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Claessen G, De Bosscher R, Janssens K, Young P, Dausin C, Claeys M, Claus P, Goetschalckx K, Bogaert J, Mitchell AM, Flannery MD, Elliott AD, Yu C, Ghekiere O, Robyns T, Van De Heyning CM, Sanders P, Kalman JM, Ohanian M, Soka M, Rath E, Giannoulatou E, Johnson R, Lacaze P, Herbots L, Willems R, Fatkin D, Heidbuchel H, La Gerche A. Reduced Ejection Fraction in Elite Endurance Athletes: Clinical and Genetic Overlap With Dilated Cardiomyopathy. Circulation 2024; 149:1405-1415. [PMID: 38109351 PMCID: PMC11062611 DOI: 10.1161/circulationaha.122.063777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 10/30/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Exercise-induced cardiac remodeling can be profound, resulting in clinical overlap with dilated cardiomyopathy, yet the significance of reduced ejection fraction (EF) in athletes is unclear. The aim is to assess the prevalence, clinical consequences, and genetic predisposition of reduced EF in athletes. METHODS Young endurance athletes were recruited from elite training programs and underwent comprehensive cardiac phenotyping and genetic testing. Those with reduced EF using cardiac magnetic resonance imaging (defined as left ventricular EF <50%, or right ventricular EF <45%, or both) were compared with athletes with normal EF. A validated polygenic risk score for indexed left ventricular end-systolic volume (LVESVi-PRS), previously associated with dilated cardiomyopathy, was assessed. Clinical events were recorded over a mean of 4.4 years. RESULTS Of the 281 elite endurance athletes (22±8 years, 79.7% male) undergoing comprehensive assessment, 44 of 281 (15.7%) had reduced left ventricular EF (N=12; 4.3%), right ventricular EF (N=14; 5.0%), or both (N=18; 6.4%). Reduced EF was associated with a higher burden of ventricular premature beats (13.6% versus 3.8% with >100 ventricular premature beats/24 h; P=0.008) and lower left ventricular global longitudinal strain (-17%±2% versus -19%±2%; P<0.001). Athletes with reduced EF had a higher mean LVESVi-PRS (0.57±0.13 versus 0.51±0.14; P=0.009) with athletes in the top decile of LVESVi-PRS having an 11-fold increase in the likelihood of reduced EF compared with those in the bottom decile (P=0.034). Male sex and higher LVESVi-PRS were the only significant predictors of reduced EF in a multivariate analysis that included age and fitness. During follow-up, no athletes developed symptomatic heart failure or arrhythmias. Two athletes died, 1 from trauma and 1 from sudden cardiac death, the latter having a reduced right ventricular EF and a LVESVi-PRS >95%. CONCLUSIONS Reduced EF occurs in approximately 1 in 6 elite endurance athletes and is related to genetic predisposition in addition to exercise training. Genetic and imaging markers may help identify endurance athletes in whom scrutiny about long-term clinical outcomes may be appropriate. REGISTRATION URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374976&isReview=true; Unique identifier: ACTRN12618000716268.
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Affiliation(s)
- Guido Claessen
- Faculty of Medicine and Life Sciences, Limburg Clinical Research Center (LCRC), Hasselt University, Biomedical Research Institute, Diepenbeek, Belgium (G.C., O.G., L.H.)
- Hartcentrum Hasselt (G.C., L.H.), KU Leuven, Belgium
- Jessa Ziekenhuis, Belgium. Department of Cardiovascular Sciences (G.C., R.D.B., M.C., P.C., T.R., R.W., A.L.G.), KU Leuven, Belgium
| | - Ruben De Bosscher
- Jessa Ziekenhuis, Belgium. Department of Cardiovascular Sciences (G.C., R.D.B., M.C., P.C., T.R., R.W., A.L.G.), KU Leuven, Belgium
- Department of Cardiovascular Diseases (R.D.B., K.G., T.R., R.W.), University Hospitals Leuven, Belgium
| | - Kristel Janssens
- HEART (Heart Exercise and Research Trials) Lab, St Vincent’s Institute of Medical Research, Fitzroy, Australia (K.J., A.M.M., A.L.G.)
- Exercise and Nutrition Research Program, The Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne Australia (K.J.)
| | - Paul Young
- Victor Chang Cardiac Research Institute, Darlinghurst, Australia (P.Y., M.O., M.S., E.R., E.G., R.J., D.F., A.L.G.)
| | | | - Mathias Claeys
- Jessa Ziekenhuis, Belgium. Department of Cardiovascular Sciences (G.C., R.D.B., M.C., P.C., T.R., R.W., A.L.G.), KU Leuven, Belgium
| | - Piet Claus
- Jessa Ziekenhuis, Belgium. Department of Cardiovascular Sciences (G.C., R.D.B., M.C., P.C., T.R., R.W., A.L.G.), KU Leuven, Belgium
| | - Kaatje Goetschalckx
- Department of Cardiovascular Diseases (R.D.B., K.G., T.R., R.W.), University Hospitals Leuven, Belgium
| | - Jan Bogaert
- Department of Imaging and Pathology (J.B.), KU Leuven, Belgium
- Department of Radiology (J.B.), University Hospitals Leuven, Belgium
| | - Amy M. Mitchell
- HEART (Heart Exercise and Research Trials) Lab, St Vincent’s Institute of Medical Research, Fitzroy, Australia (K.J., A.M.M., A.L.G.)
