was compared against that of the current guideline threshold of <60%. Three different definitions of cardiopulmonary complications were compared: Society of Thoracic Surgeons (STS), European Society of Thoracic Surgeons (ESTS), and Berry and colleagues' study.

RESULTS

In 946 patients, the ppoFEV 1 /ppoDLCO threshold of <45% was associated with a higher proportion correctly classified [79% (95% CI, 76%-81%) vs 65% (95% CI, 62%-68%); P <0.001]. The complication with the biggest difference in incidence between ppoFEV 1 /ppoDLCO of 45% to 60% and >60% was prolonged air leak [33 (13%) vs 34 (6%); P <0.001]. The predicted probability curves for cardiopulmonary complications were higher for the STS definition than for the ESTS or Berry definitions across ppoFEV 1 and ppoDLCO values.

CONCLUSIONS

The ppoFEV 1 /ppoDLCO threshold of <45% more accurately classified patients for cardiopulmonary complications after MIS lobectomy, emphasizing the need for updated risk-assessment guidelines for MIS lobectomy to optimize additional cardiopulmonary function evaluation.

Is 'Cardiopulmonary' the New 'Cardiometabolic'? Making a Case for Systems Change in COPD

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) have a syndemic relationship with shared risk factors and complex interplay between genetic, environmental, socioeconomic, and pathophysiological mechanisms. CVD is among the most common comorbidities in patients with COPD and vice versa. Patients with COPD, irrespective of their disease severity, are at increased risk of CVD morbidity and mortality, driven in part by COPD exacerbations. Despite these known interrelationships, CVD is underestimated and undertreated in patients with COPD. Similarly, COPD is an independent risk-enhancing factor for adverse cardiovascular (CV) events, yet it is not incorporated into current CV risk assessment tools, leading to under-recognition and undertreatment. There is a pressing need for systems change in COPD management to move beyond symptom control towards a comprehensive cardiopulmonary disease paradigm with proactive prevention of exacerbations and adverse cardiopulmonary outcomes and mortality. However, there is a dearth of evidence defining optimal cardiopulmonary care pathways. Fortunately, there is a precedent to support systems-level change in the field of diabetes, which evolved from glycemic control to comprehensive multi-organ risk assessment and management. Key elements included integrated multidisciplinary care, intensive risk factor management, coordination between primary and specialist care, care pathways and protocols, education and self management, and disease-modifying therapies. This commentary article draws parallels between the cardiometabolic and cardiopulmonary paradigms and makes a case for systems change towards multidisciplinary, integrated cardiopulmonary care, using the evolution in diabetes care as a potential framework.

Prediction of new-onset atrial fibrillation in patients with non-small cell lung cancer treated with curative-intent conventional radiotherapy

BACKGROUND

Atrial fibrillation (AF) is an important side effect of thoracic Radiotherapy (RT), which may impair quality of life and survival. This study aimed to develop a prediction model for new-onset AF in patients with Non-Small Cell Lung Cancer (NSCLC) receiving RT alone or as a part of their multi-modal treatment.

PATIENTS AND METHODS

Patients with stage I-IV NSCLC treated with curative-intent conventional photon RT were included. The baseline electrocardiogram (ECG) was compared with follow-up ECGs to identify the occurrence of new-onset AF. A wide range of potential clinical predictors and dose-volume measures on the whole heart and six automatically contoured cardiac substructures, including chambers and conduction nodes, were considered for statistical modeling. Internal validation with optimism-correction was performed. A nomogram was made.

RESULTS

374 patients (mean age 69 ± 10 years, 57 % male) were included. At baseline, 9.1 % of patients had AF, and 42 (11.2 %) patients developed new-onset AF. The following parameters were predictive: older age (OR=1.04, 95 % CI: 1.013-1.068), being overweight or obese (OR=1.791, 95 % CI: 1.139-2.816), alcohol use (OR=4.052, 95 % CI: 2.445-6.715), history of cardiac procedures (OR=2.329, 95 % CI: 1.287-4.215), tumor located in the upper lobe (OR=2.571, 95 % CI: 1.518-4.355), higher forced expiratory volume in 1 s (OR=0.989, 95 % CI: 0.979-0.999), higher creatinine (OR=1.008, 95 % CI: 1.002-1.014), concurrent chemotherapy (OR=3.266, 95 % CI: 1.757 to 6.07) and left atrium Dmax (OR=1.022, 95 % CI: 1.012-1.032). The model showed good discrimination (area under the curve = 0.80, 95 % CI: 0.76-0.84), calibration and positive net benefits.

CONCLUSION

This prediction model employs readily available predictors to identify patients at high risk of new-onset AF who could potentially benefit from active screening and timely management of post-RT AF.

Association between postoperative atrial fibrillation after coronary artery bypass grafting and short-term clinical outcomes

BACKGROUND

Despite advances in prevention and treatment, postoperative atrial fibrillation (POAF) is the most common type of complication undergoing cardiac surgery. This study aimed to identify the relationship between POAF and clinical outcomes after coronary artery bypass graft.

METHODS

In this cross-sectional study, we retrospectively reviewed the medical records of 324 patients who had undergone coronary artery bypass grafting in an intensive care unit between 2010 and 2019 at a tertiary hospital in Korea. Propensity score matching was used to estimate a 1:1 match (without: with POAF) using seven covariates to overcome selection bias. Kaplan-Meier survival analysis and Cox proportional hazards modeling were performed to determine the effect on intensive care unit readmission and length of hospital stay.

RESULTS

After controlling for covariates, 1:1 matching was performed for 91 patients in each group. The occurrence of postoperative atrial fibrillation was found to increase the probability of readmission to the intensive care unit, with a 23% reduced probability of readmission for every 10% increase in left ventricular ejection fraction. Multivariate analysis indicated that postoperative atrial fibrillation, chronic obstructive pulmonary disease as a comorbidity, and preoperative hemoglobin were factors affecting the length of hospitalization after surgery. The Kaplan-Meier survival analysis results indicated that the without POAF group had a higher survival rate than the with POAF group.

CONCLUSIONS

Healthcare professionals should recognize negative factors such as postoperative atrial fibrillation and abnormal hematologic parameters that impact major clinical outcomes in patients and may require closer monitoring before and after coronary artery bypass grafting.

Temporal Dynamics of Cardiovascular Risk in Patients with Chronic Obstructive Pulmonary Disease During Stable Disease and Exacerbations: Review of the Mechanisms and Implications

Introduction

Exacerbations of chronic obstructive pulmonary disease (COPD) are risk factors for severe cardiovascular (CV) events, with the risk remaining significantly elevated long after the symptomatic phase of the exacerbation. The pathophysiology underpinning the relationship between acute events of both COPD and CV diseases has been understudied. Our objectives were to review the mechanisms by which COPD exacerbations increase the risk of CV events and understand the temporality of this risk.

Methods

A pragmatic and targeted literature review was conducted with a focus on identifying recent, high-impact papers up to June 2023, guided by insights from subject matter experts including pulmonologists and cardiologists.

Results

A substantial number of inter-related mechanisms underpin the spiral of anatomical and functional deterioration of lung and heart affecting COPD patients during stable state. In turn, an exacerbation of COPD may trigger a CV event, during and beyond the symptomatic phase, due to ventilation/perfusion mismatch, oxygen supply-demand imbalance, oxidative stress, systemic inflammation, hypercoagulable state, dynamic hyperinflation, pulmonary hypertension, and sympathetic activation. However, no study was identified that explored the mechanisms by which an exacerbation confers a sustained risk of CV event.

Conclusion

While our review identified multiple dynamic and interacting pathophysiological mechanisms during and after an exacerbation of COPD that contribute to increasing the risk of a wide range of cardiac events, little is known regarding the precise long-term mechanisms after acute exacerbation to explain the persistent increased CV event risk beyond the symptomatic phase. The temporal changes in static and dynamic substrates need further characterization to better understand the different risk factors and risk periods for a CV event following the onset of an exacerbation. Moreover, guideline-directed cardiopulmonary therapies should be implemented at every opportunity; preventing exacerbations and intensively treating traditional CV risk factors should be a focus in COPD management.

