Lifestyle modifications for treatment of atrial fibrillation

Atrial fibrillation in Black American patients: A review of genetics, risk factors, and outcomes

Atrial fibrillation (AF), the most common arrhythmia in the United States, affects 6 million Americans, with numbers projected to increase to 12 million by 2030. A racial paradox difference in the incidence and prevalence of AF exists between Black and White Americans. Black Americans are less prone than White Americans to development of AF, but they display a higher burden of modifiable risk factors for cardiovascular disease and higher rates of ischemic stroke. Data pertaining to the American Heart Association Life's Simple 7 (LS7) health metrics show that Black Americans have suboptimal LS7 scores compared with White Americans on average despite lower genetic predisposition to AF. This trend suggests the impact of cardiovascular health on the development and progression of AF. Social, genetic, and lifestyle risk factors have been shown to play a role in the racial paradox and AF outcomes in Black Americans. This review summarizes factors contributing to the racial paradox and discusses suggestions for improved health outcomes in Black Americans with AF.

Modifiable risk factors and self-reported health after percutaneous coronary intervention: with and without a history of atrial fibrillation

AIMS

Atrial fibrillation (AF) and coronary artery disease have several common risk factors, and 10-15% of patients with AF undergo percutaneous coronary intervention (PCI). Little is known about changes over time in modifiable risk factors and self-reported health in patients with and without a history of AF after PCI. Therefore, the aims were to determine and compare changes in modifiable risk factors and self-reported health in patients with and without a history of AF after PCI.

METHODS AND RESULTS

CONCARDPCI, a prospective multi-centre cohort study including patients after PCI, was conducted at seven high-volume PCI centres in Norway and Denmark (n = 3417). Of these, 408 had a history of AF. Data collection was conducted at the index admission and at 2-, 6-, and 12 months after discharge. Self-reported health was assessed with RAND-12 and the myocardial infarction dimensional assessment scale. Patients with a history of AF reported poorer health at baseline. However, the physical (P = 0.012) and mental (P < 0.001) health improved over time in both groups. The patients with a history of AF reported more emotional reactions (P = 0.029) and insecurities (P = 0.015). The proportion of smokers increased from 2- to 12 months in patients with a history of AF (P = 0.041), however, decreased in patients without AF from baseline to 6 months (P < 0.001).

CONCLUSION

An intensified focus on lifestyle interventions is needed to improve modifiable risk factors and self-reported health in patients with and without a history of AF after PCI.

25-year trajectories of physical activity and atrial fibrillation risk: results from the ARIC study

Background

The relationship between serial changes in physical activity and the risk of developing atrial fibrillation (AF) has been rarely studied.

Objectives

To evaluate the association between changes in physical activity over time and the incidence of AF.

Methods

A total of 11,828 participants without AF at baseline (visit 1: 1987-1989) from the ARIC Study were included. Physical activity was measured using the modified Baecke Physical Activity Questionnaire at three different visits between 1987 and 2013. Physical activity trajectories over 25 years were identified using latent class trajectory modeling. The primary outcome was the incidence of AF. Multivariable Cox hazard regression models were used to evaluate the relationship between physical activity trajectories and the incidence of AF.

Results

Over a median follow-up of 24 years, 2,108 AF cases (17.8%) occurred. Four distinct physical activity trajectories were identified: light [n = 5,266 (43.3%)]; reduced moderate [n = 3,583 (29.0%)]; moderate [n = 2,691 (25.0%)]; and vigorous intensity [n = 288 (2.8%)]. Compared to the light group, the hazard ratio (HR) and 95% confidence interval (CI) for AF were 1.18 (1.07-1.30) (p < 0.001) for the reduced moderate group, 0.61 (0.53-0.70) (p < 0.001) for the moderate group, and 0.82 (0.59-1.12) (p = 0.21) for the vigorous group, after multivariate adjustments.

Conclusion

Maintaining moderate levels of physical activity is associated with a lower risk of AF, while a decrease in activity from moderate to light levels increases the risk. These findings highlight the importance of sustaining adequate physical activity levels for the prevention of AF.

Percutaneous Neuromodulation for Atrial Fibrillation

Percutaneous neuromodulation is emerging as a promising therapeutic approach for atrial fibrillation (AF). This article explores techniques such as ganglionated plexi (GP) ablation, and vagus nerve stimulation, pinpointing their potential in modulating AF triggers and maintenance. Noninvasive methods, such as transcutaneous low-level tragus stimulation, offer innovative treatment pathways, with early trials indicating a significant reduction in AF burden. GP ablation may address autonomic triggers, and the potential for GP ablation in neuromodulation is discussed. The article stresses the necessity for more rigorous clinical trials to validate the safety, reproducibility, and efficacy of these neuromodulation techniques in AF treatment.

Atrial Fibrillation, Atrial Myopathy, and Thromboembolism: The Additive Value of Echocardiography and Possible New Horizons for Risk Stratification

Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, and it is associated with increased stroke and dementia risk. While the established paradigm attributes these complications to blood stasis within the atria and subsequent thrombus formation with cerebral embolization, recent evidence suggests that atrial myopathy (AM) may play a key role. AM is characterized by structural and functional abnormalities of the atria, and can occur with or without AF. Moving beyond classifications based solely on episode duration, the 4S-AF characterization has offered a more comprehensive approach, incorporating patient's stroke risk, symptom severity, AF burden, and substrate assessment (including AM) for tailored treatment decisions. The "ABC" pathway emphasizes anticoagulation, symptom control, and cardiovascular risk modification and emerging evidence suggests broader benefits of early rhythm control strategies, potentially reducing stroke and dementia risk and improving clinical outcomes. However, a better integration of AM assessment into the current framework holds promise for further personalizing AF management and optimizing patient outcomes. This review explores the emerging concept of AM and its potential role as a risk factor for stroke and dementia and in AF patients' management strategies, highlighting the limitations of current risk stratification methods, like the CHA2DS2-VASc score. Echocardiography, particularly left atrial (LA) strain analysis, has shown to be a promising non-invasive tool for AM evaluation and recent studies suggest that LA strain analysis may be a more sensitive risk stratifier for thromboembolic events than AF itself, with some studies showing a stronger association between LA strain and thromboembolic events compared to traditional risk factors. Integrating it into routine clinical practice could improve patient management and targeted therapies for AF and potentially other thromboembolic events. Future studies are needed to explore the efficacy and safety of anticoagulation in AM patients with and without AF and to refine the diagnostic criteria for AM.

Global burden of atrial fibrillation/atrial flutter and its attributable risk factors from 1990 to 2021

AIMS

To devise effective preventive measures, a profound understanding of the evolving patterns and trends in atrial fibrillation (AF) and atrial flutter (AFL) burdens is pivotal. Our study was designed to quantify the burden and delineate the risk factors associated with AF and AFL across 204 countries and territories spanning 1990-2021.

METHODS AND RESULTS

Data pertaining to AF and AFL were sourced from the Global Burden of Disease Study 2021. The burden of AF/AFL was evaluated using metrics such as incidence, disability-adjusted life years (DALYs), deaths, and their corresponding age-standardized rates (ASRs), stratified by age, sex, socio-demographic index (SDI), and human development index (HDI). The estimated annual percentage change was employed to quantify changes in ASRs. Population attributable fractions were calculated to determine the proportional contributions of major risk factors to age-standardized AF/AFL deaths. This analysis encompassed the period from 1990 to 2021. Globally, in 2021, there were 4.48 million incident cases [95% uncertainty interval (UI): 3.61-5.70], 8.36 million DALYs (95% UI: 6.97-10.13) and 0.34 million deaths (95% UI: 0.29-0.37) attributed to AF/AFL. The AF/AFL burden in 2021, as well as its trends from 1990 to 2021, displayed substantial variations based on gender, SDI quintiles, and geographical regions. High systolic blood pressure emerged as the leading contributor to age-standardized AF/AFL incidence, prevalence, death, and DALY rate globally among all potential risk factors, followed closely by high body mass index.

CONCLUSION

Our study underscores the enduring significance of AF/AFL as a prominent public health concern worldwide, marked by profound regional and national variations. Despite the substantial potential for prevention and management of AF/AFL, there is a pressing imperative to adopt more cost-effective strategies and interventions to target modifiable risk factors, particularly in areas where the burden of AF/AFL is high or escalating.

Palpitations in athletes: diagnosis, workup and treatment

Palpitations are a common reason for athletes to seek medical care. Although often benign, palpitations may serve as a harbinger for underling cardiac pathology. Given the unique challenges in this population, this review will serve to discuss the basic underlying pathophysiology, which may predispose athletes to palpitations. In addition, we will review the aetiologies, diagnostic evaluation, management and counselling strategies for some of the most common diagnoses seen in athletes.

Longer and better lives for patients with atrial fibrillation: the 9th AFNET/EHRA consensus conference

AIMS

Recent trial data demonstrate beneficial effects of active rhythm management in patients with atrial fibrillation (AF) and support the concept that a low arrhythmia burden is associated with a low risk of AF-related complications. The aim of this document is to summarize the key outcomes of the 9th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA).

METHODS AND RESULTS

Eighty-three international experts met in Münster for 2 days in September 2023. Key findings are as follows: (i) Active rhythm management should be part of the default initial treatment for all suitable patients with AF. (ii) Patients with device-detected AF have a low burden of AF and a low risk of stroke. Anticoagulation prevents some strokes and also increases major but non-lethal bleeding. (iii) More research is needed to improve stroke risk prediction in patients with AF, especially in those with a low AF burden. Biomolecules, genetics, and imaging can support this. (iv) The presence of AF should trigger systematic workup and comprehensive treatment of concomitant cardiovascular conditions. (v) Machine learning algorithms have been used to improve detection or likely development of AF. Cooperation between clinicians and data scientists is needed to leverage the potential of data science applications for patients with AF.

CONCLUSIONS

Patients with AF and a low arrhythmia burden have a lower risk of stroke and other cardiovascular events than those with a high arrhythmia burden. Combining active rhythm control, anticoagulation, rate control, and therapy of concomitant cardiovascular conditions can improve the lives of patients with AF.

Multimorbidity in patients with atrial fibrillation

There is an escalating trend in both the incidence and prevalence of atrial fibrillation (AF). AF is linked to numerous other comorbidities, contributing to the emergence of multimorbidity. The sustained rise in multimorbidity and AF prevalences exerts a significant strain on healthcare systems globally. The understanding of the relation between multimorbidity and AF is essential to determine effective healthcare strategies, improve patient outcomes to adequately address the burden of AF. It not only begins with the accurate identification of comorbidities in the setting of AF. There is also the need to understand the pathophysiology of the different comorbidities and their common interactions, and how multimorbidity influences AF perpetuation. To manage the challenges that rise from the increasing incidence and prevalence of both multimorbidity and AF, such as adverse events and hospitalisations, the treatment of comorbidities in AF has already gained importance and will need to be a primary focus in the forthcoming years. There are numerous challenges to overcome in the treatment of multimorbidity in AF, whereby the identification of comorbidities is essential. Integrated care strategies focused on a comprehensive multimorbidity management with an individual-centred approach need to be determined to improve healthcare strategies and reduce the AF-related risk of frailty, cardiovascular diseases and improve patient outcomes.

Long-term Patient and Health Service Outcomes of Ablation and Antiarrhythmic Drugs in Atrial Fibrillation: A Comparative Systematic Review

Atrial fibrillation (AF) is a prevalent problem worldwide and a common cause of hospitalization, poor quality of life, and increased mortality. Although several treatments are used, the use of ablation and antiarrhythmic drug therapy has increased in the past decade. However, debate continues on the most suitable option for heart rhythm control in patients. Previous studies have largely focused on short-term outcome effects of these treatments. This systematic review aims to determine the effect of ablation compared to antiarrhythmic drugs for AF on long-term patient and health service outcomes of mortality, hospitalization, and quality of life. Three databases were systematically searched-studies were included if they reported long-term outcomes of more than 12 months comparing the 2 treatments. Title and abstract screening and subsequent full-text screening was done by 2 reviewers. Data were extracted from the final studies identified. The details of the search were recorded according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses report. A total of 2224 records were identified. After removing duplicates and screening the titles and abstracts, 68 records required full-text screening. Finally, 12 papers were included in the analysis. Eight studies reported mortality indicating ablation was superior, 2 studies reported hospitalization with opposing outcomes, and 5 quality of life studies indicating ablation was a better treatment. In studies assessing long-term outcomes, beyond 12 months, following ablation or rhythm control drugs for AF, most found a lower risk of death and greater improvement in quality of life in the ablation group.

Feasibility study of Glucagon-like peptide-1 analogues for the optimization of Outcomes in obese patients undergoing AbLation for Atrial Fibrillation (GOAL-AF) protocol

BACKGROUND

Catheter ablation for atrial fibrillation is recommended for symptomatic patients after failed medical therapy. Ablation has a higher failure rate in obese patients, and both the prevalence of atrial fibrillation and obesity are increasingly globally. The outcome of ablation can be improved if obese patients can achieve goal-oriented weight reduction prior to ablation. Conventional weight loss strategies, however, can be difficult to access and can delay ablation, thereby risking a lower chance of maintaining sinus rhythm. Effective weight-loss medications, such as the glucagon-like peptide inhibitor-1 drugs, offer the potential for incremental impact on weight loss over a shorter period of time as a bridging therapy. The aim of this study is to assess the feasibility of using liraglutide, a glucagon-like peptide inhibitor-1, in producing weight loss in obese patients before catheter ablation.

METHODS

The study is an open-label, uncontrolled, prospective single-centre feasibility study of daily liraglutide injections in the treatment of obese patients for at least 13 weeks before and 52 weeks after AF ablation. Adult patients with symptomatic AF whose body mass index ≥ 30 will be recruited from those planning to undergo ablation. Feasibility will be determined based on the recruitment rate, adherence to the medication, and the amount of weight loss achieved over the study period. Exploratory outcomes include changes in atrial structure, function, and fibrosis with weight loss evaluated by cardiac magnetic resonance imaging, electroanatomic mapping, and patient-reported outcome measure.

DISCUSSION

This study will allow us to determine whether the use of liraglutide in obese patients with atrial fibrillation undergoing ablation is feasible with adequate recruitment. The additional information on adherence and average weight loss over the study period will inform the design of a future definitive randomized controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT05221229 ). Registered on 2 February 2022.

TRIAL FUNDING

Metchley Park Medical Society and University of Birmingham Starter Fellowship, British Heart Foundation Accelerator Grant, Abbott Investigator-Initiated Study Grant.

Global burden of atrial fibrillation/flutter: Trends from 1990 to 2019 and projections until 2044

Aims

Atrial fibrillation/atrial flutter (AF/AFL) is a critical public health issue worldwide, and its epidemiological patterns have changed over the decades. This work aimed to assess the global trends of AF/AFL and attributable risks from 1990 to 2019.

Methods and results

The present study utilized data from the Global Burden of Disease Study 2019 to examine the temporal trends, attributable risks, and projections of AF/AFL. The estimated annual percentage change (EAPC) and age-standardized rate (ASR) were employed for this purpose. The findings revealed that in 2019, AF/AFL accounted for 4.72 million incident cases, 59.70 million prevalent cases, 0.32 million deaths, and 8.39 million disability-adjusted life years (DALYs). Furthermore, the results indicated that males under 70 years of age had a higher incidence, prevalence, and DALYs than females, while the rates were similar for both genders between 70 and 74 years. However, this pattern was reversed in individuals over the age of 75, with females exhibiting a higher total incidence, prevalence, and DALYs than males. The age-standardized rates (ASRs) of prevalence, incidence, mortality, and DALYs increased with an increase in the socio-demographic index (SDI). The three primary contributors to AF/AFL were high systolic blood pressure, high body-mass index, and smoking. Majority of risk factors exhibited a unimodal distribution, with a peak between the ages of 50 and 70.

Conclusions

The disease burden of AF/AFL is still severe worldwide and getting worse. To encourage prevention and treatment, systematic regional surveillance of AF/AFL should be put in place.

A New Player in the Game: Can Exergame Be of Support in the Management of Atrial Fibrillation?

Atrial fibrillation (AF) is the most common form of cardiac arrhythmia, currently affecting 2-3% of the world's population. Traditional exercise and physical activity interventions have been successfully implemented in the management of AF, with the aim of improving patients' quality of life and their exercise capacity, as well as reducing their mortality rate. Currently, new technology-mediated approaches to exercise, defined as exergame, have been shown to be successful in the delivery of exercise home-based interventions in patients with cardiovascular diseases. However, data on the effects of exergame on AF are not yet available. In this paper, we summarise the current literature on the role of traditional exercise in AF and how it affects the pathophysiology of this condition. We also review the current literature on exergame and its employment in cardiac rehabilitation and suggest its potential role in the management of AF patients. A review of the evidence suggests that traditional exercise (of light-to-moderate intensity) is beneficial in patients with AF. Additionally, exergame seems to be a promising approach for delivering exercise interventions in patients with cardiovascular diseases. Exergame may be a promising tool to improve the quality of life and exercise capacity in patients with AF, with the additional advantage of being remotely delivered, and the potential to increase patients' engagement. Proper guidelines are required to prescribe exergame interventions, considering the principles of traditional exercise prescription and applying them to this new e-health approach. Further studies are needed to validate the use of exergame in patients with AF.

Aging and atrial fibrillation: A vicious circle

Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia observed in clinical practice. Its prevalence increases dramatically with advancing age. This review article discusses the recent advances in studies investigating the relationship between aging and AF and the possible underlying mechanisms.

Wearables for early detection of atrial fibrillation and timely referral for Indigenous people ≥55 years: mixed-methods protocol

INTRODUCTION

Digital health technologies have the potential to provide cost-effective care to remote and underserved populations. To realise this potential, research must involve people not traditionally included. No research focuses on the acceptability and feasibility of older Indigenous people using wearables for early atrial fibrillation (AF) detection. This protocol compares digital augmentation against standard practice to detect AF, evaluate heart health self-efficacy and health literacy changes and identify barriers in collaboration with Aboriginal Community Controlled Health Organisations. It will establish a framework for implementing culturally safe and acceptable wearable programmes for detecting and managing AF in Indigenous adults ≥55 years and older.

METHODS

This mixed-methods research will use the Rambaldini model of collective impact, a user-centred, co-design methodology and yarning circles, a recognised Indigenous research methodology to assess the cultural safety, acceptability, feasibility and efficacy of incorporating wearables into standard care for early AF detection.

ANALYSIS

Qualitative data will be analysed to create composite descriptions of participants' experiences and perspectives related to comfort, cultural safety, convenience, confidence, family reactions and concerns. Quantitative device data will be extracted and analysed via Statistical Product and Service Solutions (SPSS).

CONCLUSION

Prioritising perspectives of older Indigenous adults on using wearables for detecting and monitoring cardiovascular disease will ensure that the findings are effective, relevant and acceptable to those impacted.

ETHICS AND DISSEMINATION

Findings will be published in open-source peer-reviewed journals, shared at professional conferences, described in lay terms and made available to the public. The AHMRC HREC Reference Number approved 1135/15.

Acquired risk factors and incident atrial fibrillation according to age and genetic predisposition

BACKGROUND AND AIMS

Atrial fibrillation (AF) is the most common sustained arrhythmia in adults. Investigations of risk factor profiles for AF according to age and genetic risk groups are essential to promote individualized strategies for the prevention and control of AF.

METHODS

A total of 409 661 participants (mean age, 56 years; 46% men) free of AF at baseline and with complete information about risk factors were included from the UK Biobank cohort. The hazard ratios and population-attributable risk (PAR) percentages of incident AF associated with 23 risk factors were examined, including 3 social factors, 7 health behaviours, 6 cardiometabolic factors, 6 clinical comorbidities, and the genetic risk score (GRS), across 3 age groups (40-49, 50-59, and 60-69 years) and 3 genetic risk groups (low, moderate, and high GRS).

RESULTS

After a follow-up of 5 027 587 person-years, 23 847 participants developed AF. Most cardiometabolic factors and clinical comorbidities showed a significant interaction with age, whereby the associations were generally strengthened in younger groups (Pinteraction < .002). However, only low LDL cholesterol, renal dysfunction, and cardiovascular disease showed a significant interaction with genetic risk, and the associations with these factors were stronger in lower genetic risk groups (Pinteraction < .002). Cardiometabolic factors consistently accounted for the largest number of incident AF cases across all age groups (PAR: 36.2%-38.9%) and genetic risk groups (34.0%-41.9%), with hypertension and overweight/obesity being the two leading modifiable factors. Health behaviours (PAR: 11.5% vs. 8.7%) and genetic risk factors (19.1% vs. 14.3%) contributed to more AF cases in the 40-49 years group than in the 60-69 years group, while the contribution of clinical comorbidities remained relatively stable across different age groups. The AF risk attributable to overall cardiometabolic factors (PAR: 41.9% in the low genetic risk group and 34.0% in the high genetic risk group) and clinical comorbidities (24.7% and 15.9%) decreased with increasing genetic risk. The impact of social factors on AF was relatively low across the groups by age and genetic risk.

CONCLUSIONS

This study provided comprehensive information about age- and genetic predisposition-related risk factor profiles for AF in a cohort of UK adults. Prioritizing risk factors according to age and genetic risk stratifications may help to achieve precise and efficient prevention of AF.

Nurse-led care after ablation of atrial fibrillation: a randomized controlled trial

AIMS

The added value of advanced practitioner nurse (APN) care after ablation of atrial fibrillation (AF) is unknown. The present study investigates the impact of APN-led care on AF recurrence, patient knowledge, lifestyle, and patient satisfaction.

METHODS AND RESULTS

Sixty-five patients undergoing AF ablation were prospectively randomized to usual care (N = 33) or intervention (N = 32) group. In addition to usual care, the intervention consisted of an educational session, three consultations spread over 6 months and telephone accessibility coordinated by the APN. Primary outcome was the AF recurrence rate at 6-month follow-up. Secondary outcomes were lifestyle factors (alcohol intake, exercise, BMI, smoking), patient satisfaction and AF knowledge measured at 1 and 6 months between groups and within each group. Study demographics at 1 month were similar, except AF knowledge was higher in the intervention group (8.6 vs. 7, P = 0.001). At 6 months, AF recurrence was significantly lower in the intervention group (13.5 vs. 39.4%, P = 0.014). Between groups, patient satisfaction and AF knowledge were significantly higher in the intervention group, respectively, 9.4 vs. 8.7 (P < 0.001) and 8.6 vs. 7.0 out of 10 (P < 0.001). Within the intervention group, alcohol intake decreased from 3.9 to 2.6 units per week (P = 0.031) and physical activity increased from 224.4 ± 210.7 to 283.8 ± 169.3 (P = 0.048). No changes occurred within the usual care group. Assignment to the intervention group was the only protective factor for AF recurrence [Exp(B) 0.299, P = 0.04] in multivariable-adjusted analysis.

CONCLUSION

Adding APN-led care after ablation of AF improves short-term clinical outcome, patient satisfaction and physical activity and decreases alcohol intake.

The Synergistic Relationship Between Atrial Fibrillation and Diabetes Mellitus: Implications for Cardiovascular and Metabolic Health

Type 2 diabetes mellitus (T2DM) and atrial fibrillation (AF) are widespread chronic conditions that profoundly impact public health. While the intricate mechanisms linking these two diseases remain incompletely understood, this review sets out to comprehensively analyze the current evidence about their pathophysiology, epidemiology, diagnosis, prognosis, and treatment. We reveal that T2DM can influence the electrical and structural properties of the atria through multiple pathways, including oxidative stress, inflammation, fibrosis, connexin remodeling, glycemic variability, and autonomic dysfunction. Moreover, it significantly influences AF's clinical course, elevating the risk of heart failure, stroke, and cardiovascular mortality. Our review also explores treatment options for individuals with T2DM and AF, encompassing antidiabetic and antiarrhythmic drugs and non-pharmacological interventions, such as cardioversion catheter ablation and direct current cardioversion. This review depicts an insight into the clinical interplay between T2DM and AF. It deepens our comprehension of the fundamental mechanisms, potential therapeutic interventions, and their implications for patient care. This comprehensive resource benefits researchers seeking to deepen their knowledge in this domain. Ultimately, our findings pave the way for more effective strategies in managing AF within the context of T2DM.

Effect of Insulin Resistance on Recurrence after Radiofrequency Catheter Ablation in Patients with Atrial Fibrillation

BACKGROUND

Whether there are many risk factors for recurrence of atrial fibrillation (AF) after ablation is unclear. The aim of this study was to investigate the relationship between insulin resistance (IR) and AF recurrence in patients without diabetes who underwent catheter ablation.

METHODS

This retrospective study included patients who underwent AF ablation between 2018 and 2019 at the First Affiliated Hospital of Zhengzhou University. Homeostasis model assessment of insulin resistance (HOMA-IR) was calculated, and a value of ≥2.69 was defined as IR. The patients were divided into two groups (group 1 HOMA-IR < 2.69, n = 163; group 2 HOMA-IR ≥ 2.69, n = 69). AF recurrence was defined as the occurrence of atrial arrhythmias of more than 30 s after the first 3 months. Univariate and multivariable Cox regression models were used to analyse the risk of AF recurrence.

RESULTS

Overall, 232 patients were enrolled (mean age, 59.9 ± 10.2 years old; female, 37.5%; paroxysmal AF, 71.6%). We found that dyslipidaemia, antiarrhythmic drug use, fasting blood glucose and fasting insulin were significantly higher in the IR group (P < 0.05). During the follow-up 1 year after ablation, 62 (26.7%) patients experienced AF recurrence. After adjusting for traditional risk factors, multivariable analysis showed that the HOMA-IR value (HR 1.259, 95% CI 1.086-1.460, P = 0.002) and left atrial diameter (LAD; HR 1.043, 95% CI 1.005-1.083, P = 0.026) were independently associated with AF recurrence.

CONCLUSIONS

The present results provide evidence that IR patients are more likely to experience AF recurrence. Improving IR status may be a potential target for reducing the postoperative recurrence rate.

Step Count, Self-reported Physical Activity, and Predicted 5-Year Risk of Atrial Fibrillation: Cross-sectional Analysis

BACKGROUND

Physical inactivity is a known risk factor for atrial fibrillation (AF). Wearable devices, such as smartwatches, present an opportunity to investigate the relation between daily step count and AF risk.

OBJECTIVE

The objective of this study was to investigate the association between daily step count and the predicted 5-year risk of AF.

METHODS

Participants from the electronic Framingham Heart Study used an Apple smartwatch. Individuals with diagnosed AF were excluded. Daily step count, watch wear time (hours and days), and self-reported physical activity data were collected. Individuals' 5-year risk of AF was estimated, using the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE)-AF score. The relation between daily step count and predicted 5-year AF risk was examined via linear regression, adjusting for age, sex, and wear time. Secondary analyses examined effect modification by sex and obesity (BMI≥30 kg/m2), as well as the relation between self-reported physical activity and predicted 5-year AF risk.

RESULTS

We examined 923 electronic Framingham Heart Study participants (age: mean 53, SD 9 years; female: n=563, 61%) who had a median daily step count of 7227 (IQR 5699-8970). Most participants (n=823, 89.2%) had a <2.5% CHARGE-AF risk. Every 1000 steps were associated with a 0.08% lower CHARGE-AF risk (P<.001). A stronger association was observed in men and individuals with obesity. In contrast, self-reported physical activity was not associated with CHARGE-AF risk.

CONCLUSIONS

Higher daily step counts were associated with a lower predicted 5-year risk of AF, and this relation was stronger in men and participants with obesity. The utility of a wearable daily step counter for AF risk reduction merits further investigation.

Prediction of incident atrial fibrillation with cardiac biomarkers and left atrial volumes

OBJECTIVE

Atrial fibrillation is a common arrhythmia associated with risk of stroke, heart failure and death. We aimed to elucidate the associations of cardiac biomarkers, echocardiographic left atrial volumetric indices and risk of prevalent and incident atrial fibrillation in the general population.

METHODS

We assessed cardiac troponin T (cTnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP), growth differentiation factor 15 (GDF-15), maximum (LAVi_max) and minimum (LAVi_min) indexed left atrial volumes and left atrial emptying fraction (LAEF) in subjects born in 1950 participating in the prospective observational cohort, Akershus Cardiac Examination 1950 Study. The Cohorts for Heart and Ageing Research in Genomic Epidemiology for Atrial Fibrillation risk score and sex was used to adjust for residual risk of atrial fibrillation.

RESULTS

Out of 3487 subjects, 157 (4.5%) had prevalent and 123 (3.5%) had incident atrial fibrillation. Echocardiographic left atrial volumes and cardiac biomarkers associated with prevalent atrial fibrillation, but GDF-15 was non-significant in adjusted analysis. Incident atrial fibrillation was predicted by LAVi_max (adjusted HR 1.51, 95% CI 1.30 to 1.75), LAVi_min (adjusted HR 1.52, 95% CI 1.35 to 1.72), LAEF (adjusted HR 1.24, 95% CI 1.04 to 1.48) and NT-proBNP (adjusted HR 1.57, 95% CI 1.32 to 1.85). cTnT and NT-proBNP provided incremental prognostic information to left atrial volumes, but GDF-15 demonstrated no prognostic value for incident atrial fibrillation.

CONCLUSIONS

In the general population, echocardiographic left atrial volumetric indices and NT-proBNP, but not cTnT and GDF-15, associate with prevalent atrial fibrillation and with risk of incident atrial fibrillation. cTnT and NT-proBNP provide incremental prognostic information to echocardiography.

Managing high-risk atrial fibrillation patients with multiple comorbidities

Atrial fibrillation (AF) patients are often high risk being elderly and having multiple comorbidities. Many risk factors are established to be associated with new onset incident AF, as well as AF-related complications such as stroke and hospitalisations. Multimorbidity AF patients are high risk and require a holistic approach to care, which should be proactively managing with an integrated care or holistic approach as per the ABC (atrial fibrillation better care) pathway.

Epidemiology and modifiable risk factors for atrial fibrillation

The global prevalence of atrial fibrillation (AF) has increased substantially over the past three decades and is currently approximately 60 million cases. Incident AF and its clinical consequences are largely the result of risk factors that can be modified by lifestyle changes. In this Review, we provide evidence that the lifetime risk of AF is modified not only by sex and race but also through the clinical risk factor and comorbidity burden of individual patients. We begin by summarizing the epidemiology of AF, focusing on non-modifiable and modifiable risk factors, as well as targets and strategies for the primary prevention of AF. Furthermore, we evaluate the role of modifiable risk factors in the secondary prevention of AF as well as the potential effects of risk factor interventions on the frequency and severity of subsequent AF episodes. We end the Review by proposing strategies that require evaluation as well as global policy changes that are needed for the prevention of incident AF and the management of recurrent episodes in patients already affected by AF.

Global burden of atrial fibrillation/atrial flutter and its attributable risk factors from 1990 to 2019

AIMS

The aim of this study was to estimate the global burden of atrial fibrillation (AF)/atrial flutter (AFL) and its attributable risk factors from 1990 to 2019.

METHODS AND RESULTS

The data on AF/AFL were retrieved from the Global Burden of Disease Study (GBD) 2019. Incidence, disability-adjusted life years (DALYs), and deaths were metrics used to measure AF/AFL burden. The population attributable fractions (PAFs) were used to calculate the percentage contributions of major potential risk factors to age-standardized AF/AFL death. The analysis was performed between 1990 and 2019. Globally, in 2019, there were 4.7 million [95% uncertainty interval (UI): 3.6 to 6.0] incident cases, 8.4 million (95% UI: 6.7 to 10.5) DALYs cases, and 0.32 million (95% UI: 0.27 to 0.36) deaths of AF/AFL. The burden of AF/AFL in 2019 and their temporal trends from 1990 to 2019 varied widely due to gender, Socio-Demographic Index (SDI) quintile, and geographical location. Among all potential risk factors, age-standardized AF/AFL death worldwide in 2019 were primarily attributable to high systolic blood pressure [34.0% (95% UI: 27.3 to 41.0)], followed by high body mass index [20.2% (95% UI: 11.2 to 31.2)], alcohol use [7.4% (95% UI: 5.8 to 9.0)], smoking [4.3% (95% UI: 2.9 to 5.9)], diet high in sodium [4.2% (95% UI: 0.8 to 10.5)], and lead exposure [2.3% (95% UI: 1.3 to 3.4)].

CONCLUSION

Our study showed that AF/AFL is still a major public health concern. Despite the advancements in the prevention and treatment of AF/AFL, especially in regions in the relatively SDI quintile, the burden of AF/AFL in regions in lower SDI quintile is increasing. Since AF/AFL is largely preventable and treatable, there is an urgent need to implement more cost-effective strategies and interventions to address modifiable risk factors, especially in regions with high or increased AF/AFL burden.

Association Between Risk Factors and Readmission for Patients With Atrial Fibrillation Treated With Catheter Ablation: Results From the Nationwide DenHeart Study

BACKGROUND

Because of high readmission rates for patients treated with ablation for atrial fibrillation (AF), there is great value in nurses knowing which risk factors make the largest contribution to readmission.

OBJECTIVE

The aims of this study were to (1) describe potential risk factors at discharge and (2) describe the associations of risk factors with readmission from 60 days to 1 year after discharge.

METHODS

Data from a national cross-sectional survey exploring patient-reported outcomes were used in conjunction with data from national health registers. This study included patients who had an ablation for AF during a single calendar year. The Hospital Anxiety and Depression Scale and questions on risk factors were included. Sociodemographic and clinical data were collected through registers, and readmissions were examined at 1 year.

RESULTS

In total, 929 of 1320 (response rate, 70%) eligible patients treated with ablation for AF completed the survey. One year after ablation, there were 333 (36%) acute readmissions for AF and 401 (43%) planned readmissions for AF. Readmissions were associated with ischemic heart disease, anxiety, and depression.

CONCLUSION

High observed readmission rates were associated with risk factors that included anxiety and depression. Postablation care should address these risk factors.

Comparison of radiofrequency ablation and antiarrhythmic drug for the treatment of atrial fibrillation: A protocol for systematic review and meta-analysis

BACKGROUND

Antiarrhythmic drugs and radiofrequency ablation are first-line treatments of atrial fibrillation, however, there exists a paucity of data regarding the potential benefit of different catheter ablation technologies versus antiarrhythmic drugs as an early rhythm strategy. We performed a protocol for systematic review and meta-analysis to compare the efficacy and safety of radiofrequency ablation and antiarrhythmic drugs for the treatment of atrial fibrillation.

METHODS

This review protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022375095). Additionally, this review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols 2015 Statement. A computerized literature search will be performed in the following electronic databases from their inceptions to November 2022: PubMed, EMBASE, MEDLINE, Cochrane Central Register of Controlled Clinical Trials, China Knowledge Resource Integrated Database, Wanfang Data Information, and Weipu Database for Chinese Technical Periodicals. The risk of bias will be assessed independently by 2 authors using the Cochrane tool of risk of bias. All statistical analyses will be conducted using the software program Review Manager version 5.3.

RESULTS

The results of this systematic review will be published in a peer-reviewed journal.

CONCLUSION

This study provides evidence of the comparison of radiofrequency ablation and antiarrhythmic drugs for the treatment of atrial fibrillation.

New concepts in atrial fibrillation pathophysiology

The current classification of atrial fibrillation (AF) is mainly focused on the clinical presentation according to the duration of AF episodes and the mode of termination, which incompletely reflect the severity and progressive nature of the underlying atrial disease. In this review article, "atrial cardiomyopathy" is discussed as a new concept in AF pathophysiology. Electrogram-, imaging-, and biomarker-derived measures and parameters to assess atrial cardiomyopathy, which will likely impact how AF is clinically classified and managed in the future, are presented.

Hypertension and atrial fibrillation

Hypertension is the most prevalent cardiovascular risk factor underlying atrial fibrillation and is present in up to 40% of patients with atrial fibrillation. Furthermore, attributable risk studies have shown that a history of hypertension contributes to up to 24% of incident atrial fibrillation. New data suggest that even early forms of hypertension (prehypertension and aortic stiffness) are associated with an increased risk of atrial fibrillation development. Hypertension and prehypertension are therefore critical mediators for the development of atrial fibrillation. Mechanisms for the association between hypertension and atrial fibrillation include diffuse electro-structural changes to the left atrium, driven by the haemodynamic and neurohormonal influences of hypertension and other, frequently coexisting, cardiovascular risk factors. Management of hypertension in atrial fibrillation should focus not only on blood pressure reduction but also on a comprehensive risk factor modification strategy. Such strategies have been shown to be associated with significant improvements in atrial fibrillation symptom burden as well as improved arrhythmia-free survival and reversal of the progression of atrial fibrillation. These strategies should focus on dietary modifications as well as prescribed exercise programmes involving a multidisciplinary team and patient-centred atrial fibrillation care. Risk factor management, supplemented by antihypertensive medications as needed, provides the optimum strategy for improving outcomes and even reversing the natural progression of atrial fibrillation in patients with hypertension.

ASSESSMENT OF AVAILABLE ONLINE EDUCATIONAL RESOURCES FOR PATIENTS WITH ATRIAL FIBRILLATION

Background

A diagnosis of atrial fibrillation (AF) often leads patients to search online for information, which can expose them to information of varied quality.

Objective

We conducted a qualitative systematic review of websites that contain useful information regarding AF.

Methods

The following terms were searched on 3 search engines (Google/Yahoo/Bing): (Atrial fibrillation for patients), (What is atrial fibrillation), (Atrial fibrillation patient information), (Atrial fibrillation educational resources). Inclusion criteria included websites with comprehensive AF information and information about treatment options. The Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) and PEMAT for Audiovisual Materials assessed understandability and actionability (score range 0-100). Those with a mean PEMAT-P score of >70, meaning acceptable understandability and actionability, underwent DISCERN score assessment of information content quality and reliability (score range 16-80).

Results

The search yielded 720 websites that underwent full review. After exclusions, 49 underwent full scoring. The mean overall PEMAT-P score was 69.3 ± 17.2. The mean PEMAT-AV score was 63.4 ± 13.6. Of the websites that scored >70% on the PEMAT-P, 23 (46%) underwent DISCERN scoring. The mean DISCERN score was 54.7 ± 4.6.

Conclusions

There is a wide variation in the understandably, actionability, and quality of websites, many not providing patient-level materials. Knowledge of quality websites could provide an important adjunct for improving patients understanding of AF.

Obesity and Atrial Fibrillation: A Narrative Review

Obesity and atrial fibrillation in the elderly population both present as significant health issues worldwide indirectly. Cases of atrial fibrillation are also rising worldwide, making it the most common type of cardiac arrhythmia. There are a variety of risk factors for atrial fibrillation. Modifiable factors include smoking, hypertension, diabetes mellitus, sedentary lifestyle, obesity, and non-modifiable include genetic predisposition. Obesity is a well-known risk factor for multiple systemic conditions like metabolic syndrome, diabetes mellitus type 2, sleep-related disorders, etc. In addition, it contributes directly to the development of various cardiovascular disorders like hypertension, myocardial infarction, and, more notably, atrial fibrillation. There are multiple mechanisms by which obesity in adults increases the risk of atrial fibrillation. Some of them are systemic inflammation caused by the increased secretion of cytokines by adipocytes, neuro-hormonal disturbances and heart structure remodeling, and weight-loss strategies have shown improvements in patients suffering from atrial fibrillation.

Current Understanding of Atrial Fibrillation Recurrence After Atrial Fibrillation Ablation: From Pulmonary Vein to Epicardium

Recurrence of atrial fibrillation (AF) after catheter ablation is common, with pulmonary vein (PV) reconnection considered the most likely cause. However, technologies such as contact force-sensing, irrigated catheters, and ablation index (AI)-guided ablation strategies have resulted in more durable PV isolation. As a result, it is difficult to predict which patients will develop AF recurrence despite durable PV isolation, with evolving non-PV atrial substrates thought to be a key contributor to late recurrences. Deciphering the complex mechanisms of AF recurrence beyond the cornerstone of PV isolation therefore remains challenging. Recently, there have been several important advances that may lead to better understanding and treatment of this challenging clinical entity: percutaneous epicardial access and mapping, late gadolinium enhancement magnetic resonance imaging (LGE-MRI), improvements in high-resolution electroanatomic mapping, and new ablation energy sources, specifically pulsed-field ablation. This review aims to synthesize the current literature in an effort to better understand arrhythmia mechanisms and treatment targets in patients with AF/Atrial tachycardia (AT) recurrence post-ablation. This article is protected by copyright. All rights reserved.

Comprehensive metabolomic characterization of atrial fibrillation

Background

Using human humoral metabolomic profiling, we can discover the diagnostic biomarkers and pathogenesis of disease. The specific characterization of atrial fibrillation (AF) subtypes with metabolomics may facilitate effective and targeted treatment, especially in early stages.

Objectives

By investigating disturbed metabolic pathways, we could evaluate the diagnostic value of biomarkers based on metabolomics for different types of AF.

Methods

A cohort of 363 patients was enrolled and divided into a discovery and validation set. Patients underwent an electrocardiogram (ECG) for suspected AF. Groups were divided as follows: healthy individuals (Control), suspected AF (Sus-AF), first diagnosed AF (Fir-AF), paroxysmal AF (Par-AF), persistent AF (Per-AF), and AF causing a cardiogenic ischemic stroke (Car-AF). Serum metabolomic profiles were determined by gas chromatography–mass spectrometry (GC-MS) and liquid chromatography–quadrupole time-of-flight mass spectrometry (LC-QTOF-MS). Metabolomic variables were analyzed with clinical information to identify relevant diagnostic biomarkers.

Results

The metabolic disorders were characterized by 16 cross-comparisons. We focused on comparing all of the types of AF (All-AFs) plus Car-AF vs. Control, All-AFs vs. Car-AF, Par-AF vs. Control, and Par-AF vs. Per-AF. Then, 117 and 94 metabolites were identified by GC/MS and LC-QTOF-MS, respectively. The essential altered metabolic pathways during AF progression included D-glutamine and D-glutamate metabolism, glycerophospholipid metabolism, etc. For differential diagnosis, the area under the curve (AUC) of specific metabolomic biomarkers ranged from 0.8237 to 0.9890 during the discovery phase, and the predictive values in the validation cohort were 78.8–90.2%.

Conclusions

Serum metabolomics is a powerful way to identify metabolic disturbances. Differences in small–molecule metabolites may serve as biomarkers for AF onset, progression, and differential diagnosis.

Atrial Fibrillation: Is Rhythm Control Required, and If So, How, and What Is the Internist's Role?

Atrial fibrillation-no primary care physician can escape it! Atrial fibrillation is the most common tachyarrhythmia encountered in clinical practice-whether family practice, internal medicine, cardiology, pulmonology medicine, etc. Moreover, with growth of the older segment of our population and better survival of patients with cardiovascular disorders, the incidence and prevalence of atrial fibrillation are both increasing progressively. Currently, a review of major guidelines shows that the treatment approach to atrial fibrillation involves 4 "pillars"-treatment of contributory comorbidities ("upstream therapy"), control of the ventricular response to the rapid atrial rates during atrial fibrillation, prevention of thromboembolism with oral anticoagulation or left atrial appendage occlusion (except in the minority of patients at too low a thromboembolic risk), and rhythm control in those patients who require it. The latter is the most complex of the 4, and many, if not most, primary care physicians currently prefer to leave this "pillar" to the care of a cardiologist or electrophysiologist. Nonetheless, it is important for the primary care physician to be familiar with the rhythm treatment components and choices (both overall and, specifically, the ones in which they must participate) as they will impact many interactions with their patients in multiple ways. This review details for the primary care physician the components of care regarding rhythm control of atrial fibrillation and the areas in which the primary care physician/internist must be knowledgeable and proactively involved.

Metabolic Inflexibility as a Pathogenic Basis for Atrial Fibrillation

Atrial fibrillation (AF), the most common sustained arrhythmia, is closely intertwined with metabolic abnormalities. Recently, a metabolic paradox in AF pathogenesis has been suggested: under different forms of pathogenesis, the metabolic balance shifts either towards (e.g., obesity and diabetes) or away from (e.g., aging, heart failure, and hypertension) fatty acid oxidation, yet they all increase the risk of AF. This has raised the urgent need for a general consensus regarding the metabolic changes that predispose patients to AF. “Metabolic flexibility” aptly describes switches between substrates (fatty acids, glucose, amino acids, and ketones) in response to various energy stresses depending on availability and requirements. AF, characterized by irregular high-frequency excitation and the contraction of the atria, is an energy challenge and triggers a metabolic switch from preferential fatty acid utilization to glucose metabolism to increase the efficiency of ATP produced in relation to oxygen consumed. Therefore, the heart needs metabolic flexibility. In this review, we will briefly discuss (1) the current understanding of cardiac metabolic flexibility with an emphasis on the specificity of atrial metabolic characteristics; (2) metabolic heterogeneity among AF pathogenesis and metabolic inflexibility as a common pathological basis for AF; and (3) the substrate-metabolism mechanism underlying metabolic inflexibility in AF pathogenesis.

Epicardial adipose tissue, obesity and the occurrence of atrial fibrillation: an overview of pathophysiology and treatment methods

INTRODUCTION

Obesity is a chronic disease, which has significant health consequences and is a staggering burden to health care systems. Obesity can have harmful effects on the cardiovascular system, including heart failure, hypertension, coronary heart disease, and atrial fibrillation (AF). One of the possible substrates might be epicardial adipose tissue (EAT), which can be the link between AF and obesity. EAT is a fat deposit located between the myocardium and the visceral pericardium. Numerous studies have demonstrated that EAT plays a pivotal role in this relationship regarding atrial fibrillation.

AREAS COVERED

This review will focus on the role of obesity and the occurrence of atrial fibrillation (AF) and examine the connection between these and epicardial adipose tissue (EAT). The first part of this review will explain the pathophysiology of EAT and its association with the occurrence of AF. Secondly, we will review bariatric and metabolic surgery and its effects on EAT and AF.

EXPERT COMMENTARY

In this review, the epidemiology, pathophysiology, and treatments methods of AF are explained. Secondly the effects on EAT were elucidated. Due to the complex pathophysiological link between EAT, AF, and obesity, it is still uncertain which treatment strategy is superior.

Paroxysmal Atrial Fibrillation Associated With the Trigger Sequence of Strenous Exercise Followed By Cold Water Ingestion

BACKGROUND

Patients often present to the emergency department with paroxysmal atrial fibrillation. There is increasing recognition that, in a subset of patients, certain clinical triggers mediated via the autonomic nervous system may precipitate episodes of atrial fibrillation. Although identification of these triggers may be critical for prevention of future episodes, they may be overlooked by treating physicians.

CASE REPORT

We describe an otherwise healthy 64-year-old physician who presented on two separate occasions to the emergency department with atrial fibrillation. He was electrically cardioverted successfully into normal sinus rhythm and discharged without medications both times. The patient ultimately recognized that both episodes occurred in the setting of strenuous exercise followed soon after by ingestion of cold water. Since avoiding this sequence he has not had any episodes of atrial fibrillation in the ensuing 7 years. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians often encounter patients who present with paroxysmal atrial fibrillation, some of whom may have autonomic triggers or trigger sequences that precipitated it. Although our single case report cannot prove that the sequence described caused the atrial fibrillation, we hope the case can serve to highlight the increasing awareness that, in a subset of patients with paroxysmal atrial fibrillation, identification of specific triggers could be critical in prevention and should be sought.

Early Detection of Atrial Fibrillation in Community Pharmacies-CRIFAFARMA Study

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia to appear in clinical practice. People with AF have 5 times the risk of stroke compared to the general population.

OBJECTIVE

This study aimed to determine the prevalence of AF in people over the age of 50 without known AF, who presented to a community pharmacy to check their cardiovascular risk factors, to identify risk factors associated with AF, and to assess the risk of stroke in people who screened positive for AF.

METHODS

A multicenter observational descriptive study of a screening program took place from May to December 2016. A blood pressure monitor (Microlife Watch BP Home) was used to screen for AF, and the CHA2DS2-VASc questionnaire was used to assess stroke risk.

RESULTS

The study included 452 adults over the age of 50. The CRIFAFARMA study detected a prevalence of AF of 9.1%. Risk factors for AF were: age of 75 years or older (P = .024), lack of physical activity (P = .043), diabetes (P < .001), dyslipidemia (P = .003), and history of cardiovascular disease (P = .003). Diabetes (OR 2.79, P = .005) and dyslipidemia (OR 2.16, P = .031) had a combined explanatory capacity in the multivariable logistic regression model adjusted for age. 85% were at high risk of stroke according to the CHA2DS2-VASc scale.

CONCLUSIONS

AF was detected in more than 9% of the included population. Factors associated with AF were advanced age, lack of physical activity, diabetes, dyslipidemia, and history of cardiovascular disease, with diabetes and dyslipidemia standing out as the factors with independent explanatory capacity.

Heart failure with preserved ejection fraction: recent concepts in diagnosis, mechanisms and management

It is estimated that half of all patients with heart failure (HF) have HF with preserved ejection fraction (HFpEF). Yet this form of HF remains a diagnostic and therapeutic challenge. Differentiating HFpEF from other causes of dyspnoea may require advanced diagnostic methods, such as exercise echocardiography, invasive haemodynamics and investigations for 'HFpEF mimickers'. While the classification of HF has relied heavily on cut-points in left ventricular ejection fraction (LVEF), recent evidence points towards a gradual shift in underlying mechanisms, phenotypes and response to therapies as LVEF increases. For example, among patients with HF, the proportion of hospitalisations and deaths due to cardiac causes decreases as LVEF increases. Medication classes that are efficacious in HF with reduced ejection fraction (HFrEF) have been less so at higher LVEF ranges, decreasing the risk of HF hospitalisation but not cardiovascular or all-cause death in HFpEF. These observations reflect the burden of non-cardiac comorbidities as LVEF increases and highlight the complex pathophysiological mechanisms, both cardiac and non-cardiac, underpinning HFpEF. Treatment with sodium-glucose cotransporter 2 inhibitors reduces the risk of composite cardiovascular events, driven by a reduction in HF hospitalisations; renin-angiotensin-aldosterone blockers and angiotensin-neprilysin inhibitors result in smaller reductions in HF hospitalisations among patients with HFpEF. Comprehensive management of HFpEF includes exercise as well as treatment of risk factors and comorbidities. Classification based on phenotypes may facilitate a more targeted approach to treatment than LVEF categorisation, which sets arbitrary cut-points when LVEF is a continuum. This narrative review summarises the pathophysiology, diagnosis, classification and management of patients with HFpEF.

Association between triglyceride-glucose index and atrial fibrillation: A retrospective observational study

BACKGROUND

Insulin resistance is associated with atrial remodeling as well as atrial fibrillation (AF). However, there was limited evidence on the relationship of triglyceride-glucose index (TyG) index, a simple, valuable marker of insulin resistance, with AF. Thus, we aimed to investigate the association between TyG index and AF among hospitalized patients.

METHODS

A retrospective observational study was conducted in Daping Hospital, which included 356 hospitalized patients from the Department of Cardiology. Clinical and biochemical parameters were collected from electronic medical records and AF was diagnosed from electrocardiogram (ECG) findings.

RESULTS

We found that the TyG index was significantly higher in the AF group than in the group without AF. Multivariate logistic regression revealed that hypertension (OR = 1.756, 95%CI 1.135-2.717, P = 0.011) and TyG index (OR = 2.092, 95%CI 1.412-3.100, P<0.001) were positively associated with AF. The analysis of the area under the ROC curve was performed and revealed that area under curve (AUC) of TyG index was 0.600 (95%CI, 0.542-0.659, P = 0.001), the optimal critical value was 8.35, the sensitivity was 65.4%, and the specificity was 52.0%. Additional subgroup analyses of diabetic and non-diabetic subjects were also performed and found the TyG index was increased in non-diabetic subjects with AF. Furthermore, a logistic regression analysis showed TyG index was associated with AF (OR = 3.065, 95% CI, 1.819-5.166, P<0.001) in non-diabetic subjects. However, TyG index was not associated with AF in diabetic subjects.

CONCLUSION

Elevated TyG index is an independent risk factor for AF among non-diabetic hospitalized patients.

Heart failure with preserved ejection fraction: An alternative paradigm to explain the clinical implications of atrial fibrillation

Atrial fibrillation (AF) is associated with exercise intolerance, stroke, and all-cause mortality. However, whether this can be solely attributable to the arrhythmia itself or alternative mechanisms remains controversial. Heart failure with preserved ejection (HFpEF) commonly coexists with AF and may contribute to the poor outcomes associated with AF. Indeed, several invasive hemodynamic studies have confirmed that patients with AF are at increased risk of underlying HFpEF and that the presence of HFpEF may have important prognostic implications in these patients.

Mechanistically, AF and HFpEF are closely linked. Both conditions are driven by the presence of common cardiovascular risk factors and are associated with left atrial (LA) myopathy, characterized by mechanical and electrical dysfunction. Progressive worsening of this left atrial (LA) myopathy is associated with both increased AF burden and worsening HFpEF. In addition, there is growing evidence to suggest that worsening LA myopathy is associated with poorer outcomes in both conditions and that reversal of the LA myopathy could improve outcomes. In this review article, we will present the epidemiologic and mechanistic evidence underlying the common coexistence of AF and HFpEF, discuss the importance of a progressive LA myopathy in the pathogenesis of both conditions, and review the evidence from important invasive hemodynamic studies. Finally, we will review the prognostic implications of HFpEF in patients with AF and discuss the relative merits of AF burden reduction vs HFpEF reduction in improving outcomes of patients with AF and HFpEF.

Long-term outcome of targeted therapy of underlying conditions in patients with early persistent atrial fibrillation and heart failure: data of the RACE 3 trial

AIMS

The Routine vs. Aggressive risk factor driven upstream rhythm Control for prevention of Early persistent atrial fibrillation (AF) in heart failure (HF) (RACE 3) trial demonstrated that targeted therapy of underlying conditions improved sinus rhythm maintenance at 1 year. We now explored the effects of targeted therapy on the additional co-primary endpoints; sinus rhythm maintenance and cardiovascular outcome at 5 years.

METHODS AND RESULTS

Patients with early persistent AF and mild-to-moderate stable HF were randomized to targeted or conventional therapy. Both groups received rhythm control therapy according to guidelines. The targeted group additionally received four therapies: angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers (ARBs), statins, mineralocorticoid receptor antagonists (MRAs), and cardiac rehabilitation. The presence of sinus rhythm and cardiovascular morbidity and mortality at 5-year follow-up were assessed. Two hundred and sixteen patients consented for long-term follow-up, 107 were randomized to targeted and 109 to conventional therapy. At 5 years, MRAs [76 (74%) vs. 10 (9%) patients, P < 0.001] and statins [81 (79%) vs. 59 (55%), P < 0.001] were used more in the targeted than conventional group. Angiotensin-converting enzyme inhibitors/ARBs and physical activity were not different between groups. Sinus rhythm was present in 49 (46%) targeted vs. 43 (39%) conventional group patients at 5 years (odds ratio 1.297, lower limit of 95% confidence interval 0.756, P = 0.346). Cardiovascular mortality and morbidity occurred in 20 (19%) in the targeted and 15 (14%) conventional group patients, P = 0.353.

CONCLUSION

In patients with early persistent AF and HF superiority of targeted therapy in sinus rhythm maintenance could not be preserved at 5-year follow-up. Cardiovascular outcome was not different between groups.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT00877643.

Clinical phenotypes of patients with non-valvular atrial fibrillation as defined by a cluster analysis: A report from the J-RHYTHM registry

Background

Atrial fibrillation (AF) is a heterogeneous condition caused by various underlying disorders and comorbidities. A cluster analysis is a statistical technique that attempts to group populations by shared traits. Applied to AF, it could be useful in classifying the variables and complex presentations of AF into phenotypes of coherent, more tractable subpopulations.

Objectives

This study aimed to characterize the clinical phenotypes of AF using a national AF patient registry using a cluster analysis.

Methods

We used data of an observational cohort that included 7406 patients with non-valvular AF enrolled from 158 sites participating in a nationwide AF registry (J-RHYTHM). The endpoints analyzed were all-cause mortality, thromboembolisms, and major bleeding.

Results

The optimal number of clusters was found to be 4 based on 40 characteristics. They were those with (1) a younger age and low rate of comorbidities (n = 1876), (2) a high rate of hypertension (n = 4579), (3) high bleeding risk (n = 302), and (4) prior coronary artery disease and other atherosclerotic comorbidities (n = 649). The patients in the younger/low comorbidity cluster demonstrated the lowest risk for all 3 endpoints. The atherosclerotic comorbidity cluster had significantly higher adjusted risks of total mortality (odds ratio [OR], 3.70; 95% confidence interval [CI], 2.37–5.80) and major bleeding (OR, 5.19; 95% CI, 2.58–10.9) than the younger/low comorbidity cluster.

Conclusions

A cluster analysis identified 4 distinct groups of non-valvular AF patients with different clinical characteristics and outcomes. Awareness of these groupings may lead to a differentiated patient management for AF.

Updates on epicardial adipose tissue mechanisms on atrial fibrillation

Obesity is a well-known risk factor for atrial fibrillation (AF). Local epi-myocardial or intra-myocardial adiposity caused by aging, obesity, or cardiovascular disease (CVD) is considered to be a better predictor of the risk of AF than general adiposity. Some of the described mechanisms suggest that epicardial adipose tissue (EAT) participates in structural remodeling owing to its endocrine activity or its infiltration between cardiomyocytes. Epicardial fat also wraps up the ganglionated plexi that reach the myocardium. Although the increment of volume/thickness and activity of EAT might modify autonomic activity, autonomic system dysfunction might also change the endocrine activity of epicardial fat in a feedback response. As a result, new preventive therapeutic strategies are focused on reducing adiposity and weight loss before AF ablation or inhibiting autonomic neurotransmitter secretion on fat pads during open-heart surgery to reduce the recurrence or postoperative risk of AF. In this manuscript, we review some of the novel findings regarding the pathophysiology and associated risk factors of AF, with special emphasis on the role of EAT in the electrical, structural, and molecular mechanisms of AF initiation and maintenance. In addition, we have included a brief note provided on epicardial fat preclinical models that could be useful for identifying new therapeutic targets.

Early atrial fibrillation detection and the transition to comprehensive management

Current atrial fibrillation (AF) guidelines recommend screening for AF in individuals above 65 years or with other characteristics suggestive of increased stroke risk. Several mobile health (mHealth) approaches are available to identify AF. Although most wearables or ECG machines include algorithms to detect AF, an ECG confirmation of AF is necessary to establish a suspected diagnosis of AF. Early detection of AF is important to allow early initiation of AF management, and early rhythm control therapy lowered risk of adverse cardiovascular outcomes among patients with early AF aged >75 or with a CHA2DS2-VASc score ≥2 and cardiovascular conditions in the EAST-AFNET 4 study. Strategies for early AF detection should be always linked to a comprehensive work-up infrastructure organized within an integrated care pathway to allow early initiation and guidance of AF treatment in newly detected AF patients. In this review article, we summarize strategies and mHealth approaches for early AF detection and the transition to early AF management including AF symptoms evaluation and assessment of AF progression as well as AF risk factors.

Prediction of AF in Heart Failure With Preserved Ejection Fraction: Incremental Value of Left Atrial Strain

OBJECTIVES

This study sought to identify the factors associated with incident atrial fibrillation (AF) in a well-characterized heart failure with preserved ejection fraction (HFpEF) population, with special focus on left atrial (LA) strain.

BACKGROUND

AF is associated with HFpEF, with adverse consequences. Effective risk evaluation might allow the initiation of protective strategies.

METHODS

Clinical evaluation and echocardiography, including measurements of peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and LA volume index (LAVI), were obtained in 170 patients with symptomatic HFpEF (mean age, 65 ± 8 years), free of baseline AF. AF was identified by standard 12-lead electrocardiogram, review of relevant medical records (including Holter documentation), and surveillance with a portable single-lead electrocardiogram device over 2 weeks. Results were validated in the 103 patients with HFpEF from the Karolinska-Rennes (KaRen) study.

RESULTS

Over a median follow-up of 49 months, incident AF was identified in 39 patients (23%). Patients who developed AF were older; had higher clinical risk scores, brain natriuretic peptide, creatinine, LAVI, and LV mass; lower LA strain and exercise capacity; and more impaired LV diastolic function. PACS, PALS, and LAVI were the most predictive parameters for AF (area under receiver-operating characteristic curve: 0.76 for PACS, 0.71 for PALS, and 0.72 for LAVI). Nested Cox regression models showed that the predictive value of PACS and PALS was independent from and incremental to clinical data, LAVI, and E/e' ratio. Classification and regression trees analysis identified PACS ≤12.7%, PALS ≤29.4%, and LAVI >34.3 ml/m² as discriminatory nodes for AF, with a 33-fold greater hazard of AF (p < 0.001) in patients categorized as high risk. The classification and regression trees algorithm discriminated high and low AF risk in the validation cohort.

CONCLUSIONS

PACS and PALS provide incremental predictive information about incident AF in HFpEF. The inclusion of these LA strain components to the diagnostic algorithm may help guide screening and further monitoring for AF risk in this population.

Motivation of overweight patients with atrial fibrillation to lose weight or to follow a weight loss management program: a cross-sectional study

AIMS

Overweight increases the risk of recurrence and progression of atrial fibrillation (AF). This study assesses the knowledge of overweight AF patients about the relation between their weight and AF, to gauge their motivation losing weight and/or following weight reduction programs.

METHODS

A multicenter cross-sectional descriptive study was performed at three Belgian hospitals. A validated self-developed questionnaire was presented to AF patients with a body mass index (BMI) >27 kg/m² and it addressed: motivation to reduce weight and its related factors; knowledge about the relation between weight and AF; and interest in weight reduction programs.

RESULTS

One hundred and forty-three patients completed the questionnaire. 75.5% was currently motivated to reduce weight. Multivariate regression analysis showed that a higher BMI, a college/university degree, male gender, without hypertension, previous weight loss attempt(s) and living with a partner, were significantly associated with greater motivation for weight reduction. Only 69.9% of the patients was aware of the positive effect of weight reduction on the progression of AF. A completely home-based/telerehabilitation program was the preferred approach for 57.9% of the patients.

CONCLUSIONS

AF patients with overweight need to be better informed about overweight as a risk factor for AF. Female AF patients with a lower degree of education, hypertension, living alone, who have never attempted to reduce weight and with a lower but still elevated BMI need more external motivation to lose weight. A tailored weight reduction program (home-based) is the preferred option for patients. This will require further development and validation of telecoaching programs for this patient group.