| | - Michael D. Flannery
- Department of Medicine, University of Melbourne, Parkville, Australia (M.D.F., J.M.K., A.L.G.)
| | - Adrian D. Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Australia (A.D.E., P.S.)
| | - Chenglong Yu
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (C.Y., P.L.)
| | - Olivier Ghekiere
- Faculty of Medicine and Life Sciences, Limburg Clinical Research Center (LCRC), Hasselt University, Biomedical Research Institute, Diepenbeek, Belgium (G.C., O.G., L.H.)
- Department of Radiology (O.G.), KU Leuven, Belgium
| | - Tomas Robyns
- Jessa Ziekenhuis, Belgium. Department of Cardiovascular Sciences (G.C., R.D.B., M.C., P.C., T.R., R.W., A.L.G.), KU Leuven, Belgium
- Department of Cardiovascular Diseases (R.D.B., K.G., T.R., R.W.), University Hospitals Leuven, Belgium
| | - Caroline M. Van De Heyning
- Department of Cardiovascular Sciences, University of Antwerp, Belgium (C.M.V.D.H., H.H.)
- Department of Cardiology, University Hospital Antwerp, Belgium (C.M.V.D.H., H.H.)
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Australia (A.D.E., P.S.)
| | - Jonathan M. Kalman
- Department of Medicine, University of Melbourne, Parkville, Australia (M.D.F., J.M.K., A.L.G.)
- Department of Cardiology, Royal Melbourne Hospital, Australia (J.M.K.)
| | - Monique Ohanian
- Victor Chang Cardiac Research Institute, Darlinghurst, Australia (P.Y., M.O., M.S., E.R., E.G., R.J., D.F., A.L.G.)
| | - Magdalena Soka
- Victor Chang Cardiac Research Institute, Darlinghurst, Australia (P.Y., M.O., M.S., E.R., E.G., R.J., D.F., A.L.G.)
| | - Emma Rath
- Victor Chang Cardiac Research Institute, Darlinghurst, Australia (P.Y., M.O., M.S., E.R., E.G., R.J., D.F., A.L.G.)
| | - Eleni Giannoulatou
- Victor Chang Cardiac Research Institute, Darlinghurst, Australia (P.Y., M.O., M.S., E.R., E.G., R.J., D.F., A.L.G.)
| | - Renee Johnson
- Victor Chang Cardiac Research Institute, Darlinghurst, Australia (P.Y., M.O., M.S., E.R., E.G., R.J., D.F., A.L.G.)
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Kensington, Australia (R.J., D.F.)
| | - Paul Lacaze
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (C.Y., P.L.)
| | - Lieven Herbots
- Faculty of Medicine and Life Sciences, Limburg Clinical Research Center (LCRC), Hasselt University, Biomedical Research Institute, Diepenbeek, Belgium (G.C., O.G., L.H.)
- Hartcentrum Hasselt (G.C., L.H.), KU Leuven, Belgium
| | - Rik Willems
- Jessa Ziekenhuis, Belgium. Department of Cardiovascular Sciences (G.C., R.D.B., M.C., P.C., T.R., R.W., A.L.G.), KU Leuven, Belgium
- Department of Cardiovascular Diseases (R.D.B., K.G., T.R., R.W.), University Hospitals Leuven, Belgium
| | - Diane Fatkin
- Victor Chang Cardiac Research Institute, Darlinghurst, Australia (P.Y., M.O., M.S., E.R., E.G., R.J., D.F., A.L.G.)
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Kensington, Australia (R.J., D.F.)
- Cardiology Department, St Vincent’s Hospital, Darlinghurst, Australia (D.F.)
| | - Hein Heidbuchel
- Department of Cardiovascular Sciences, University of Antwerp, Belgium (C.M.V.D.H., H.H.)
- Department of Cardiology, University Hospital Antwerp, Belgium (C.M.V.D.H., H.H.)
| | - André La Gerche
- Jessa Ziekenhuis, Belgium. Department of Cardiovascular Sciences (G.C., R.D.B., M.C., P.C., T.R., R.W., A.L.G.), KU Leuven, Belgium
- HEART (Heart Exercise and Research Trials) Lab, St Vincent’s Institute of Medical Research, Fitzroy, Australia (K.J., A.M.M., A.L.G.)
- Victor Chang Cardiac Research Institute, Darlinghurst, Australia (P.Y., M.O., M.S., E.R., E.G., R.J., D.F., A.L.G.)
- Department of Medicine, University of Melbourne, Parkville, Australia (M.D.F., J.M.K., A.L.G.)
- Cardiology Department, St Vincent’s Hospital Melbourne, Fitzroy, Australia (A.L.G.)
- National Centre for Sports Cardiology, Fitzroy, Australia (A.L.G.)
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Ariyaratnam JP, Mishima RS, Kadhim K, Emami M, Fitzgerald JL, Thiyagarajah A, Dziano JK, Howie JO, Middeldorp ME, Sanders P, Elliott AD. Utility and Validity of the HFA-PEFF and H 2FPEF Scores in Patients With Symptomatic Atrial Fibrillation. JACC Heart Fail 2024:S2213-1779(24)00146-X. [PMID: 38520461 DOI: 10.1016/j.jchf.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Diagnosis of heart failure with preserved ejection fraction (HFpEF) in patients with atrial fibrillation (AF) represents a significant clinical challenge. Two diagnostic scoring tools have been developed to aid the noninvasive diagnosis of HFpEF: the HFA-PEFF (Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final etiology) and the H2FPEF scoring systems. OBJECTIVES The purpose of this study was to evaluate the performance of these 2 scoring tools for the diagnosis of HFpEF against a gold standard of invasive evaluation in a cohort of patients with AF. METHODS The authors recruited consecutive patients with symptomatic AF and preserved ejection fraction who were scheduled for an AF ablation procedure. Gold-standard invasive diagnosis of HFpEF was performed at the AF ablation procedure using mean left atrial pressure at rest and following infusion of 500 mL fluid. Each participant was scored according to the noninvasive HFA-PEFF and H2FPEF scoring systems. Sensitivity and specificity analyses were performed to assess the accuracy of these scoring systems in diagnosing HFpEF. RESULTS In total, 120 participants were recruited. HFpEF was diagnosed invasively in 88 (73.3%) participants, whereas 32 (26.7%) had no HFpEF. Using the HFA-PEFF score, 38 (31.7%) participants had a high probability of HFpEF and 82 (68.3%) had low/intermediate probability of HFpEF. Using the H2FPEF tool, 72 (60%) participants had a high probability of HFpEF and 48 (40%) had intermediate probability. A high HFA-PEFF (≥5 points) score could diagnose HFpEF with a sensitivity of 40% and a specificity of 91%, and a high H2FPEF score (≥6 points) could diagnose HFpEF with a sensitivity of 69% and specificity of 66%. Overall diagnostic accuracy was similar using both tools (AUC: 0.663 vs 0.707, respectively; P = 0.636). CONCLUSIONS Against a gold standard of invasively diagnosed HFpEF, the HFA-PEFF and H2FPEF scores demonstrate only moderate accuracy in patients with AF and should be utilized with caution in this cohort of patients. (Characterising Left Atrial Function and Compliance in Atrial Fibrillation; ACTRN12620000639921).
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Affiliation(s)
- Jonathan P Ariyaratnam
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ricardo S Mishima
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Kadhim Kadhim
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mehrdad Emami
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - John L Fitzgerald
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Anand Thiyagarajah
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jenelle K Dziano
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jackson O Howie
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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Ariyaratnam JP, Mishima RS, McNamee O, Emami M, Thiyagarajah A, Fitzgerald JL, Gallagher C, Sanders P, Elliott AD. Exercise echocardiography to assess left atrial function in patients with symptomatic AF. Int J Cardiol Heart Vasc 2024; 50:101324. [PMID: 38204984 PMCID: PMC10776650 DOI: 10.1016/j.ijcha.2023.101324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/30/2023] [Accepted: 12/10/2023] [Indexed: 01/12/2024]
Abstract
Background Left atrial (LA) function contributes to the augmentation of cardiac output during exercise. However, LA response to exercise in patients with atrial fibrillation (AF) is unknown. We explored the LA mechanical response to exercise and the association between LA dysfunction and exercise intolerance. Methods We recruited consecutive patients with symptomatic AF and preserved left ventricular ejection fraction (LVEF). Participants underwent exercise echocardiography and cardiopulmonary exercise testing (CPET). Two-dimensional and speckle-tracking echocardiography were performed to assess LA function at rest and during exercise. Participants were grouped according to presenting rhythm (AF vs sinus rhythm). The relationship between LA function and cardiorespiratory fitness in patients maintaining SR was assessed using linear regression. Results Of 177 consecutive symptomatic AF patients awaiting AF ablation, 105 met inclusion criteria; 31 (29.5 %) presented in AF whilst 74 (70.5 %) presented in SR. Patients in SR augmented LA function from rest to exercise, increasing LA emptying fraction (LAEF) and LA reservoir strain. In contrast, patients in AF demonstrated reduced LAEF and reservoir strain at rest, with failure to augment either parameter during exercise. This was associated with reduced VO2Peak compared to those in SR (18.4 ± 5.6 vs 22.5 ± 7.7 ml/kg/min, p = 0.003). In patients maintaining SR, LAEF and reservoir strain at rest and during exercise were associated with VO2Peak, independent of LV function. Conclusion The maintenance of SR in patients with AF is associated with greater LA reservoir function at rest and greater augmentation with exercise compared to patients in AF. In patients in SR, reduced LA function is associated with reduced exercise tolerance, independent of LV function.
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Affiliation(s)
- Jonathan P. Ariyaratnam
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health & Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Ricardo S. Mishima
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health & Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Olivia McNamee
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health & Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Mehrdad Emami
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health & Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Anand Thiyagarajah
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health & Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - John L. Fitzgerald
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health & Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health & Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Adrian D. Elliott
- Corresponding authors at: Centre for Heart Rhythm Disorders, Department of Cardiology, Royal Adelaide Hospital, 1 Port Road, Adelaide, SA 5000, Australia.
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Ariyaratnam JP, Elliott AD, Sanders P. Reply: Subclinical Heart Failure With Preserved Ejection Fraction in Patients With Atrial Fibrillation. JACC Heart Fail 2024; 12:423. [PMID: 38326006 DOI: 10.1016/j.jchf.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/28/2023] [Indexed: 02/09/2024]
Affiliation(s)
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia.
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Verdicchio CV, Mahajan R, Middeldorp ME, Gallagher C, Mishima RS, Lau DH, Sanders P, Elliott AD. Influence of sex on efficacy of exercise training for patients with symptomatic atrial fibrillation: insights from the ACTIVE-AF randomized controlled trial. Eur J Prev Cardiol 2023; 30:2006-2014. [PMID: 37486229 DOI: 10.1093/eurjpc/zwad242] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 07/25/2023]
Abstract
AIMS Exercise training reduces recurrence of arrhythmia and symptom severity amongst patients with symptomatic, non-permanent atrial fibrillation (AF). However, there is little evidence on whether this effect is modified by patient sex. In a sub-analysis from the ACTIVE-AF (A Lifestyle-based, PhysiCal AcTIVity IntErvention for Patients With Symptomatic Atrial Fibrillation) randomized controlled trial, we compared the effects of exercise training on AF recurrence and symptom severity between men and women. METHODS AND RESULTS The ACTIVE-AF study randomized 120 patients (69 men, 51 women) with paroxysmal or persistent AF to receive an exercise intervention combining supervised and home-based aerobic exercise over 6 months or to continue standard medical care. Patients were followed over a 12-month period. The co-primary outcomes were recurrence of AF, off anti-arrhythmic medications and without catheter ablation, and AF symptom severity scores. By 12 months, recurrence of AF was observed in 50 (73%) men and 34 (67%) women. In an intention-to-treat analysis, there was a between-group difference in favour of the exercise group for both men [hazard ratio (HR) 0.52, 95% confidence interval (CI): 0.29-0.91, P = 0.022] and women (HR 0.47, 95% CI: 0.23-0.95, P = 0.035). At 12 months, symptom severity scores were lower in the exercise group compared with controls amongst women but not for men. CONCLUSION An exercise-based intervention reduced arrhythmia recurrence for both men and women with symptomatic AF. Symptom severity was reduced with exercise in women at 12 months. No difference was observed in symptom severity for men. REGISTRATION Australia and New Zealand Clinical Trials Registry: ACTRN12615000734561.
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Affiliation(s)
- Christian V Verdicchio
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, North Terrace, Adelaide 5000, South Australia, Australia
- Faculty of Medicine & Health, University of Sydney, Sydney, Australia
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, North Terrace, Adelaide 5000, South Australia, Australia
- Department of Cardiology, Lyell McEwin Health Service, Adelaide, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, North Terrace, Adelaide 5000, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide 5000, South Australia, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, North Terrace, Adelaide 5000, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide 5000, South Australia, Australia
| | - Ricardo S Mishima
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, North Terrace, Adelaide 5000, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide 5000, South Australia, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, North Terrace, Adelaide 5000, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide 5000, South Australia, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, North Terrace, Adelaide 5000, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide 5000, South Australia, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, North Terrace, Adelaide 5000, South Australia, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide 5000, South Australia, Australia
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Affiliation(s)
- Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health & Medical Research Institute and Royal Adelaide Hospital, 5000, Adelaide, Australia
| | - Emelia J Benjamin
- Cardiovascular Medicine Sections, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health & Medical Research Institute and Royal Adelaide Hospital, 5000, Adelaide, Australia
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Ariyaratnam JP, Elliott AD, Mishima RS, Kadhim K, McNamee O, Kuklik P, Emami M, Malik V, Fitzgerald JL, Gallagher C, Lau DH, Sanders P. Identification of Subclinical Heart Failure With Preserved Ejection Fraction in Patients With Symptomatic Atrial Fibrillation. JACC Heart Fail 2023; 11:1626-1638. [PMID: 37676212 DOI: 10.1016/j.jchf.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) commonly coexist. We hypothesize that patients with symptomatic AF but without overt clinical HF commonly exhibit subclinical HFpEF according to established hemodynamic criteria. OBJECTIVES The authors sought to use invasive hemodynamics to investigate the prevalence and implications of subclinical HFpEF in AF ablation patients. METHODS Consecutive symptomatic AF ablation patients were prospectively recruited. Diagnosis of subclinical HFpEF was undertaken by invasive assessment of left atrial pressure (LAP). Participants had HFpEF if the baseline mean LAP was >15 mm Hg and early HFpEF if the mean LAP was >15 mm Hg after a 500-mL fluid challenge. LA compliance was assessed invasively by monitoring the LAP and LA diameter during direct LA infusion of 15 mL/kg normal saline. LA compliance was calculated as Δ LA diameter/ΔLAP. LA cardiomyopathy was further studied with exercise echocardiography and electrophysiology study. Functional impact was evaluated using cardiopulmonary exercise testing and the AF Symptom Severity questionnaire. RESULTS Of 120 participants, 57 (47.5%) had HFpEF, 31 (25.8%) had early HFpEF, and 32 (26.7%) had no HFpEF. Both HFpEF and early HFpEF were associated with lower LA compliance compared with those without HFpEF (P < 0.001). Participants with HFpEF and early HFpEF also displayed decreased LA emptying fraction (P = 0.004), decreased LA voltage (P = 0.001), decreased VO2peak (P < 0.001), and increased AF symptom burden (P = 0.002) compared with those without HFpEF. CONCLUSIONS Subclinical HFpEF is common in AF ablation patients and is characterized by a LA cardiomyopathy, decreased cardiopulmonary reserve and increased symptom burden. The diagnosis of HFpEF may identify patients with AF with the potential to benefit from novel HFpEF therapies. (Characterising Left Atrial Function and Compliance in Atrial Fibrillation; ACTRN12620000639921).
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Affiliation(s)
- Jonathan P Ariyaratnam
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Ricardo S Mishima
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Kadhim Kadhim
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Olivia McNamee
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Pawel Kuklik
- Department of Cardiology, Asklepios Hospital St. Georg, Hamburg, Germany, Faculty of Medicine, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Mehrdad Emami
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Varun Malik
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - John L Fitzgerald
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia.
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Elliott AD, Lau D. The Race to Improve Care for Athletes with Atrial Fibrillation. Heart Lung Circ 2023; 32:1274-1276. [PMID: 38052502 DOI: 10.1016/j.hlc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Affiliation(s)
- Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, SA, Australia; South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dennis Lau
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Royal Adelaide Hospital, Adelaide, SA, Australia; Australian Dysautonomia and Arrhythmia Research Collaborative, The University of Adelaide, SA, Australia.
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Tu SJ, Gallagher C, Elliott AD, Bradbury KE, Marcus GM, Linz D, Pitman BM, Middeldorp ME, Hendriks JM, Lau DH, Sanders P, Wong CX. Associations of dietary patterns, ultra-processed food and nutrient intake with incident atrial fibrillation. Heart 2023; 109:1683-1689. [PMID: 37460193 DOI: 10.1136/heartjnl-2023-322412] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/08/2023] [Indexed: 10/28/2023] Open
Abstract
OBJECTIVE To examine the associations between specific dietary patterns and incident atrial fibrillation (AF). METHODS Using data from the UK Biobank, dietary intakes were calculated from 24-hour diet recall questionnaires. Indices representing adherence to dietary patterns (Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH) and plant-based diets) were scored, and ultra-processed food consumption was studied as a percentage of total food mass consumed. Incident AF hospitalisations were assessed in Cox regression models. RESULTS A total of 121 300 individuals were included, with 4 579 incident AF cases over a median follow-up of 8.8 years. Adherence to Mediterranean-style or DASH diets was associated with a lower incidence of AF in minimally adjusted analyses (HR for highest vs lowest quintile 0.87 (95% CI 0.80-0.96) and HR 0.78 (95% CI 0.71-0.86), respectively). However, associations were no longer significant after accounting for lifestyle factors (HR 0.95 (95% CI 0.87-1.04) and 0.94 (95% CI 0.86-1.04) respectively), with adjustment for body mass index responsible for approximately three-quarters of the effect size attenuation. Plant-based diets were not associated with AF risk in any models. Greatest ultra-processed food consumption was associated with a significant increase in AF risk even in fully adjusted models (HR 1.13 (95% CI 1.02-1.24)), and a 10% increase in absolute intake of ultra-processed food was associated with a 5% increase in AF risk (HR 1.05 (95% CI 1.01-1.08)). CONCLUSION With the possible exception of reducing ultra-processed food consumption, these findings suggest that attention to other modifiable risk factors, particularly obesity, may be more important than specific dietary patterns for the primary prevention of AF.
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Affiliation(s)
- Samuel J Tu
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Kathryn E Bradbury
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Gregory M Marcus
- Department of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco, San Francisco, California, USA
| | - Dominik Linz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, Netherlands
| | - Bradley M Pitman
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jeroen M Hendriks
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Christopher X Wong
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Department of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco, San Francisco, California, USA
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Elliott AD, Ariyaratnam J, Howden EJ, La Gerche A, Sanders P. Influence of exercise training on the left atrium: implications for atrial fibrillation, heart failure, and stroke. Am J Physiol Heart Circ Physiol 2023; 325:H822-H836. [PMID: 37505470 DOI: 10.1152/ajpheart.00322.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/24/2023] [Accepted: 07/24/2023] [Indexed: 07/29/2023]
Abstract
The left atrium (LA) plays a critical role in receiving pulmonary venous return and modulating left ventricular (LV) filling. With the onset of exercise, LA function contributes to the augmentation in stroke volume. Due to the growing focus on atrial imaging, there is now evidence that structural remodeling and dysfunction of the LA is associated with adverse outcomes including incident cardiovascular disease. In patients with established disease, pathological changes in atrial structure and function are associated with exercise intolerance, increased hospital admissions and mortality, independent of left ventricular function. Exercise training is widely recommended in patients with cardiovascular disease to improve patient outcomes and maintain functional capacity. There are widely documented changes in LV function with exercise, yet less attention has been given to the LA. In this review, we first describe LA physiology at rest and during exercise, before exploring its association with cardiac disease outcomes including atrial fibrillation, heart failure, and stroke. The adaptation of the LA to short- and longer-term exercise training is evaluated through review of longitudinal studies of exercise training in healthy participants free of cardiovascular disease and athletes. We then consider the changes in LA structure and function among patients with established disease, where adverse atrial remodeling may be implicated in the disease process. Finally, we consider important future directions for assessment of atrial structure and function using novel imaging modalities, in response to acute and chronic exercise.
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Affiliation(s)
- Adrian D Elliott
- Center for Heart Rhythm Disorders, University of Adelaide, South Australian Health and Medical Research Institute and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jonathan Ariyaratnam
- Center for Heart Rhythm Disorders, University of Adelaide, South Australian Health and Medical Research Institute and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Erin J Howden
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Andre La Gerche
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Prashanthan Sanders
- Center for Heart Rhythm Disorders, University of Adelaide, South Australian Health and Medical Research Institute and Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Noubiap JJ, Tu SJ, Emami M, Middeldorp ME, Elliott AD, Sanders P. Incident atrial fibrillation in relation to ventilatory parameters: a prospective cohort study. Can J Cardiol 2023; 39:614-622. [PMID: 36773703 DOI: 10.1016/j.cjca.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND There is a paucity of data on the association between respiratory function and atrial fibrillation (AF). This study aimed to assess the relationship between forced expiratory volume (FEV1), forced vital capacity (FVC), and FEV1/FVC and incident AF. METHODS We performed an analysis of prospectively collected data from the UK Biobank. We included all participants with available spirometry and excluded those with a prior AF. Incident AF was ascertained through hospitalization and death records, and dose-response associations were assessed using multivariable Cox regression analysis with adjustment for known AF risk factors. RESULTS We studied 348,219 white individuals (54.1% female) with a median age of 58.1 (IQR 50.8-63.5) years. Over a median follow-up time of 11.5 years (IQR: 11.0-12.6 years), a total of 18,188 incident AF events occurred. After standardization to sex, age, and height, the risk of AF consistently increased with decreasing FEV1 percentage predicted, FEV1 z-score, and FVC z-score. The risk of AF linearly increased with decreasing FEV1/FVC ratio, and those that had airway obstruction as defined by an FEV1/FVC ratio < 0.70 had a 23% greater risk of incident AF (aHR 1.23, 95% CI 1.19-1.28) compared to those without airway obstruction. Patients with known chronic obstructive pulmonary disease and asthma were at 40% (aHR 1.40, 95% CI 1.29-1.51) and 17% (aHR 1.17, 95% CI 1.12-1.22) increased risk of incident AF. CONCLUSION These findings indicate that reduced ventilatory function is associated with increased risk of AF independently of age, sex, smoking, and other known AF risk factors.
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Affiliation(s)
| | - Samuel J Tu
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | - Mehrdad Emami
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia.
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12
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Elliott AD, Middeldorp ME, Van Gelder IC, Albert CM, Sanders P. Author Correction: Epidemiology and modifiable risk factors for atrial fibrillation. Nat Rev Cardiol 2023; 20:429. [PMID: 36650290 DOI: 10.1038/s41569-023-00834-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia.,Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia.,Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center (CMA), Los Angeles, CA, USA
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Christine M Albert
- Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center (CMA), Los Angeles, CA, USA
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia. .,Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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13
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Affiliation(s)
- Jeroen M Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia .,Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
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14
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Elliott AD, Verdicchio CV, Mahajan R, Middeldorp ME, Gallagher C, Mishima RS, Hendriks JML, Pathak RK, Thomas G, Lau DH, Sanders P. An Exercise and Physical Activity Program in Patients With Atrial Fibrillation: The ACTIVE-AF Randomized Controlled Trial. JACC Clin Electrophysiol 2022; 9:455-465. [PMID: 36752479 DOI: 10.1016/j.jacep.2022.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 11/22/2022] [Accepted: 12/05/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND There are limited data on the effect of exercise interventions on atrial fibrillation (AF) recurrence and symptoms. OBJECTIVES The aim of this study was to determine the efficacy of an exercise and physical activity intervention on AF burden and symptoms among patients with symptomatic AF. METHODS This prospective, randomized controlled trial included 120 patients with paroxysmal or persistent, symptomatic AF, randomized 1:1 to receive an exercise intervention, combining home and supervised aerobic exercise over 6 months, or to receive usual care. The coprimary outcomes were: 1) AF recurrence, off antiarrhythmic medications and without catheter ablation; and 2) symptom severity assessed by using a validated questionnaire. RESULTS By 12 months, freedom from AF was achieved in 24 (40%) of 60 patients in the exercise group and 12 (20%) of 60 patients in the control group (HR: 0.50: 95% CI: 0.33 to 0.78). At 6 months, AF symptom severity was lower in the exercise group compared with the control group (mean difference -2.3; 95% CI: -4.3 to -0.2; P = 0.033). This difference persisted at 12 months (-2.3; 95% CI: -4.5 to -0.1; P = 0.041). Total symptom burden was lower at 6 months in the exercise group but not at 12 months. Peak oxygen consumption was increased in the exercise group at both 6 and 12 months. There were no between-group differences in cardiac structure or function, body mass index, or blood pressure. CONCLUSIONS Participation in an exercise-based intervention over 6 months reduced arrhythmia recurrence and improved symptom severity among patients with AF. (A Lifestyle-based, PhysiCal AcTIVity IntErvention for Patients With Symptomatic Atrial Fibrillation [the ACTIVE-AF Study]; ACTRN12615000734561).
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Affiliation(s)
- Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia. https://twitter.com/Elliott_AD
| | - Christian V Verdicchio
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, Adelaide, Australia
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, Adelaide, Australia; Department of Cardiology, Lyell McEwin Health Service, Adelaide, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Ricardo S Mishima
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Jeroen M L Hendriks
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia; Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Rajeev K Pathak
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, Adelaide, Australia; Canberra Heart Rhythm, Canberra Hospital, Canberra, Australia
| | - Gijo Thomas
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, Adelaide, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and South Australian Health & Medical Research Institute, Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia.
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Mishima RS, Ariyaratnam JP, Pitman BM, Malik V, Emami M, McNamee O, Stokes MB, Lau DH, Sanders P, Elliott AD. Cardiorespiratory fitness, obesity and left atrial function in patients with atrial fibrillation. IJC Heart & Vasculature 2022; 42:101083. [PMID: 35971520 PMCID: PMC9375161 DOI: 10.1016/j.ijcha.2022.101083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/26/2022] [Accepted: 07/05/2022] [Indexed: 11/18/2022]
Abstract
Background Low cardiorespiratory fitness (CRF) and obesity are related to the development and maintenance of atrial fibrillation (AF). The aim of this study was to determine the association between CRF, obesity and left atrial (LA) mechanical parameters in patients with AF. Methods A cohort of 154 consecutive paroxysmal and persistent AF patients (Age: 62 ± 10, 26% female) referred for exercise stress testing and transthoracic echocardiography were included. We included patients in sinus rhythm with preserved left ventricular ejection fraction who were able to complete a maximal exercise test. Left atrial strain in the reservoir (LASr), booster (LASb) and conduit (LASc) phases were assessed using dedicated software. LA stiffness, emptying fraction (LAEF) and LA to LV ratio were calculated using previously described formulas. Results CRF was positively associated with LAEF (β = 1.3, 95% CI 0.1–2.3, p = 0.02), reservoir (β = 1.5, 95% CI 0.9–2.1, p < 0.001), booster (β = 0.8, 95% CI 0.4–1.2, p < 0.001) and conduit strain (β = 0.7, 95% CI 0.3–1.1, p = 0.001). We observed an inverse association between CRF and both LA stiffness index (β = −0.02, 95% CI (−0.03)–(−0.01), p < 0.001) and LA to LV ratio (β = −0.03, 95% CI (−0.04)–(−0.01), p < 0.001). Obese patients had significantly higher indexed LA volumes compared to overweight and normal BMI patients. The association between obesity and measures of LA function and stiffness did not reach statistical significance. Conclusion Among AF patients, higher CRF was independently associated with greater LA function and compliance. Obesity was associated with higher LA volumes yet preserved mechanical function.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Adrian D. Elliott
- Corresponding author at: Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide 5000, Australia.
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Ariyaratnam JP, Sanders P, Elliott AD. Atrial fibrillation ablation in patients with heart failure with preserved ejection fraction: Complexities in diagnosis and treatment. Heart Rhythm O2 2022; 3:509-510. [PMID: 36340498 PMCID: PMC9626876 DOI: 10.1016/j.hroo.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
| | | | - Adrian D. Elliott
- Address reprint requests and correspondence: Dr Adrian D. Elliott, PhD, Centre for Heart Rhythm Disorders, Department of Cardiology, Royal Adelaide Hospital, Adelaide, 5000, Australia.
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Hanna-Rivero N, Tu SJ, Elliott AD, Pitman BM, Gallagher C, Lau DH, Sanders P, Wong CX. Anemia and iron deficiency in patients with atrial fibrillation. BMC Cardiovasc Disord 2022; 22:204. [PMID: 35508964 PMCID: PMC9066804 DOI: 10.1186/s12872-022-02633-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/13/2022] [Indexed: 12/11/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac tachyarrhythmia and has a rising global prevalence. Given the increasing burden of AF-related symptoms and complications, new approaches to management are required. Anemia and iron deficiency are common conditions in patients with AF. Furthermore, emerging evidence suggests that the presence of anemia may be associated with worse outcome in these patients. The role of anemia and iron deficiency has been extensively explored in other cardiovascular states, such as heart failure and ischemic heart disease. In particular, the role of iron repletion amongst patients with heart failure is now an established treatment modality. However, despite the strong bidirectional inter-relationship between AF and heart failure, the implications of anemia and iron-deficiency in AF have been scarcely studied. This area is of mechanistic and clinical relevance given the potential that treatment of these conditions may improve symptoms and prognosis in the increasing number of individuals with AF. In this review, we summarise the current published literature on anemia and iron deficiency in patients with AF. We discuss AF complications such as stroke, bleeding, and heart failure, in addition to AF-related symptoms such as exercise intolerance, and the potential impact of anemia and iron deficiency on these. Finally, we summarize current research gaps on anemia, iron deficiency, and AF, and underscore potential research directions.
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Affiliation(s)
- Nicole Hanna-Rivero
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Samuel J Tu
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Bradley M Pitman
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia
| | - Christopher X Wong
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia.
- Department of Cardiology, Royal Adelaide Hospital, Port Road, Adelaide, 5000, Australia.
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Ariyaratnam JP, Mishima RS, Emami M, Malik V, Fitzgerald JL, Lau DH, Gallagher C, Elliott AD, Sanders P. PO-669-08 LEFT ATRIAL CARDIOMYOPATHY UNDERPINS THE RELATIONSHIP BETWEEN ATRIAL FIBRILLATION AND HEART FAILURE WITH PRESERVED EJECTION FRACTION. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Tu SJ, Gallagher C, Elliott AD, Pitman BM, Hendriks JML, Lau DH, Sanders P, Wong CX. PO-670-02 DIETARY MACRONUTRIENT INTAKE AND INCIDENT ATRIAL FIBRILLATION: AN OBSERVATIONAL STUDY OF 123,151 INDIVIDUALS. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ariyaratnam JP, Mishima RS, Emami M, O'Shea C, Gallagher C, Sanders P, Elliott AD. PO-670-08 LEFT ATRIAL FUNCTION AND CHRONOTROPIC INCOMPETENCE MORE INFLUENTIAL THAN CARDIAC RHYTHM IN PREDICTING CARDIORESPIRATORY FITNESS IN PATIENTS WITH ATRIAL FIBRILLATION. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Tu SJ, Gallagher C, Elliott AD, Pitman BM, Hendriks JML, Lau DH, Sanders P, Wong CX. PO-683-04 ADHERENCE TO SPECIFIC DIETARY PATTERNS AND RISK OF ATRIAL FIBRILLATION: DATA FROM THE UK BIOBANK. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Seeley MC, Gallagher C, Elliott AD, McCaffrey N, Lau DH. PO-659-04 LOW HEALTH RELATED QUALITY OF LIFE AND HIGH DISABILITY IN POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME: A COMPARATIVE STUDY WITH NORMATIVE POPULATION. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Malik V, Nguyen MT, Seeley MC, Thiyagarajah A, Elliott AD, Arnolda LF, Sanders P, Lau DH. Abnormal Cardiac Remodeling in Postural Orthostatic Tachycardia Syndrome. JACC Clin Electrophysiol 2022; 8:1044-1046. [DOI: 10.1016/j.jacep.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
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Tu SJ, Gallagher C, Elliott AD, Linz D, Pitman BM, Hendriks JML, Lau DH, Sanders P, Wong CX. Alcohol intake and bradyarrhythmia risk: a cohort study of 407 948 individuals. Europace 2022; 24:1469-1474. [PMID: 35178566 PMCID: PMC9559907 DOI: 10.1093/europace/euac007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS There is a paucity of epidemiological evidence on alcohol and the risk of bradyarrhythmias. We thus characterized associations of total and beverage-specific alcohol consumption with incident bradyarrhythmias using data from the UK Biobank. METHODS AND RESULTS Alcohol consumption reported at baseline was calculated as UK standard drinks (8 g alcohol)/week. Bradyarrhythmia events were defined as sinus node dysfunction (SND), high-level atrioventricular block (AVB), and permanent pacemaker implantations. Outcomes were assessed through hospitalization and death records, and dose-response associations were characterized using Cox regression models with correction for regression dilution bias. We studied 407 948 middle-aged individuals (52.4% female). Over a median follow-up time of 11.5 years, a total of 8 344 incident bradyarrhythmia events occurred. Increasing total alcohol consumption was not associated with an increased risk of bradyarrhythmias. Beer and cider intake were associated with increased bradyarrhythmia risk up to 12 drinks/week; however, no significant associations were observed with red wine, white wine, or spirit intake. When bradyarrhythmia outcomes were analysed separately, a negative curvilinear was observed for total alcohol consumption and risk of SND, but no clear association with AVB was observed. CONCLUSION In this predominantly White British cohort, increasing total alcohol consumption was not associated with an increased risk of bradyarrhythmias. Associations appeared to vary according to the type of alcoholic beverage and between different types of bradyarrhythmias. Further epidemiological and experimental studies are required to clarify these findings.
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Affiliation(s)
- Samuel J Tu
- Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Dominik Linz
- Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Bradley M Pitman
- Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Jeroen M L Hendriks
- Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, Adelaide SA 5000, Australia.,Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Christopher X Wong
- Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, Adelaide SA 5000, Australia
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Malik V, