Supervised Obesity Reduction Trial for AF Ablation Patients: Results from the SORT-AF trial

2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation

Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.

Obesity effect on newly diagnosed and recurrent post-ablation atrial fibrillation: a systematic review and meta-analysis

BACKGROUND AND AIMS

The role of overweight and obesity in the development of atrial fibrillation (AF) is well established; however, the differential effect on the occurrence and recurrence of AF remains uncertain. The aim of this review is to compare the effect of underweight and varying degrees of obesity on onset of AF and in recurrent post-ablation AF, and, when possible, in relation to sex.

METHODS

A systematic literature search was conducted in PubMed, Embase, and Cochrane Library from inception to January 31, 2023. Studies reporting frequency of newly-diagnosed AF and of recurrent post-ablation AF in different BMI categories, were included. 3400 records were screened and 50 met the inclusion criteria. Standardized data search and abstraction were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement. Data were extracted from the manuscripts and were analyzed using a random effect model. The outcome was the occurrence of AF in population studies and in patients undergoing ablation.

RESULTS

Data from 50 studies were collected, of which 27 for newly-diagnosed AF and 23 for recurrent post-ablation AF, for a total of 15,134,939 patients, of which 15,115,181 in studies on newly-diagnosed AF and 19,758 in studies on recurrent post-ablation AF. Compared to normal weight, the increase in AF was significant (p < 0.01) for overweight, obese, and morbidly obese patients for newly-diagnosed AF, and for obese and morbidly obese patients for recurrent post-ablation AF. Newly-diagnosed AF was more frequent in obese female than obese male patients.

CONCLUSION

The effect of increased BMI was greater on the onset of AF, and obese women were more affected than men.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

Catheter Ablation for Atrial Fibrillation-Influence of Modifiable Risk Factors and Ablation Modality on Procedural Efficacy and Safety

BACKGROUND

Modifiable lifestyle risk factors, in particular obesity and related conditions, are important drivers of atrial fibrillation (AF), impacting the severity of symptoms and influence the efficacy and safety of treatment.

OBJECTIVE

The study aimed to assess the impact of modifiable lifestyle factors on the effectiveness and safety of AF ablation, and examine the procedural characteristics, efficacy, safety and cost outcomes of cryoballoon vs radiofrequency ablation, in a real-world clinical setting.

METHOD

Patients undergoing catheter ablation for AF (June 2017 to December 2020) were included in this retrospective analysis. Efficacy and safety outcomes were obtained from electronic medical records and state-wide databases. The primary outcome was successful isolation of the pulmonary veins and freedom from AF without repeat ablation or ongoing antiarrhythmic therapy at 12 months.

RESULTS

The study included 141 patients (mean age 60±11 years, 57% male). The average body mass index (BMI) was 29.2±5.6 kg/m2. Ablation by cryoballoon was undertaken in 59% (radiofrequency 41%). Acutely successful pulmonary vein isolation was achieved in 92%, however, only 52% (n=74) met the primary outcome (successful isolation of the pulmonary veins and freedom from AF without repeat ablation or ongoing antiarrhythmic therapy) at 12 months. Successful management of AF was more likely in patients with lower BMI (p=0.006; particularly with BMI <27 kg/m2; p=0.004) and weight (p=0.003), and in those without obstructive sleep apnoea (p=0.032). The only independent predictor of the primary outcome was BMI (β=0.25, p=0.004). Over 75% of complications occurred in those with BMI ≥27 kg/m2.

CONCLUSIONS

Catheter ablation for AF is more likely to be unsuccessful in patients with uncontrolled risk factors, particularly obesity. Risk factor optimisation may improve procedural success and reduce the risk of procedural complications.

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.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

The Role of Risk Factor Modification in Atrial Fibrillation: Outcomes in Catheter Ablation

The management of atrial fibrillation has evolved significantly over the last ten years with advancements in medical and catheter ablation approaches, but these have limited success when used in isolation. Trends in the management of lifestyle modifications have surfaced, as it is now better understood that modifiable risk factors contribute significantly to the development and propagation of atrial fibrillation, as well as failure of treatment. International guidelines have integrated the role of lifestyle modification in the management of atrial fibrillation and specifically in the persistent form of atrial fibrillation; these guidelines must be addressed prior to considering catheter ablation. Effective risk factor modification is critical in increasing the likelihood of an arrhythmia-free survival following catheter ablation.

Atrial fibrillation: stroke prevention

Stroke prevention is central to the management of patients with atrial fibrillation (AF) which has moved towards a more holistic or integrative care approach. The published evidence suggests that management of AF patients following such a holistic approach based on the Atrial fibrillation Better Care (ABC) pathway is associated with a lower risk of stroke and adverse events. Risk assessment, re-assessment and use of direct oral anticoagulants (DOACs) are important for stroke prevention in AF. The stroke and bleeding risks of AF patients are not static and should be re-assessed regularly. Bleeding risk assessment is to address and mitigate modifiable bleeding risk factors, and to identify high bleeding risk patients for early review and follow-up. Well-controlled comorbidities and healthy lifestyles also play an important role to achieve a better clinical outcome. Digital health solutions are increasingly relevant in the diagnosis and management of patients with AF, with the potential to improve stroke prevention. In this review, we provide an update on stroke prevention in AF, including importance of holistic management, risk assessment/re-assessment, and stroke prevention for special AF populations. Evidence-based and structured management of AF patients would reduce the risk of stroke and other adverse events.

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.

Risk factors modification in atrial fibrillation: a brief review

INTRODUCTION

Atrial fibrillation (AF) is a supraventricular arrhythmia characterized by fibrillatory waves in the atria with an irregular ventricular rhythm. It is the most common arrhythmia treated in clinical practice. AF is associated with approximately five-fold increase in risk of cerebrovascular accident (stroke) and two-fold increase in cognitive dysfunction and all-cause mortality.

AREAS COVERED

Multiple risk factors have been identified for development of AF including age, hypertension, diabetes, and obesity. Primary and secondary prevention strategies aimed at reducing the incidence of AF can have a dramatic clinical and economic impact. Multiple studies have shown that lifestyle interventions can reduce predisposing factors, reverse the pathophysiology behind AF, and decrease disease burden. In this brief review we aim at exploring the current state of knowledge regarding risk factor modifications that decrease incidence and prevalence of AF.

EXPERT OPINION

This is an evolving field of research and further studies to elucidate the magnitude of effect of these interventions as well as the pathophysiological mechanisms driving these effects are underway.

The effect of weight loss on recurrence of atrial fibrillation after catheter ablation: A systematic review and meta-analysis

BACKGROUND

Obesity is associated with an increased risk of developing recurrent atrial fibrillation (AF) after catheter ablation (CA). However, the current data on weight loss interventions show inconsistent results in preventing the recurrence of AF after CA.

METHODS

We conducted a systematic search in MEDLINE and EMBASE to identify studies that reported the outcome of recurrence of AF after CA in obese patients undergoing weight interventions. The subgroup analysis included: (1) Weight loss versus no weight loss, (2) >10% weight loss versus <10% weight loss, (3) <10% weight loss versus no weight loss, (4) Follow-up <12 months, and (5) Follow-up >12 months after CA. Mantel-Haenszel risk ratios with a 95% confidence interval (CI) were calculated using a random effects model and for heterogeneity, I2 statistics were reported.

RESULTS

A total of 10 studies (one randomized controlled trial and nine observational studies) comprising 1851 patients were included. The recurrence of AF was numerically reduced in the weight loss group (34.5%) versus no weight loss group (58.2%), but no statistically significant difference was observed (risk ratio [RR] = 0.76; 95% CI: 0.49-1.18, p = .22). However, there was a statistically significant reduction in recurrence of AF with weight loss versus no weight loss at follow-up >12 months after CA (RR = 0.47; 95% CI: 0.32-0.68, p < .0001). At follow-up >12 months after CA, both >10% weight loss versus <10% weight loss (RR = 0.49; 95% CI: 0.31-0.80, p = .004) and <10% weight loss versus no weight loss (RR = 0.39; 95% CI: 0.31-0.49, p < .00001) were associated with a statistically significant reduction in recurrent AF.

CONCLUSION

In patients with AF undergoing CA, weight loss is associated with reducing recurrent AF at > 12 months after ablation and these benefits are consistently seen with both >10% and <10% weight loss. The benefits of weight loss in preventing recurrent AF after CA should be examined in larger studies with extended follow-up duration.

Lifestyle changes in atrial fibrillation management and intervention

Atrial fibrillation (AF) is one of the most common arrhythmias in adults, and its continued rise in the United States is complicated by the increased incidence and prevalence of several AF risk factors, such as obesity, physical inactivity, hypertension, obstructive sleep apnea, diabetes mellitus, coronary artery disease, and alcohol, tobacco, or caffeine use. Lifestyle and risk factor modification has been proposed as an additional pillar of AF therapy, added to rhythm control, rate control, and anticoagulation, to reduce AF burden and risk. Although emerging evidence largely supports the integration of lifestyle and risk factor management in clinical practice, randomized clinical trials investigating the long-term sustainability and reproducibility of these benefits remain sparse. The purpose of this review is to discuss potentially reversible risk factors on AF, share evidence for the impact on AF by modification of these risk factors, and then provide an overview of the effects of reversing or managing these risk factors on the success of various AF management strategies, such as antithrombotic, rate control, and rhythm control therapies.

Impact of Weight Loss on Atrial Fibrillation

Atrial fibrillation (AF) is a prevalent and persistent irregular heart rhythm that is expected to dramatically increase in prevalence in the next few decades. Several established cardiovascular risk factors, including obesity, play a significant impact in developing AF. Obesity, characterized by a high body mass index (BMI), is particularly concerning as it directly elevates the risk of AF and other cardiovascular comorbidities. This review explores the complex interplay between obesity and AF, specifically highlighting the reversible nature of obesity-induced cardiac remodeling with weight loss. As we will soon discover, several insights from weight management offer promising strategies for AF prevention and management.

Metabolic Syndrome and Atrial Fibrillation: Different Entities or Combined Disorders

Obesity, hypertension, insulin resistance, and dyslipidemia are all clusters of an entity called "Metabolic Syndrome". The global trends of this syndrome's incidence/prevalence continue to increase reciprocally, converting it into a massive epidemic problem in the medical community. Observing the risk factors of atrial fibrillation, a medical condition that is also converted to a scourge, almost all parts of the metabolic syndrome are encountered. In addition, several studies demonstrated a robust correlation between metabolic syndrome and the occurrence of atrial fibrillation. For atrial fibrillation to develop, a combination of the appropriate substrate and a trigger point is necessary. The metabolic syndrome affects the left atrium in a multifactorial way, leading to atrial remodeling, thus providing both the substrate and provoking the trigger needed, which possibly plays a substantial role in the progression of atrial fibrillation. Due to the remodeling, treatment of atrial fibrillation may culminate in pernicious sequelae, such as repeated catheter ablation procedures. A holistic approach of the patient, with simultaneous treatment of both entities, is suggested in order to ensure better outcomes for the patients.

Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal

Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.

Cryoballoon pulmonary vein isolation for atrial fibrillation in obese patients: A non-inferiority analysis

Background

Patients with obesity are at higher risk of developing atrial fibrillation (AF) and benefit from radiofrequency ablation. Potentially, cryoballoon ablation (CBA) may be equally effective and safe in such patients.

Methods

We conducted a prospective, single-center study to investigate whether CBA for pulmonary vein isolation is as effective and safe in obese patients as it is in non-obese controls. Primary efficacy endpoint was recurrence of AF, atrial flutter or atrial tachycardia after a 90-day blanking period. Safety endpoints were death, stroke or procedure-associated complications. Conduction of a subgroup analysis regarding the impact of additional diabetes was predefined in case the primary efficacy endpoint was met. The study was event driven and powered for noninferiority.

Results

A total of 949 patients underwent CBA (251 obese with mean body-mass-index 33.5 ± 3 kg/m2 and 698 non-obese with mean body-mass-index 25.3 ± 3 kg/m2) during a 5-year recruitment period. Median follow-up was 15 months. The primary efficacy endpoint occurred in 78/251 obese and 247/698 non-obese patients (12-months Kaplan-Meier event-rate estimates, hazard ratio 0.79; 95% confidence interval [CI], 0.58 to 1.07; log-rank P = 0.0002 for noninferiority). No differences were observed in safety end point occurrence (P = 0.78). The occurrence of primary efficacy end point was found to be unaffected by the presence of diabetes in the prespecified subgroup analysis (log-rank P = 0.57).

Conclusion

CBA is effective and safe in obese and DM patients. Weighing the high cardiovascular risk of obese patients against a reduction of cardiovascular events by early rhythm control, CBA should be offered to this patient population.

Impact of obesity on catheter ablation of atrial fibrillation: Patient characteristics, procedural complications, outcomes, and quality of life

INTRODUCTION

Obesity is a well-known risk factor for atrial fibrillation (AF). We aim to evaluate the effect of baseline obesity on procedural complications, AF recurrence, and symptoms following catheter ablation (CA).

METHODS

All consecutive patients undergoing AF ablation (2013-2021) at our center were enrolled in a prospective registry. The study included all consecutive patients with available data on body mass index (BMI). Primary endpoint was AF recurrence based on electrocardiographic documentation. Patients were categorized into five groups according to their baseline BMI. Patients survey at baseline and at follow-up were used to calculate AF symptom severity score (AFSS) as well as AF burden (mean of AF duration score and AF frequency score; scale 0: no AF to 10: continuous and 9 frequencies/durations in between). Patients were scheduled for follow-up visits with 12-lead electrocardiogram at 3, 6, and 12 months after ablation, and every 6 months thereafter.

RESULTS

A total of 5841 patients were included (17% normal weight, 34% overweight, 27% Class I, 13% Class II, and 9% Class III obesity). Major procedural complications were low (1.5%) among all BMI subgroups. At 3 years AF recurrence was the highest in Class III obesity patients (48%) followed by Class II (43%), whereas Class I, normal, and overweight had similar results with lower recurrence (35%). In multivariable analyses, Class III obesity (BMI ≥ 40) was independently associated with increased risk for AF recurrence (hazard ratio, 1.30; confidence interval, 1.06-1.60; p = .01), whereas other groups had similar risk in comparison to normal weight. Baseline AFSS was lowest in normal weight, and highest in Obesity-III, median (interquartile range) 10 (5-16) versus 15 (10-21). In all groups, CA resulted in a significant improvement in their AFSS with a similar magnitude among the groups. At follow-up, AF burden was minimal and did not differ significantly between the groups.

CONCLUSION

AF ablation is safe with a low complication rate across all BMI groups. Morbid obesity (BMI ≥ 40) was significantly associated with reduced AF ablation success. However, ablation resulted in improvement in QoL including reduction of the AFSS, and AF burden regardless of BMI.

Obesity and atrial fibrillation: Prevalence, pathogenesis, and prognosis

The prevalence of atrial fibrillation (AF) and obesity are rising significantly. There is a shared association between these conditions with obesity predisposing individuals to a number of shared risk factors. In addition, obesity in itself has been shown to cause changes to the structure, function and hemodynamics of the heart. There is evidence to show that weight-loss has significant impact on AF symptoms, burden and more recently the potential to reverse the type of AF. Through risk factor management and in the case of morbid obesity, bariatric surgery, there is an improved prognosis for patients with AF and obesity. In this paper we provide a review of the current data on obesity and AF prevalence, pathogenesis and prognosis.

Effect of Multifactorial Risk Factor Interventions on Atrial Fibrillation: A Systematic Review and Meta-Analysis

Evidence supports the benefit of managing atrial fibrillation (AF) specific risk factors in secondary prevention of AF. However, a comprehensive summary of the effect of multifactorial risk factor interventions on outcomes of patients with AF over long-term is lacking. We searched MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL databases from inception to October 2021 for both randomized controlled trials (RCT) and observational studies comparing multifactorial risk factor interventions to usual care in patients with AF. Fifteen studies (10 RCT, 5 observational) with 3786 patients were included (mean age 63.8 years, 64.0% males). Follow-up ranged from 3 to 42 months. We found no significant effects of multifactorial risk factor interventions on AF recurrence [pooled relative risk (RR): 0.93, 95% CI: 0.74-1.16, P = 0.51, I² = 54%], AF-related rehospitalization at 12 months (RR: 0.69, 95% CI: 0.43-1.11, P= 0.13, I² = 0%), cardiovascular rehospitalization at 12 months (RR: 0.76, 95% CI: 0.53-1.09, P= 0.13, I² = 53%), or AF-related adverse events at 12 and 15 months. However, multifactorial interventions were associated with reduced AF-related symptoms and improved health-related quality of life (HRQoL) at all studied time points. Current evidence does not support consistent associations between multifactorial risk factor interventions and AF recurrence after rhythm control therapy or AF-related or cardiovascular hospitalization in patients with AF. However, these interventions are associated with clinically relevant improvement in AF-related symptoms and HRQoL. Additional randomized studies are required to evaluate the impact of multifactorial risk factor interventions on patient-centered health outcomes.

Imaging in atrial fibrillation: A way to assess atrial fibrosis and remodeling to assist decision-making

The 2020 ESC atrial fibrillation (AF) guidelines suggest the novel 4S-AF scheme for the characterization of AF. Imaging techniques could be helpful for this objective in everyday clinical practice, and information derived from these techniques reflects basic aspects of the pathophysiology of AF, which may facilitate treatment decision-making, and optimal management of AF patients. The aim of this review is to provide an overview of the mechanisms associated with atrial fibrosis and to describe imaging techniques that may help the management of AF patients in clinical practice. Transthoracic echocardiography is the most common procedure given its versatility, safety, and simplicity. Transesophageal echocardiography provides higher resolution exploration, and speckle tracking echocardiography can provide incremental functional and prognostic information over conventional echocardiographic parameters. In addition, LA deformation imaging, including LA strain and strain rate, are related to the extent of fibrosis. On the other hand, multidetector-row computed tomography and cardiac magnetic resonance provide higher resolution data and more accurate assessment of the dimensions, structure, and spatial relationships of the LA. Imaging is central when deciding on catheter ablation or cardioversion, and helps in selecting those patients who will really benefit from these procedures. Moreover, imaging enhances the understanding of the underlying mechanisms of atrial remodeling and might assists in refining the risk of stroke, which help to select the best medical therapies/interventions. In summary, evaluation of LA enlargement, LA remodeling and fibrosis with imaging techniques adds clinical and prognostic information and should be assessed as a part of routine comprehensive AF evaluation.

[Rehabilitation for atrial fibrillation : Impact on arrhythmia and cumulative risk factors]

BACKGROUND

Atrial fibrillation (AF) occurs in cardiovascular diseases but also in hyperthyroidism. The independent risk factors (RF) that are cumulatively the cause of AF include arterial hypertension, obesity, malnutrition, alcohol and tobacco consumption, lack of exercise, diabetes mellitus, and sleep-related breathing disorders. These cause and reinforce each other and are amplified by psychosocial RF. This also leads to morphological consequences such as atrial cardiomyopathy or diastolic heart failure (HFpEF). Therapy focuses on stroke prophylaxis through anticoagulation and rhythm or frequency control of the AF.

AIM

The risk factors of AF are presented here in detail. RF control must be included in the management of AF. Effective risk management should definitely include the patient's lifestyle.

RESULTS AND CONCLUSION

Although RF management can be integrated into the acute medical and outpatient treatment of AF, there is little scope to deal with the individual risk profile of individual patients. With the bio-psycho-social treatment approach, cardiological rehabilitation offers the opportunity to establish individual, lifestyle-oriented risk management and to achieve symptomatic improvement, decreased AF burden, better performance, and a better quality of life through correctly dosed training. Further studies to clarify the question of whether clinical endpoints such as hospitalization or morbidity and mortality are reduced by cardiac rehabilitation in AF are desirable.

Association between weight loss and outcomes in patients undergoing atrial fibrillation ablation: a systematic review and dose-response meta-analysis

BACKGROUND

Obesity is an strong risk factor for atrial fibrillation (AF), and obesity can affect the prognosis of AF. However, the role of weight loss on outcomes after ablation remains unclear.

OBJECTIVES

This study aims to determine the relationship between weight loss and outcomes in patients with AF ablation, as well as the potential dose-response relationship.

METHODS

The Cochrane Library, PubMed, and Embase databases were searched to identify studies that reported a relationship between weight loss and ablation up to August 17, 2021. Relative risks (RRs) were pooled using random-effects models.

RESULTS

One randomized, open-labeled clinical trial and seven cohort studies involving 1283 patients were included. The mean body mass index of all included studies was over 30 kg/m². The clinical trial showed a non-significant benefit of weight loss intervention on AF recurrence (Odd risk [OR] = 1.02, 95% confidence interval [CI] 0.70-1.47). Meta-analysis based on observational studies showed that the recurrence rate of AF after ablation was significantly reduced (RR = 0.43, 95% CI 0.22-0.81, I² = 97%) in relatively obese patients with weight loss compared with the control group. Each 10% reduction in weight was associated with a decreased risk of AF recurrence after ablation (RR = 0.54, 95% CI 0.33-0.88) with high statistical heterogeneity (I² = 76%). An inverse linear association (P_{non-linearity} = 0.27) between AF relapse and increasing weight loss was found.

CONCLUSIONS

Our results first suggest an inverse dose-response association between weight loss and risk of recurrent AF after ablation, with moderate certainty.

The Efficacy of Telemedicine Rehabilitation Programs In Regard Of Risk Factors Control In Patients With Paroxysmal Atrial Fibrillation Aftercatheter Ablation

Aim      To evaluate changes in traditional risk factors (RF) during cardiac rehabilitation (CR) programs with remote support in patients with paroxysmal atrial fibrillation (AF) after catheter ablation (CA).Material and methods  The lack of control of cardiovascular RFs is a predictor for AF recurrence after CA, development of complications, and decreased life expectancy. Telemedical CR programs may improve the control of RF and enhance the CR efficacy. This randomized controlled clinical study in three parallel groups included 135 patients aged 35 to 79 years. In groups 1 and 2, CR programs with remote support were performed, which included a single personal consulting for the disease, achieving control of all patient's RFs, and remote support during 3 months (group 1, by phone and group 2, by e-mail). Participants of group 3 received standard recommendations. Body weight, blood pressure (BP), blood lipids, smoking status, and physical activity (PA) were determined at baseline and at 12 months after CA with the IPAQ questionnaire.Results In both intervention groups at 12 months, there were positive changes in RF: body weight index decreased by 3.6 % in group 1 (р=0.01) and by 2.3 % in group 2 (р=0.002) vs. 0 in the control group; systolic BP decreased by 7.1 % (p&lt;0.001) and 1.5 % (p=0.003) in groups 1 and 2 (vs. increases by 3.3 % in group 2); total cholesterol decreased by 9.4 % (p&lt;0.001) and by 6.3 % (p=0.003), respectively, (vs. 0 in group 3); values of metabolic equivalents (METs) used for walking increased by 55.0 % (р=0.014), 75.0 % (р=0.001), and 1.4 % in groups 1, 2 and 3, respectively. No significant intergroup differences in the frequency of AF recurrence, repeated CA, and hospitalizations were found.Conclusion      CR programs with remote support provide improved control of BP, body weight, blood cholesterol, and AF in patients with AF after CA, according to the results of the one-year follow-up.

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.

Weight loss and atrial fibrillation: a review

PURPOSE OF REVIEW

Despite technological advancements in catheter ablation, patients with atrial fibrillation often require multiple ablations, with diminishing returns depending on duration and persistence. Although early ablation is vital, modification of atrial fibrillation disease can be achieved with modification of existing risk factors. Obesity is an important modifiable risk factor, but there does not appear to be a consensus on the best method or goal for weight reduction.

RECENT FINDINGS

The relationship between atrial fibrillation and obesity has been acknowledged. This review examines the clinical evidence demonstrating the benefit of weight reduction in the management of atrial fibrillation. In particular, this review compares the different approaches of recent studies.

SUMMARY

On the basis of the literature, the authors recommend a structured weight loss programme with dietary and behavioural modifications individualized to each patient and including the implementation of physical activity. Consideration of bariatric surgery is appropriate in certain patients with obesity.

Short- and long-term risk of atrial fibrillation recurrence after first time ablation according to body mass index: a nationwide Danish cohort study

AIMS

Overweight is associated with increased risk of atrial fibrillation (AF), but the impact of overweight and AF recurrence after ablation is less clear. Despite this, an increasing number of AF ablations are carried out in overweight patients. We investigated the impact of body mass index (BMI) on AF recurrence rates after ablation.

METHODS AND RESULTS

Through Danish nationwide registers, all patients undergoing first-time AF ablation between 2010 and 2018 were identified. Exposure of interest was BMI. The primary outcome was recurrent AF, defined from either any usage of antiarrhythmic medication, AF hospitalization, cardioversion, or re-ablation. A total of 9188 patients were included. Median age and interquartile range was 64 (60-75) in the normal-weight group and 60 (53-66) in the morbidly obese. There was an increase in comorbidity burden with increasing BMI, including a higher prevalence of heart failure, chronic obstructive pulmonary disease, diabetes, and hypertension. At 1- and 5-year follow ups, recurrence rates of AF increased incrementally by BMI categories. The hazard ratios and 95% confidence intervals of recurrent AF after ablation were 1.15 (1.07-1.23), 1.18 (1.09-1.28), and 1.26 (1.13-1.41) in overweight, obese, and morbidly obese, respectively, compared with normal-weight patients. Procedure duration and X-ray dose exposure also increased with increasing BMI.

CONCLUSION

Following AF ablation, recurrence rates of AF increased incrementally with increasing BMI. Therefore, aggressive weight management pre ablation in overweight patients could potentially provide substantial benefits and improve short- and long-term outcomes after ablation.

[Metabolic syndrome and atrial fibrillation]

Metabolic syndrome is defined by the simultaneous occurrence of the cardiovascular risk factors obesity, hypertension, diabetes and dyslipidemia. Overweight, in particular, is continuously increasing in many countries. In this respect, metabolic syndrome is a strong risk factor for atrial fibrillation. Only few data are available on the influence of obesity on antiarrhythmic drugs. Sodium channel blockers, in particular, appear to show a reduced effectiveness. Direct oral anticoagulants can be used for anticoagulation in obese patients. With a body weight > 140 kg, a plasma level measurement is recommended. Severe overweight reduces the chances of successful ablation treatment and leads to more complications. Consistent treatment of the metabolic syndrome, and in particular weight reduction, can significantly improve the risk and the frequency of atrial fibrillation, the associated symptoms and the success of treatment for maintaining cardiac rhythm.

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.

Harmful Impact of Tobacco Smoking and Alcohol Consumption on the Atrial Myocardium

Tobacco smoking and alcohol consumption are widespread exposures that are legal and socially accepted in many societies. Both have been widely recognized as important risk factors for diseases in all vital organ systems including cardiovascular diseases, and with clinical manifestations that are associated with atrial dysfunction, so-called atrial cardiomyopathy, especially atrial fibrillation and stroke. The pathogenesis of atrial cardiomyopathy, atrial fibrillation, and stroke in context with smoking and alcohol consumption is complex and multifactorial, involving pathophysiological mechanisms, environmental, and societal aspects. This narrative review summarizes the current literature regarding alterations in the atrial myocardium that is associated with smoking and alcohol.

Lifestyle Modification and Atrial Fibrillation: Critical Care for Successful Ablation

Management of atrial fibrillation (AF) requires a comprehensive approach due to the limited success of medical or procedural approaches in isolation. Multiple modifiable risk factors contribute to the development and progression of the underlying substrate, with a heightened risk of progression evident with inadequate risk factor management. With increased mortality, stroke, heart failure and healthcare utilisation linked to AF, international guidelines now strongly support risk factor modification as a critical pillar of AF care due to evidence demonstrating the efficacy of this approach. Effective lifestyle management is key to arrest and reverse the progression of AF, in addition to increasing the likelihood of freedom from arrhythmia following catheter ablation.

Impact of Body Mass Index on Cryoablation of atrial fibrillation: Patient characteristics, procedural data and long-term outcomes

BACKGROUND

Ablation of atrial fibrillation in the context of obesity can be challenging. We sought to evaluate the role of cryoballoon pulmonary vein isolation (CB-PVI) in obese patients with symptomatic atrial fibrillation (AF).

METHODS

Patients with a BMI≥25 kg/m² and symptomatic AF who underwent CB-PVI were retrospectively enrolled. Three groups were defined (G1: BMI of 25-29 kg/m² ; G2: BMI of 30-34 kg/m² ; G3: BMI≥35 kg/m² ).

RESULTS

600 patients were included (59% male; 66±11 years old); 337, 149, 114 were assigned to G1, G2 and G3, respectively. Acute procedural success was recorded in 99,7% of patients. Procedural and fluoroscopy time were comparable but radiation dose was significantly higher in G3. Procedural complications were 3% in G1, 5,4% in G2 and 8,8% in G3 (p=0,01). The overall freedom from AF after 1-year was 77%. G3 had a significantly worse 1-year success rate compared to G1 and G2 (G3:66,5% vs. G1:78,4%; p=0,015 and vs. G2:82,5%; p=0,008) with a reduced 1-year success in paroxysmal AF (G1:84,0%; G2:86,3% and G3:69,6%) but not in persistent AF (G1:68,7%; G2:77,4% and G3:62,1%). G3 showed similar success rates irrespective of AF form (PAF 69,6% vs. persAF 62,1%; p=0,501).

CONCLUSION

Cryoballoon ablation in obese patients can be effective with an acceptable safety profile, 77% of patients were in stable SR at one year. Severe obese patients (BMI≥35) showed reduced procedural safety and 1-year success rate. In association with life style modification, CB ablation may represent a strategy to enhance rhythm control in the context of obesity. This article is protected by copyright. All rights reserved.

Effect of weight loss on recurrence of atrial fibrillation after ablative therapy: a systematic review and meta-analysis

BACKGROUND

Landmark trials have shown superiority of ablative therapy over medical therapy in certain subpopulation with atrial fibrillation (AF). Previous studies have demonstrated an association between weight loss and reduced rates of recurrence of AF after ablation. The objective of this study is to determine if weight loss reduces the recurrence of AF after ablation.

METHODS

An extensive literature search and systematic review of studies of weight loss on recurrence of AF after ablative therapy was performed. Risk ratio (RR) and 95% confidence intervals were measured for weight loss group versus control group in each study, and comparative analysis as well as subgroup analysis was made.

RESULTS

Eight studies with a total of 1,425 patients were included. Overall, studies of patients who lost weight demonstrated lower recurrence of AF (RR 0.35; 95% CI 0.18-0.67). However, subgroup analysis of studies which included patients who lost ≥10% weight loss from baseline showed lower recurrence of AF (RR 0.18; 95% 0.03-0.89), whereas studies which included patients with <10% weight loss did not (RR 1.00; 95% 0.51-1.96). Studies of patients who had less than 12-month history of AF (RR 0.24; 95% CI 0.11-0.57) and those who lost weight prior to ablation (RR 0.40; 95% CI 0.20-0.79) also had lower recurrence of AF.

CONCLUSION

Weight loss is associated with lower long-term recurrence of AF after ablative therapy. Studies of patients with ≥10% weight loss, less than 12-month history of AF, and weight loss prior to ablation experience lower recurrence of AF.

Impact of obesity on acute complications of catheter ablation for cardiac arrhythmia

BACKGROUND

The prevalence of obesity is increasing. However, data on the periprocedural complication rate of catheter ablation for arrhythmia in patients stratified by body mass index (BMI) is scarce.

METHODS AND RESULTS

This study included 1000 consecutive patients (age 62.0±14.4 years) undergoing catheter ablation for cardiac arrhythmia. The primary study endpoint was any periprocedural major complication (cardiac tamponade, pseudoaneurysm, arteriovenous fistula, transient ischemic attack, stroke, valve damage, myocardial infarction or death). The mean BMI was 27.6±5.1 kg/m² and the majority of patients were overweight (BMI 25.0-29.9 kg/m² , 43.4%). A BMI of 30.0-34.9 kg/m² (Class I obesity) was present in 177 (17.7%) of patients, a BMI of 35.0-39.9 kg/m² (Class II obesity) in 67 (6.7%) and a BMI ≥40 kg/m² (Class III obesity) in 16 (1.6%). There were 31 major complications (3.1%) and one fatality (0.1%) due to terminal heart failure in a patient undergoing palliative ventricular tachycardia ablation. There was no significant impact of the BMI on the rate of major complications (p= 0.495). Compared to normal weight patients, odds ratios for complications in overweight patients, as well as class I, II and III obesity were 1.1 (95% confidence interval (CI) 0.8; 1.7), 1.3 (CI 0.6; 2.6), 1.4 (CI 0.5; 4.1) and 1.6 (CI 0.4; 6.3), respectively. Radiation exposure and procedure duration were significantly increased in obese patients (p<0.001 and p=0.001 respectively).

CONCLUSION

In this study, obesity did not have a significant impact on the incidence of periprocedural complications after CA for cardiac arrhythmia. This article is protected by copyright. All rights reserved.

The Effect of Obesity, Hypertension, Diabetes Mellitus, Alcohol, and Sleep Apnea on the Risk of Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia associated with a two-fold increase in mortality caused by a higher risk of stroke and heart failure. Currently, AF is present in ~ 2 % of the general population, and its incidence and prevalence are increasing. Obesity, hypertension, diabetes mellitus, obstructive sleep apnea, and alcohol consumption increase the risk of AF. Each unit of increase in BMI increases the risk of AF by 3 %, and intensive weight loss is also associated with reduced AF recurrence. Hypertension increases the risk of AF by 50 % in men and by 40 % in women, and explains ≈ 20 % of new AF cases. Patients with obstructive sleep apnea are at four times higher risk of developing AF than subjects without sleep apnea. Higher concentrations of pro-inflammatory cytokines, higher amounts of epicardial adipose tissue, and a higher degree of ventricular diffuse myocardial fibrosis are present in AF patients and patients with the aforementioned metabolic disorders. Several prospective cohort studies and randomized trials have been initiated to show whether weight loss and treatment of other risk factors will be associated with a reduction in AF recurrences.

Identifying Atrial Fibrillation Mechanisms for Personalized Medicine

Atrial fibrillation (AF) is a major cause of heart failure and stroke. The early maintenance of sinus rhythm has been shown to reduce major cardiovascular endpoints, yet is difficult to achieve. For instance, it is unclear how discoveries at the genetic and cellular level can be used to tailor pharmacotherapy. For non-pharmacologic therapy, pulmonary vein isolation (PVI) remains the cornerstone of rhythm control, yet has suboptimal success. Improving these therapies will likely require a multifaceted approach that personalizes therapy based on mechanisms measured in individuals across biological scales. We review AF mechanisms from cell-to-organ-to-patient from this perspective of personalized medicine, linking them to potential clinical indices and biomarkers, and discuss how these data could influence therapy. We conclude by describing approaches to improve ablation, including the emergence of several mapping systems that are in use today.