Metabolic remodelling in atrial fibrillation: manifestations, mechanisms and clinical implications

Atrial fibrillation (AF) is a continually growing health-care burden that often presents together with metabolic disorders, including diabetes mellitus and obesity. Current treatments often fall short of preventing AF and its adverse outcomes. Accumulating evidence suggests that metabolic disturbances can promote the development of AF through structural and electrophysiological remodelling, but the underlying mechanisms that predispose an individual to AF are aetiology-dependent, thus emphasizing the need for tailored therapeutic strategies to treat AF that target an individual's metabolic profile. AF itself can induce changes in glucose, lipid and ketone metabolism, mitochondrial function and myofibrillar energetics (as part of a process referred to as 'metabolic remodelling'), which can all contribute to atrial dysfunction. In this Review, we discuss our current understanding of AF in the setting of metabolic disorders, as well as changes in atrial metabolism that are relevant to the development of AF. We also describe the potential of available and emerging treatment strategies to target metabolic remodelling in the setting of AF and highlight key questions and challenges that need to be addressed to improve outcomes in these patients.

A Research Agenda to Improve Outcomes in Patients with Chronic Obstructive Pulmonary Disease and Cardiovascular Disease: An Official American Thoracic Society Research Statement

Background: Individuals with chronic obstructive pulmonary disease (COPD) are often at risk for or have comorbid cardiovascular disease and are likely to die of cardiovascular-related causes. Objectives: To prioritize a list of research topics related to the diagnosis and management of patients with COPD and comorbid cardiovascular diseases (heart failure, atherosclerotic vascular disease, and atrial fibrillation) by summarizing existing evidence and using consensus-based methods. Methods: A literature search was performed. References were reviewed by committee co-chairs. An international, multidisciplinary committee, including a patient advocate, met virtually to review evidence and identify research topics. A modified Delphi approach was used to prioritize topics in real time on the basis of their potential for advancing the field. Results: Gaps spanned the translational science spectrum from basic science to implementation: 1) disease mechanisms; 2) epidemiology; 3) subphenotyping; 4) diagnosis and management; 5) clinical trials; 6) care delivery; 7) medication access, adherence, and side effects; 8) risk factor mitigation; 9) cardiac and pulmonary rehabilitation; and 10) health equity. Seventeen experts participated, and quorum was achieved for all votes (>80%). Of 17 topics, ≥70% agreement was achieved for 12 topics after two rounds of voting. The range of summative Likert scores was -15 to 25. The highest priority was "Conduct pragmatic clinical trials with patient-centered outcomes that collect both pulmonary and cardiac data elements." Health equity was identified as an important topic that should be embedded within all research. Conclusions: We propose a prioritized research agenda with the purpose of stimulating high-impact research that will hopefully improve outcomes among people with COPD and cardiovascular disease.

The incidence of atrial fibrillation detected by implantable loop recorders: a comparison between patients with and without embolic stroke of undetermined source

Aims

Stroke is the most debilitating outcome of atrial fibrillation (AF). The use of implantable loop recorders increases the detection of AF episodes among patients with embolic stroke of undetermined source. The significance of device-detected AF, or subclinical AF, is unknown. This study aimed to compare the incidence of AF detected by implantable loop recorder in patients with and without embolic stroke of undetermined source.

Methods and results

We retrospectively studied all patients without known AF who were referred to our institution for implantable loop recorder implantation following embolic stroke of undetermined source, syncope, or palpitations from March 2009 to November 2019. The primary endpoint was any detection of AF or atrial flutter by implantable loop recorder. Seven hundred and fifty patients were included and followed up for a mean duration of 731 days (SD 443). An implantable loop recorder was implanted following embolic stroke of undetermined source in 323 and for assessment of syncope, palpitations, or another reason in 427 patients. The incidence of AF was significantly (P < 0.001) higher among patients with embolic stroke of undetermined source compared with the non-embolic stroke of undetermined source group; 48.6% vs. 13.8% (for any duration of AF) and 32.2% vs. 12.4% (for AF lasting ≥30 s) both P < 0.001. Kaplan-Meier analysis showed significantly higher incidence of AF for incremental durations of AF up to >5.5 h, but not >24 h. This was driven by longest AF durations of <6 min and between 5.5 h and 24 h, suggesting a bimodal distribution. In a multivariable Cox regression analysis, embolic stroke of undetermined source independently conferred an almost 5-fold increase in the hazard for any duration of AF.

Conclusion

The incidence of AF is significantly higher amongst embolic stroke of undetermined source vs. non-embolic stroke of undetermined source patients monitored constantly by an implantable loop recorder. A high number of embolic stroke of undetermined source survivors have short-duration AF episodes. Further work is needed to determine the optimal treatment strategy of these AF episodes in embolic stroke of undetermined source.

Low-dose azithromycin prophylaxis in patients with atrial fibrillation and chronic obstructive pulmonary disease

Low-dose azithromycin prophylaxis is associated with improved outcomes in people suffering frequent exacerbations of chronic obstructive pulmonary disease (COPD), but the use of macrolides in patients with cardiovascular disease has been debated. To investigate the risk of adverse events after COPD exacerbations in patients with atrial fibrillation (AF) treated with azithromycin prophylaxis. Retrospective cohort study within the TriNetX Platform, including AF patients with COPD exacerbations. Risks of primary and secondary outcomes were recorded up to 30 days post-COPD exacerbations and compared between azithromycin users and azithromycin non-users. The primary outcomes were the risks for a composite of (1) cardiovascular (all-cause death, heart failure, ventricular arrhythmias, ischemic stroke, myocardial infarction, and cardiac arrest), and (2) hemorrhagic events (intracranial hemorrhage (ICH), and gastro-intestinal bleeding). Cox-regression analyses compared outcomes between groups after propensity score matching (PSM). After PSM, azithromycin users (n = 2434, 71 ± 10 years, 49% females) were associated with a lower 30-day risk of post-exacerbation cardiovascular (HR 0.67, 95% CI 0.61-0.73) and hemorrhagic composite outcome (HR 0.45, 95% CI 0.32-0.64) compared to azithromycin non-users (n = 2434, 72 ± 11 years, 51% females). The beneficial effect was consistent for each secondary outcomes, except ICH. On sensitivity analyses, the reduced risk of adverse events in azithromycin users was irrespective of smoking status, exacerbation severity, and type of oral anticoagulation. Azithromycin prophylaxis is associated with a lower risk of all-cause death, thrombotic and hemorrhagic events in AF patients with COPD. The possible role of azithromycin prophylaxis as part of the integrated care management of AF patients with COPD needs further study.

The Current Molecular and Cellular Landscape of Chronic Obstructive Pulmonary Disease (COPD): A Review of Therapies and Efforts towards Personalized Treatment

Chronic obstructive pulmonary disease (COPD) ranks as the third leading cause of global illness and mortality. It is commonly triggered by exposure to respiratory irritants like cigarette smoke or biofuel pollutants. This multifaceted condition manifests through an array of symptoms and lung irregularities, characterized by chronic inflammation and reduced lung function. Present therapies primarily rely on maintenance medications to alleviate symptoms, but fall short in impeding disease advancement. COPD's diverse nature, influenced by various phenotypes, complicates diagnosis, necessitating precise molecular characterization. Omics-driven methodologies, including biomarker identification and therapeutic target exploration, offer a promising avenue for addressing COPD's complexity. This analysis underscores the critical necessity of improving molecular profiling to deepen our comprehension of COPD and identify potential therapeutic targets. Moreover, it advocates for tailoring treatment strategies to individual phenotypes. Through comprehensive exploration-based molecular characterization and the adoption of personalized methodologies, innovative treatments may emerge that are capable of altering the trajectory of COPD, instilling optimism for efficacious disease-modifying interventions.

Electrocardiographic alterations in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality, and its incidence has grown within several years, quickly becoming the third leading cause of mortality. The disease is characterized by alveolar destruction, air-trapping, and chronic inflammation due to persistent exposure to a large spectrum of harmful particles. The diagnosis of COPD is made by demonstration of persistent and not fully reversible airflow limitation, and different phenotypes may be recognized based on pathophysiological, clinical, and radiological features. However, COPD is a systemic disease with effects involving several organs. For example, mechanical and functional alterations secondary to COPD involve heart function. Indeed, cardiovascular diseases are highly prevalent in patients affected by COPD and represent the primary cause of mortality in such patients. An electrocardiogram is a simple and cheap test that gives much information about the heart status of COPD patients. Consequently, variations from "normality" can be appreciated in these patients, with the most frequent abnormalities being P-wave, QRS axis, and ventricular repolarization abnormalities, in addition to conduction alterations and a vast number of arrhythmias. As a result, ECG should be routinely performed as a valuable tool to recognize alterations due to COPD (i.e., mechanical and functional) and possible associated heart diseases. This review aims to describe the typical ECG features in most COPD patients and to provide a systematic summary that can be used in clinical practice.

Atrial High-Rate Episodes in Elderly Patients: The Anticoagulation Therapy Dilemma

Atrial fibrillation (AF) has been associated with higher morbidity and mortality rates, especially in older patients. Subclinical atrial fibrillation (SCAF) is defined as the presence of atrial high-rate episodes (AHREs) > 190 bpm for 10 consecutive beats > 6 min and <24 h, as detected by cardiac implanted electronic devices (CIEDs). The selection of eligible patients for anticoagulation therapy among elderly individuals with AHREs detected through CIEDs remains a contentious issue. The meta-analysis of ARTESiA and NOAH-AFNET 6 clinical trials revealed that taking Edoxaban or Apixaban as oral anticoagulation therapy can reduce the risk of stroke by approximately 32% while increasing the risk of major bleeding by approximately 62%. However, it is still unclear which are, among patients with SCAF, those who can take the highest net clinical benefit from anticoagulant therapy. The present review summarizes the current evidence on this intriguing issue and suggests strategies to try to better stratify the risk of stroke and systemic embolism in patients with AHREs. We propose incorporating some parameters including chronic kidney disease (CKD), obesity, enlarged left atrial volume, the efficacy in blood pressure management, and frailty into the traditional CHA2DS2-VASc score. Future trials will be needed to verify the clinical usefulness of the proposed prognostic score mainly in the view of a personalized therapeutic approach in patients with SCAF.

Detrimental Impact of Atrial Fibrillation among Patients Hospitalized for Acute Exacerbation of COPD: Results of a Population-Based Study in Spain from 2016 to 2021

Background/Objectives: To analyze changes in the prevalence of atrial fibrillation (AF) in patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD); to evaluate hospital outcomes according to AF status, assessing sex differences; to identify factors associated with AF presence; and to analyze variables associated with in-hospital mortality (IHM) in AE-COPD patients with AF. Methods: We used data from the Registry of Specialized Care Activity-Basic Minimum Data Set (RAE-CMBD) to select patients aged ≥40 years with COPD in Spain (2016-2021). We stratified the study population according to AF presence and sex. The propensity score matching (PSM) methodology was employed to create comparable groups based on age, admission year, and comorbidities at the time of hospitalization. Results: We identified 399,196 hospitalizations that met the inclusion criteria. Among them, 20.58% had AF. The prevalence of AF rose from 2016 to 2021 (18.26% to 20.95%), though the increase was only significant in men. The median length of hospital stay (LOHS) and IHM were significantly higher in patients with AF than in those without AF. After PSM, IHM remained significantly higher for man and women with AF. Older age, male sex, and several comorbidities were factors associated with AF. Additionally, older age, male sex, different comorbidities including COVID-19, hospitalization in the year 2020, mechanical ventilation, and intensive care unit (ICU) admission were associated with higher IHM in patients with AE-COPD and AF. Conclusions: AF prevalence was high in patients hospitalized for AE-COPD, was higher in men than in women, and increased over time. AF presence was associated with worse outcomes. The variables associated with IHM in hospitalized AE-COPD patients with AF were older age, male sex, different comorbidities including COVID-19 presence, hospitalization in the year 2020, need of mechanical ventilation, and ICU admission.

Factors associated with non-fatal heart failure and atrial fibrillation or flutter within the first 30 days post COPD exacerbation: a nested case-control study

BACKGROUND

An immediate, temporal risk of heart failure and arrhythmias after a Chronic Obstructive Pulmonary Disease (COPD) exacerbation has been demonstrated, particularly in the first month post-exacerbation. However, the clinical profile of patients who develop heart failure (HF) or atrial fibrillation/flutter (AF) following exacerbation is unclear. Therefore we examined factors associated with people being hospitalized for HF or AF, respectively, following a COPD exacerbation.

METHODS

We conducted two nested case-control studies, using primary care electronic healthcare records from the Clinical Practice Research Datalink Aurum linked to Hospital Episode Statistics, Office for National Statistics for mortality, and socioeconomic data (2014-2020). Cases had hospitalization for HF or AF within 30 days of a COPD exacerbation, with controls matched by GP practice (HF 2:1;AF 3:1). We used conditional logistic regression to explore demographic and clinical factors associated with HF and AF hospitalization.

RESULTS

Odds of HF hospitalization (1,569 cases, 3,138 controls) increased with age, type II diabetes, obesity, HF and arrhythmia history, exacerbation severity (hospitalization), most cardiovascular medications, GOLD airflow obstruction, MRC dyspnea score, and chronic kidney disease. Strongest associations were for severe exacerbations (adjusted odds ratio (aOR)=6.25, 95%CI 5.10-7.66), prior HF (aOR=2.57, 95%CI 1.73-3.83), age≥80 years (aOR=2.41, 95%CI 1.88-3.09), and prior diuretics prescription (aOR=2.81, 95%CI 2.29-3.45). Odds of AF hospitalization (841 cases, 2,523 controls) increased with age, male sex, severe exacerbation, arrhythmia and pulmonary hypertension history and most cardiovascular medications. Strongest associations were for severe exacerbations (aOR=5.78, 95%CI 4.45-7.50), age≥80 years (aOR=3.15, 95%CI 2.26-4.40), arrhythmia (aOR=3.55, 95%CI 2.53-4.98), pulmonary hypertension (aOR=3.05, 95%CI 1.21-7.68), and prescription of anticoagulants (aOR=3.81, 95%CI 2.57-5.64), positive inotropes (aOR=2.29, 95%CI 1.41-3.74) and anti-arrhythmic drugs (aOR=2.14, 95%CI 1.10-4.15).

CONCLUSIONS

Cardiopulmonary factors were associated with hospitalization for HF in the 30 days following a COPD exacerbation, while only cardiovascular-related factors and exacerbation severity were associated with AF hospitalization. Understanding factors will help target people for prevention.

Outcomes of coronary artery bypass grafting (CABG) in patients with OSA-COPD overlap syndrome versus COPD alone: an analysis of US Nationwide Inpatient Sample

BACKGROUND

Obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) are associated with unfavorable outcomes following coronary artery bypass grafting (CABG). The purpose of this study was to compare in-hospital outcomes of patients with COPD alone versus OSA-COPD overlap after CABG.

METHODS

Data of adults ≥ 18 years old with COPD who received elective CABG between 2005 and 2018 were extracted from the US Nationwide Inpatient Sample (NIS). Patients were divided into two groups: with OSA-COPD overlap and COPD alone. Propensity score matching (PSM) was employed to balance the between-group characteristics. Logistic and linear regression analyses determined the associations between study variables and inpatient outcomes.

RESULTS

After PSM, data of 2,439 patients with OSA-COPD overlap and 9,756 with COPD alone were analyzed. After adjustment, OSA-COPD overlap was associated with a significantly increased risk of overall postoperative complications (adjusted odd ratio [aOR] = 1.12, 95% confidence interval [CI]: 95% CI: 1.01-1.24), respiratory failure/prolonged mechanical ventilation (aOR = 1.27, 95%CI: 1.14-1.41), and non-routine discharge (aOR = 1.16, 95%CI: 1.03-1.29), and AKI (aOR = 1.14, 95% CI: 1.00-1.29). Patients with OSA-COPD overlap had a lower risk of in-hospital mortality (adjusted odd ratio [aOR] = 0.53, 95% CI: 0.35-0.81) than those with COPD only. Pneumonia or postoperative atrial fibrillation (AF) risks were not significantly different between the 2 groups. Stratified analyses revealed that, compared to COPD alone, OSA-COPD overlap was associated with increased respiratory failure/prolonged mechanical ventilation risks among patients ≥ 60 years, and both obese and non-obese subgroups. In addition, OSA-COPD overlap was associated with increased risk of AKI among the older and obese subgroups.

CONCLUSION

In US adults who undergo CABG, compared to COPD alone, those with OSA-COPD are at higher risks of non-routine discharge, AKI, and respiratory failure/prolonged mechanical ventilation, but a lower in-hospital mortality. No increased risk of AF was noted.

Cardiovascular disease and risk in COPD: a state of the art review

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) and cardiovascular diseases (CVD) commonly co-exist. Outcomes of people living with both conditions are poor in terms of symptom burden, receiving evidence-based treatment and mortality. Increased understanding of the underlying mechanisms may help to identify treatments to relieve this disease burden. This narrative review covers the overlap of COPD and CVD with a focus on clinical presentation, mechanisms, and interventions. Literature up to December 2023 are cited.

AREAS COVERED

1. What is COPD 2. The co-existence of COPD and cardiovascular disease 3. Mechanisms of cardiovascular disease in COPD. 4. Populations with COPD are at risk of CVD 5. Complexity in the co-diagnosis of COPD in those with cardiovascular disease. 6. Therapy for COPD and implications for cardiovascular events and risk. 7. Cardiovascular risk and exacerbations of COPD. 8. Pro-active identification and management of CV risk in COPD.

EXPERT OPINION

The prospective identification of co-morbid COPD in CVD patients and of CVD and CV risk in people with COPD is crucial for optimizing clinical outcomes. This includes the identification of novel treatment targets and the design of clinical trials specifically designed to reduce the cardiovascular burden and mortality associated with COPD. Databases searched: Pubmed, 2006-2023.

Practicality and Safety of Electrical Pulmonary Vein Isolation and Left Atrial Appendage Ligation in Lung Transplant Recipients With Pretransplant Atrial Fibrillation

Background

Lung transplant surgery creates surgical pulmonary vein isolation (PVI) as a routine part of the procedure. However, many patients with pretransplant atrial fibrillation continue to have atrial fibrillation at 1 y. We hypothesized that the addition of electrical PVI and left atrial appendage isolation/ligation (LAL) to the lung transplant procedure restores sinus rhythm at 1 y in patients with pretransplant atrial fibrillation.

Methods

We retrospectively reviewed all adult lung transplant recipients at the University of California Los Angeles from April 2006 to August 2021. All patients with pretransplant atrial fibrillation underwent concomitant PVI/LAL and were compared with lung transplant recipients without preoperative atrial fibrillation. In-hospital outcomes; 1-y survival; and the incidence of stroke, cardiac readmissions, repeat ablations, and sinus rhythm (composite endpoint) were examined at 1 y for the PVI/LAL cohort.

Results

Sixty-one lung transplant recipients with pretransplant atrial fibrillation underwent concomitant PVI/LAL. No patient in the PVI/LAL cohort required cardiac-related readmission or catheter ablation for atrial fibrillation within 1 y of transplantation. Freedom from the composite endpoint of death, stroke, cardiac readmission, and repeat ablation for atrial fibrillation at 1 y was 85% (95% confidence interval, 73%-92%) for lung transplant recipients treated with PVI/LAL.

Conclusions

The addition of PVI/LAI to the lung transplant operation in patients with pretransplant atrial fibrillation was safe and effective in maintaining sinus rhythm and baseline risk of stroke at 1 y.

Atrial fibrillation: comorbidities, lifestyle, and patient factors

Modern anticoagulation therapy has dramatically reduced the risk of stroke and systemic thromboembolism in people with atrial fibrillation (AF). However, AF still impairs quality of life, increases the risk of stroke and heart failure, and is linked to cognitive impairment. There is also a recognition of the residual risk of thromboembolic complications despite anticoagulation. Hence, AF management is evolving towards a more comprehensive understanding of risk factors predisposing to the development of this arrhythmia, its' complications and interventions to mitigate the risk. This review summarises the recent advances in understanding of risk factors for incident AF and managing these risk factors. It includes a discussion of lifestyle, somatic, psychological, and socioeconomic risk factors. The available data call for a practice shift towards a more individualised approach considering an increasingly broader range of health and patient factors contributing to AF-related health burden. The review highlights the needs of people living with co-morbidities (especially with multimorbidity), polypharmacy and the role of the changing population demographics affecting the European region and globally.

Association of Atrial Fibrillation with Insomnia in the Elderly Population

INTRODUCTION/OBJECTIVES

Insomnia is a common sleep disorders that affects most individuals in the United States, and worldwide. Insomnia is linked with an increased risk of atrial fibrillation (AF) in adults, although the strengths of association were weak, especially in the elderly population. AF is estimated to affect approximately 3 to 6 million people in the United States. We studied the association of AF with insomnia in the elderly population.

METHODS

We reviewed the electronic medical records of elderly patients who received care in an internal medicine office from July 1, 2020 through June 30, 2021. Patients were grouped into AF group, and a group without AF (NOAF). Association of insomnia and other variables were compared between the 2 groups.

RESULTS

Among 2428 patients, 341 (14%) had AF. Patients in the AF group were significantly older compared to no-AF group (80.3 ± 7.9 vs 76.1 ± 7.4 years; P < .001). A higher frequency of men was noted in AF group versus NOAF group (54.3 vs 42.0%; P < .001). The frequency of insomnia was significantly higher in AF group versus NOAF group (14.1 vs 9.5%; P < .05). Additionally, greater frequencies of associations of other comorbid medical conditions were noted in the AF group compared to NOAF group, such as cerebrovascular accident (CVA; 12.9 vs 5.4%; P < .001), transient ischemic attack (TIA; 7.0 vs 3.0%; P < .001), dementia (5.9 vs 3.3%; P < .05), coronary artery disease (CAD; 34.9 vs 18.3%; P < .001), congestive heart failure (CHF; 21.1 vs 3.8%; P < .001), other cardiac arrhythmias (53.4 vs 6.3%; P < .001), chronic obstructive pulmonary disease (COPD; 12.3 vs 5.7%; P < .001), obstructive sleep apnea (OSA; 17.6 vs 11.8%; P = .003), chronic kidney disease (CKD; 22.9 vs 11.9%; P < .001), anemia (23.2 vs 13.0%; P < .001), and cancer (36.1 vs 27.9%; P = .002). There was significantly greater odds of AF in patients who had insomnia (OR = 1.972, CI = 1.360-2.851; P < .001).

CONCLUSION

AF was associated with insomnia in the elderly population. Higher frequencies of association of AF were also seen with older age, male sex, White race, CVA, TIA, dementia, CAD, CHF, other cardiac arrhythmias, COPD, OSA, CKD, anemia, and cancer.

Impact of chronic obstructive pulmonary disease in patients with atrial fibrillation: an analysis from the GLORIA-AF registry

AIMS

Chronic obstructive pulmonary disease (COPD) may influence management and prognosis of atrial fibrillation (AF), but this relationship has been scarcely explored in contemporary global cohorts. We aimed to investigate the association between AF and COPD, in relation to treatment patterns and major outcomes.

METHODS AND RESULTS

From the prospective, global GLORIA-AF registry, we analysed factors associated with COPD diagnosis, as well as treatment patterns and risk of major outcomes in relation to COPD. The primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). A total of 36 263 patients (mean age 70.1 ± 10.5 years, 45.2% females) were included; 2,261 (6.2%) had COPD. The prevalence of COPD was lower in Asia and higher in North America. Age, female sex, smoking, body mass index, and cardiovascular comorbidities were associated with the presence of COPD. Chronic obstructive pulmonary disease was associated with higher use of oral anticoagulant (OAC) [adjusted odds ratio (aOR) and 95% confidence interval (CI): 1.29 (1.13-1.47)] and higher OAC discontinuation [adjusted hazard ratio (aHR) and 95% CI: 1.12 (1.01-1.25)]. Chronic obstructive pulmonary disease was associated with less use of beta-blocker [aOR (95% CI): 0.79 (0.72-0.87)], amiodarone and propafenone, and higher use of digoxin and verapamil/diltiazem. Patients with COPD had a higher hazard of primary composite outcome [aHR (95% CI): 1.78 (1.58-2.00)]; no interaction was observed regarding beta-blocker use. Chronic obstructive pulmonary disease was also associated with all-cause death [aHR (95% CI): 2.01 (1.77-2.28)], MACEs [aHR (95% CI): 1.41 (1.18-1.68)], and major bleeding [aHR (95% CI): 1.48 (1.16-1.88)].

CONCLUSION

In AF patients, COPD was associated with differences in OAC treatment and use of other drugs; Patients with AF and COPD had worse outcomes, including higher mortality, MACE, and major bleeding.

Repurposing catheter ablation work-up to detect expiratory airflow limitation in patients with atrial fibrillation

Background

In atrial fibrillation (AF) patients, presence of expiratory airflow limitation may negatively impact treatment outcomes. AF patients are not routinely screened for expiratory airflow limitation, but existing examinations can help identify at-risk individuals. We aimed to assess the diagnostic value of repurposing existing assessments from the pre-ablation work-up to identify and understand the characteristics of affected patients.

Methods

We screened 110 consecutive AF patients scheduled for catheter ablation with handheld spirometry. Routine pre-ablation work-up included cardiac computed tomographic angiography (CCTA), transthoracic echocardiography and polygraphy. CCTA was analyzed qualitatively for emphysema and airway abnormalities. Multivariate logistic regression analysis was performed to determine predictors of expiratory airflow limitation.

Results

We found that 25 % of patients had expiratory airflow limitation, which was undiagnosed in 86 % of these patients. These patients were more likely to have pulmonary abnormalities on CCTA, including emphysema (odds ratio [OR] 4.2, 95 % confidence interval [CI] 1.12-15.1, p < 0.05) and bronchial wall thickening (OR 2.6, 95 % CI 1.0-6.5, p < 0.05). The absence of pulmonary abnormalities on CCTA accurately distinguished patients with normal lung function from those with airflow limitation (negative predictive value: 85 %). Echocardiography and polygraphy did not contribute significantly to identifying airflow limitation.

Conclusions

In conclusion, routine pre-ablation CCTA can detect pulmonary abnormalities in AF patients with airflow limitation, guiding further pulmonary assessment. Future studies should investigate its impact on ablation procedure success.

Sleep-Disordered Breathing, Hypoxia, and Pulmonary Physiologic Influences in Atrial Fibrillation

BACKGROUND

We leverage a large clinical cohort to elucidate sleep-disordered breathing and sleep-related hypoxia in incident atrial fibrillation (AF) development given the yet unclear contributions of sleep-related hypoxia and pulmonary physiology in sleep-disordered breathing and AF.

METHODS AND RESULTS

Patients who underwent sleep studies at Cleveland Clinic January 2, 2000, to December 30, 2015, comprised this retrospective cohort. Cox proportional hazards models were used to examine apnea hypopnea index, percentage time oxygen saturation <90%, minimum and mean oxygen saturation, and maximum end-tidal carbon dioxide on incident AF adjusted for age, sex, race, body mass index, cardiopulmonary disease and risk factors, antiarrhythmic medications, and positive airway pressure. Those with spirometry were additionally adjusted for forced expiratory volume in 1 second, forced vital capacity, and forced expiratory volume in 1 second/forced vital capacity. This cohort (n=42 057) was 50.7±14.1 years, 51.3% men, 74.1% White individuals, had median body mass index 33.2 kg/m2, and 1947 (4.6%) developed AF over 5 years. A 10-unit apnea hypopnea index increase was associated with 2% higher AF risk (hazard ratio [HR], 1.02 [95% CI, 1.00-1.03]). A 10-unit increase in percentage time oxygen saturation <90% and 10-unit decreases in mean and minimum oxygen saturation were associated with 6% (HR, 1.06 [95% CI, 1.04-1.08]), 30% (HR, 1.30 [95% CI, 1.18-1.42]), and 9% (HR, 1.09 [95% CI, 1.03-1.15]) higher AF risk, respectively. After adjustment for spirometry (n=9683 with available data), only hypoxia remained significantly associated with incident AF, although all coefficients were stable.

CONCLUSIONS

Sleep-related hypoxia was associated with incident AF in this clinical cohort, consistent across 3 measures of hypoxia, persistent after adjustment for pulmonary physiologic impairment. Findings identify a strong role for sleep-related hypoxia in AF development without pulmonary physiologic interdependence.

Identification of key genes and regulatory networks involved in the Comorbidity of atrial fibrillation and chronic obstructive pulmonary disease

Background

The underlying molecular processes of atrial fibrillation (AF) and chronic obstructive pulmonary disease (COPD) are frequently linked to increased morbidity and mortality when they co-occur. However, their underlying molecular mechanisms are questioned due to their incomplete analysis.

Objective

This study aimed to identify common differentially expressed genes (DEGs) in AF and COPD patients and investigate their potential biological functions and pathways. We hope to complement and update previous research through clearer figure presentation and different bioinformatic analysis methods with different datasets.

Methods

We used statistical analysis to identify DEGs in the expression profiles of AF and COPD patients using datasets from the Gene Expression Omnibus database. To ascertain whether the common DEGs were functionally enriched, Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway analyses were used. In addition, we generated protein‒protein interaction networks and identified significant hub genes. Furthermore, the hub genes were used to analyze transcription factor (TF)-gene interactions and TF-miRNA coregulatory networks, and their expression levels were validated in additional datasets.

Results

We identified a total of 15 DEGs that were upregulated, whereas 36 were downregulated in AF and COPD patients. The DEGs were commonly expressed in both AF and COPD patients, with functional enrichment analysis revealing their involvement in metabolic processes and neuron-to-neuron synapses. We identified significant hub genes, including TGM2, ITPR1, CHL1, ALDOC, RPS3, FBLN2, NDUFS2, ITGA5, CTNNB1, RBP1, CLSTN2, FABP5, EPHA4, LDHA, and HNRNPL, and analyzed their coexpression and biological functions. TF-gene interaction and TF-miRNA coregulatory network analyses revealed the regulatory relationships of the hub genes. Additional datasets were analyzed to validate hub gene expression, and ALDOC, HNRNPL, and NDUFS2 displayed similar processes in AF and COPD patients.

Conclusions

In our study, we demonstrate that metabolic processes and neuron-to-neuron synaptic connections may contribute to the cooccurrence of AF and COPD. The identified hub genes and regulatory networks may act as potential biomarkers and therapeutic targets for these diseases.

Systematic review and meta-analysis of prevalence of undiagnosed major cardiac comorbidities in COPD

Background

It is often stated that heart disease is underdiagnosed in COPD. Evidence for this statement comes from primary studies, but these have not been synthesised to provide a robust estimate of the burden of undiagnosed heart disease.

Methods

A systematic review of studies using active diagnostic techniques to establish the prevalence of undiagnosed major cardiac comorbidities in patients with COPD was carried out. MEDLINE, Embase, Scopus and Web of Science were searched for terms relating to heart failure (specifically, left ventricular systolic dysfunction (LVSD), coronary artery disease (CAD) and atrial fibrillation), relevant diagnostic techniques and COPD. Studies published since 1980, reporting diagnosis rates using recognised diagnostic criteria in representative COPD populations not known to have heart disease were included. Studies were classified by condition diagnosed, diagnostic threshold used and whether participants had stable or exacerbated COPD. Random-effects meta-analysis of prevalence was conducted where appropriate.

Results

In general, prevalence estimates for undiagnosed cardiac comorbidities in COPD had broad confidence intervals, with significant study heterogeneity. Most notably, a prevalence of undiagnosed LVSD of 15.8% (11.1-21.1%) was obtained when defined as left ventricular ejection fraction <50%. Undiagnosed CAD was found in 2.3-18.0% of COPD patients and atrial fibrillation in 1.4% (0.3-3.5%).

Conclusion

Further studies using recent diagnostic advances, and investigating therapeutic interventions for patients with COPD and heart disease are needed.

Implementation of a screening and management pathway for chronic obstructive pulmonary disease in patients with atrial fibrillation

AIMS

Chronic obstructive pulmonary disease (COPD) negatively impacts the efficacy of heart rhythm control treatments in patients with atrial fibrillation (AF). Although COPD is recognized as a risk factor for AF, practical guidance about how and when to screen for COPD is not available. Herein, we describe the implementation of an integrated screening and management pathway for COPD into the existing pre-ablation work-up in an AF outpatient clinic infrastructure.

METHODS AND RESULTS

Consecutive unselected patients accepted for AF catheter ablation in the Maastricht University Medical Center+ were prospectively screened for airflow limitation using handheld (micro)spirometry at the pre-ablation outpatient clinic supervised by an AF nurse. Patients with results suggestive of airflow limitation were offered referral to the pulmonologist. Handheld (micro)spirometry was performed in 232 AF patients, which provided interpretable results in 206 (88.8%) patients. Airflow limitation was observed in 47 patients (20.3%). Out of these 47 patients, 29 (62%) opted for referral to the pulmonologist. The primary reason for non-referral was low perceived symptom burden. Using this screening strategy 17 (out of 232; 7.3%) ultimately received a diagnosis of chronic respiratory disease, either COPD or asthma.

CONCLUSION

A COPD care pathway can successfully be embedded in an existing AF outpatient clinic infrastructure, using (micro)spirometry and remote analysis of results. Although one out of five patients had results suggestive of an underlying chronic respiratory disease, only 62% of these patients opted for a referral. Pre-selection of patients as well as patient education might increase the diagnostic yield and requires further research.

Characteristics associated with poor atrial fibrillation-related quality of life in adults with atrial fibrillation

PURPOSE

Few studies have examined the relationship between poor atrial fibrillation-related quality of life (AFQoL) and a battery of geriatric factors. The objective of this study is to describe factors associated with poor AFQoL in older adults with atrial fibrillation (AF) with a focus on sociodemographic and clinical factors and a battery of geriatric factors.

METHODS

Cross-sectional analysis of a prospective cohort study of participants aged 65+ with high stroke risk and AF. AFQoL was measured using the validated Atrial Fibrillation Effect on Quality of Life (score 0-100) and categorized as poor (<80) or good (80-100). Chi-square and t -tests evaluated differences in factors across poor AFQoL and significant characteristics ( P  < 0.05) were entered into a logistic regression model to identify variables related to poor AFQoL.

RESULTS

Of 1244 participants (mean age 75.5), 42% reported poor AFQoL. Falls in the past 6 months, pre/frail and frailty, depression, anxiety, social isolation, vision impairment, oral anticoagulant therapy, rhythm control, chronic obstructive pulmonary disease and polypharmacy were associated with higher odds of poor AFQoL. Marriage and college education were associated with a lower odds of poor AFQoL.

CONCLUSIONS

More than 4 out of 10 older adults with AF reported poor AFQoL. Geriatric factors associated with higher odds of reporting poor AFQoL include recent falls, frailty, depression, anxiety, social isolation and vision impairment. Findings from this study may help clinicians screen for patients with poor AFQoL who could benefit from tailored management to ensure the delivery of patient-centered care and improved well being among older adults with AF.

Spirometry in atrial fibrillation: what's the catch?

INTRODUCTION

People with COPD rarely have COPD alone, and the commonest co-morbidities occurring with COPD are cardiovascular. Whilst multiple studies have explored the association between major cardiovascular events and COPD, less attention has been paid to arrhythmias, specifically atrial fibrillation (AF). AF and COPD frequently occur together, posing challenges in diagnosis and management. In this review, we describe the relationship between AF and COPD epidemiologically and physiologically, demonstrating the role of spirometry as a diagnostic and disease management tool.

AREAS COVERED

We provide epidemiological evidence that COPD and AF are independent risk factors for one another, that either disease is highly prevalent amongst people with the other, and that they have shared risk factors; all of which contribute to adverse prognostic. We elucidated common pathophysiological mechanisms implicated in AF-COPD. We ultimately present the epidemiological and physiological evidence with a view to highlight specific areas where we feel spirometry is of value in the management of AF-COPD.

EXPERT OPINION

AF and COPD commonly co-occur, there is often diagnostic delay, increased risk of reduced cardioversion success, and missed opportunity to intervene to reduce stroke risk. Greater awareness and timelier diagnosis and guideline directed management may improve outcomes for people with both diseases.

Incidence of clinical atrial fibrillation and related complications using a screening algorithm at a nationwide level

AIMS

In a recent position paper, the European Heart Rhythm Association (EHRA) proposed an algorithm for the screening and management of arrhythmias using digital devices. In patients with prior stroke, a systematic screening approach for atrial fibrillation (AF) should always be implemented, preferably immediately after the event. Patients with increasing age and with specific cardiovascular or non-cardiovascular comorbidities are also deemed to be at higher risk. From a large nationwide database, the aim was to analyse AF incidence rates derived from this new EHRA algorithm.

METHODS AND RESULTS

Using the French administrative hospital discharge database, all patients hospitalized in 2012 without a history of AF, and with at least a 5-year follow-up (FU) (or if they died earlier), were included. The yearly incidence of AF was calculated in each subgroup defined by the algorithm proposed by EHRA based on a history of previous stroke, increasing age, and eight comorbidities identified via International Classification of Diseases 10th Revision codes. Out of the 4526 104 patients included (mean age 58.9 ± 18.9 years, 64.5% women), 1% had a history of stroke. Among those with no history of stroke, 18% were aged 65-74 years and 21% were ≥75 years. During FU, 327 012 patients had an incidence of AF (yearly incidence 1.86% in the overall population). Implementation of the EHRA algorithm divided the population into six risk groups: patients with a history of stroke (group 1); patients > 75 years (group 2); patients aged 65-74 years with or without comorbidity (groups 3a and 3b); and patients < 65 years with or without comorbidity (groups 4a and 4b). The yearly incidences of AF were 4.58% per year (group 2), 6.21% per year (group 2), 3.50% per year (group 3a), 2.01% per year (group 3b), 1.23% per year (group 4a), and 0.35% per year (group 4b). In patients aged < 65 years, the annual incidence of AF increased progressively according to the number of comorbidities from 0.35% (no comorbidities) to 9.08% (eight comorbidities). For those aged 65-75 years, the same trend was observed, i.e. increasing from 2.01% (no comorbidities) to 11.47% (eight comorbidities).

CONCLUSION

These findings at a nationwide scale confirm the relevance of the subgroups in the EHRA algorithm for identifying a higher risk of AF incidence, showing that older patients (>75 years, regardless of comorbidities) have a higher incidence of AF than those with prior ischaemic stroke. Further studies are needed to evaluate the usefulness of algorithm-based risk stratification strategies for AF screening and the impact of screening on major cardiovascular event rates.

EXAcerbations of COPD and their OutcomeS on CardioVascular diseases (EXACOS-CV) Programme: protocol of multicountry observational cohort studies

INTRODUCTION

In patients with chronic obstructive pulmonary disease (COPD), the risk of certain cardiovascular (CV) events is increased by threefold to fivefold in the year following acute exacerbation of COPD (AECOPD), compared with a non-exacerbation period. While the effect of severe AECOPD is well established, the relationship of moderate exacerbation or prior exacerbation to elevated risk of CV events is less clear. We will conduct cohort studies in multiple countries to further characterise the association between AECOPD and CV events.

METHODS AND ANALYSIS

Retrospective longitudinal cohort studies will be conducted within routinely collected electronic healthcare records or claims databases. The study cohorts will include patients meeting inclusion criteria for COPD between 1 January 2014 and 31 December 2018. Moderate exacerbation is defined as an outpatient visit and/or medication dispensation/prescription for exacerbation; severe exacerbation is defined as hospitalisation for COPD. The primary outcomes of interest are the time to (1) first hospitalisation for a CV event (including acute coronary syndrome, heart failure, arrhythmias or cerebral ischaemia) since cohort entry or (2) death. Time-dependent Cox proportional hazards models will compare the hazard of a CV event between exposed periods following exacerbation (split into these periods: 1-7, 8-14, 15-30, 31-180 and 181-365 days) and the unexposed reference time period, adjusted on time-fixed and time-varying confounders.

ETHICS AND DISSEMINATION

Studies have been approved in Canada, Japan, the Netherlands, Spain and the UK, where an institutional review board is mandated. For each study, the results will be published in peer-reviewed journals.

Cardioselective versus Non-Cardioselective Beta-Blockers and Outcomes in Patients with Atrial Fibrillation and Chronic Obstructive Pulmonary Disease

Background: Atrial fibrillation (AF) and chronic obstructive pulmonary disease (COPD) have been independently associated with increased mortality; however, there is no evidence regarding beta-blocker cardioselectivity and long-term outcomes in patients with AF and concurrent COPD. Methods: This post hoc analysis of the MISOAC-AF randomized trial (NCT02941978) included patients hospitalized with comorbid AF. At discharge, all patients were classified according to the presence of COPD; patients with COPD on beta-blockers were classified according to beta-blocker cardioselectivity. Adjusted hazard ratios (aHRs) were calculated by using multivariable Cox regression models. The primary outcome was all-cause mortality, and the secondary outcomes were cardiovascular mortality and hospitalizations. Results: Of 1103 patients with AF, 145 (13%) had comorbid COPD. Comorbid COPD was associated with an increased risk of all-cause (aHR, 1.33; 95% confidence interval (CI), 1.02 to 1.73) and cardiovascular mortality (aHR 1.47; 95% CI, 1.10 to 1.99), but not with increased risk of hospitalizations (aHR 1.10; 95% CI, 0.82 to 1.48). The use of cardioselective versus non-cardioselective beta-blockers was associated with similar all-cause mortality (aHR 1.10; 95% CI, 0.63 to 1.94), cardiovascular mortality (aHR 1.33; 95% CI, 0.71 to 2.51), and hospitalizations (aHR 1.65; 95% CI 0.80 to 3.38). Conclusions: In recently hospitalized patients with AF, the presence of COPD was independently associated with increased risk of all-cause and cardiovascular mortality. No difference between cardioselective and non-cardioselective beta-blockers, regarding clinical outcomes, was identified.

Combining bioinformatics and machine learning to identify common mechanisms and biomarkers of chronic obstructive pulmonary disease and atrial fibrillation

Background

Patients with chronic obstructive pulmonary disease (COPD) often present with atrial fibrillation (AF), but the common pathophysiological mechanisms between the two are unclear. This study aimed to investigate the common biological mechanisms of COPD and AF and to search for important biomarkers through bioinformatic analysis of public RNA sequencing databases.

Methods

Four datasets of COPD and AF were downloaded from the Gene Expression Omnibus (GEO) database. The overlapping genes common to both diseases were screened by WGCNA analysis, followed by protein-protein interaction network construction and functional enrichment analysis to elucidate the common mechanisms of COPD and AF. Machine learning algorithms were also used to identify key biomarkers. Co-expression analysis, “transcription factor (TF)-mRNA-microRNA (miRNA)” regulatory networks and drug prediction were performed for key biomarkers. Finally, immune cell infiltration analysis was performed to evaluate further the immune cell changes in the COPD dataset and the correlation between key biomarkers and immune cells.

Results

A total of 133 overlapping genes for COPD and AF were obtained, and the enrichment was mainly focused on pathways associated with the inflammatory immune response. A key biomarker, cyclin dependent kinase 8 (CDK8), was identified through screening by machine learning algorithms and validated in the validation dataset. Twenty potential drugs capable of targeting CDK8 were obtained. Immune cell infiltration analysis revealed the presence of multiple immune cell dysregulation in COPD. Correlation analysis showed that CDK8 expression was significantly associated with CD8+ T cells, resting dendritic cell, macrophage M2, and monocytes.

Conclusions

This study highlights the role of the inflammatory immune response in COPD combined with AF. The prominent link between CDK8 and the inflammatory immune response and its characteristic of not affecting the basal expression level of nuclear factor kappa B (NF-kB) make it a possible promising therapeutic target for COPD combined with AF.

Atrial fibrillation and chronic obstructive pulmonary disease: diagnostic sequence and mortality risk

BACKGROUND AND AIMS

Chronic obstructive pulmonary disease (COPD) is present in 13% of atrial fibrillation (AF) patients. In patients diagnosed with both AF and COPD, we aimed to assess overall mortality risk and its association with temporal sequence in AF and COPD diagnosis.

METHODS

This nationwide study assessed all patients aged 18-85 years diagnosed with both COPD and AF between 1999 and 2018 in Denmark. Three groups were defined according to the temporal sequence of diagnosis: COPD diagnosed at least 6 months before AF (COPD-First), AF diagnosed at least 6 months before COPD (AF-First) and COPD, and AF diagnosed within a 6-months' time frame (AF∼COPD).

RESULTS

We included 62 806 patients (75.0 years; 56.5% males). After 5 years of follow-up, 31 494 (50.1%) died. Mortality was highest in the COPD-First group (COPD-First: 52.8%; AF-First: 46.0%; AF∼COPD 50.6%). In a multivariable Cox-regression model adjusted for age, sex, type 2 diabetes, history of acute myocardial infarction, hypertension, heart failure, dyslipidemia, cancer, chronic kidney disease, and stroke, the AF∼COPD group (HR 1.19, 95% CI 1.16-1.23; P < 0.001) and COPD-First group (HR 1.30, 95% CI 1.27-1.33; P < 0.001) had a higher risk of death compared with the AF-First group. A restricted cubic spline analysis showed that the earlier the COPD was diagnosed, the worse is the prognosis.

CONCLUSION

Patients with concomitant AF and COPD had a very poor prognosis and the temporal sequence in diagnosis was differentially associated with prognosis, where a COPD diagnosis preceding an AF diagnosis was accompanied with a higher mortality risk compared with a COPD diagnosis following an AF diagnosis.

Incident atrial fibrillation in relation to ventilatory parameters: a prospective cohort study

BACKGROUND

There is a paucity of data on the association between respiratory function and atrial fibrillation (AF). This study aimed to assess the relationship between forced expiratory volume (FEV1), forced vital capacity (FVC), and FEV1/FVC and incident AF.

METHODS

We performed an analysis of prospectively collected data from the UK Biobank. We included all participants with available spirometry and excluded those with a prior AF. Incident AF was ascertained through hospitalization and death records, and dose-response associations were assessed using multivariable Cox regression analysis with adjustment for known AF risk factors.

RESULTS

We studied 348,219 white individuals (54.1% female) with a median age of 58.1 (IQR 50.8-63.5) years. Over a median follow-up time of 11.5 years (IQR: 11.0-12.6 years), a total of 18,188 incident AF events occurred. After standardization to sex, age, and height, the risk of AF consistently increased with decreasing FEV1 percentage predicted, FEV1 z-score, and FVC z-score. The risk of AF linearly increased with decreasing FEV1/FVC ratio, and those that had airway obstruction as defined by an FEV1/FVC ratio < 0.70 had a 23% greater risk of incident AF (aHR 1.23, 95% CI 1.19-1.28) compared to those without airway obstruction. Patients with known chronic obstructive pulmonary disease and asthma were at 40% (aHR 1.40, 95% CI 1.29-1.51) and 17% (aHR 1.17, 95% CI 1.12-1.22) increased risk of incident AF.

CONCLUSION

These findings indicate that reduced ventilatory function is associated with increased risk of AF independently of age, sex, smoking, and other known AF risk factors.

The Overlap Syndrome of Obstructive Sleep Apnea and Chronic Obstructive Pulmonary Disease: A Systematic Review

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) are common diseases that strongly impact the quality and length of life. Their coexistence is determined by overlap syndrome (OS). This systematic review aims to define the significance of these comorbidities according to the current state of knowledge. For this systematic review, we searched PubMed, Scopus, and Cochrane for studies published between 2018 and 26 October 2022, to find original, observational, human studies published in English, where the diagnosis of COPD was according to the Global Initiative for Obstructive Lung Disease guidelines and the diagnosis of OSA was based on polysomnography. The quality of studies was assessed using the Newcastle-Ottawa quality assessment tool for cohort and case-control studies, as well as its modification for cross-sectional studies. Of the 1548 records identified, 38 were eligible and included in this systematic review. The included studies covered a total population of 27,064 participants. This paper summarizes the most important, up-to-date information regarding OS, including the prevalence, meaning of age/gender/body mass index, polysomnography findings, pulmonary function, comorbidities, predicting OSA among COPD patients, and treatment of this syndrome.

Dyspnea in patients with atrial fibrillation: Mechanisms, assessment and an interdisciplinary and integrated care approach

Atrial fibrillation (AF) is the most common sustained heart rhythm disorder and is often associated with symptoms that can significantly impact quality of life and daily functioning. Palpitations are the cardinal symptom of AF and many AF therapies are targeted towards relieving this symptom. However, up to two-third of patients also complain of dyspnea as a predominant self-reported symptom. In clinical practice it is often challenging to ascertain whether dyspnea represents an AF-related symptom or a symptom of concomitant cardiovascular and non-cardiovascular comorbidities, since common AF comorbidities such as heart failure and chronic obstructive pulmonary disease share similar symptoms. In addition, therapeutic approaches specifically targeting dyspnea have not been well validated. Thus, assessing and treating dyspnea can be difficult. This review describes the latest knowledge on the burden and pathophysiology of dyspnea in AF patients. We discuss the role of heart rhythm control interventions as well as the management of AF risk factors and comorbidities with the goal to achieve maximal relief of dyspnea. Given the different and often complex mechanistic pathways leading to dyspnea, dyspneic AF patients will likely profit from an integrated multidisciplinary approach to tackle all factors and mechanisms involved. Therefore, we propose an interdisciplinary and integrated care pathway for the work-up of dyspnea in AF patients.

Prevalence of asymptomatic atrial fibrillation among multimorbid elderly patients: diagnostic implications

Advancing age of the global population is one of the main reasons for the uprising trend in atrial fibrillation (AF) prevalence worldwide leading to a proper "AF epidemic". Strictly related to the increasing prevalence of AF in the elderly is the relevant burden of cardiac end extra-cardiac comorbidities that these patients show. Patients with AF are frequently asymptomatic (i.e., asymptomatic or silent AF) and thus the arrhythmia is generally underdiagnosed. Detainment of proper treatment in elderly and comorbid patients may potentially result in significant morbidity and mortality. Therefore, in recent years, several screening strategies (systematic vs opportunistic screening) for asymptomatic AF have been developed and early diagnosis of AF is an important treatment goal that can improve prognosis. This review will focus on the prevalence of asymptomatic AF in the elderly, frequently associated comorbidities, screening strategies, and implications for a correct AF diagnosis.

Atrial Flutter in Particular Patient Populations

"Despite being one of the best understood cardiac arrhythmias, the clinical meaning of atrial flutter varies according to the specific context, and its optimal treatment may be limited by both the suboptimal response to rate/rhythm control drugs and by the complexity of the underlying substrate. In this article, we present a state-of-the-art overview of mechanisms, prognostic impact, and medical/interventional management options for atrial flutter in several specific patient populations, including heart failure, cardiomyopathies, muscular dystrophies, posttransplant patients, patients with respiratory disorders, athletes, and subjects with preexcitation, aiming to stimulate further research in this challenging field and facilitate appropriate patient care."

The performance of five models compared with atrial high rate episodes predicts new atrial fibrillation after cardiac implantable electronic devices implantation

Aims

Several predicting models have been evaluated for new‐onset atrial fibrillation (AF) in several clinical conditions, but never in patients with cardiac implantable electronic devices (CIED). We aimed to evaluate the five predicting models compared with atrial high rate episodes (AHRE) to predict new AF in patients with CIED.

Methods and Results

We retrospective enrolled 470 consecutive patients with CIED and without a history of AF. The five predicting models, including CHA₂DS₂‐VASc score, C₂HEST score, mCHEST score, HAT₂CH₂ score, and HAVOC score were used. The primary endpoint was new AF documented by 12‐lead electrocardiography (ECG) or 30‐s ECG strip. Multivariable Cox regression analysis was used to determine variables associated with independent factors of new AF. Patients' median age was 76 years and 58.7% were male. During follow‐up (median 29 months), 34 new AF occurred (incidence rate 2.99/100 patient‐years, 95% CI 1.67–6.20). Multivariable Cox regression analysis showed AHRE ≥6 min and 24 h, and HAT₂CH₂ score were independent predictors for new AF. Optimal AHRE cutoff value was 9.3 min with highest Youden index (AUC, 0.806; 95% CI, 0.722–0.889; p < .001). The AF occurrence rate of AHRE ≥9.3 min was 7 times AHRE <9.3 min (p < .001).

Conclusions

We compared 5 predicting models for new AF in patients with CIED and without a history of AF. AHRE ≥6 min and 24 h, and HAT₂CH₂ score were independent predictors for AF.

Impact of COPD or Asthma on the Risk of Atrial Fibrillation: A Systematic Review and Meta-Analysis

BACKGROUND

Respiratory diseases related to chronic pulmonary ventilation dysfunction are mainly composed of chronic obstructive pulmonary disease (COPD) and asthma. Our meta-analysis aimed to illustrate the association of COPD or asthma with risk of atrial fibrillation (AF).

METHODS

We systematically searched the databases of the PubMed, Embase, and Cochrane library until December 2021 for studies focusing on the relationship between COPD or asthma and AF risk. Due to the potential heterogeneity across studies, the random-effects model was used to pool the studies.

RESULTS

Our meta-analysis included 14 studies. Based on the random-effects model, the pooled analysis showed that COPD (risk ratio[RR] = 1.74, 95% confidence interval [CI]: 1.70-1.79) and asthma (RR = 1.08, 95% CI: 1.04-1.12) were significantly associated with an increased risk of AF. The results did not change after each study was excluded.

CONCLUSION

Our current data suggested that COPD or asthma with associated with an increased risk of AF.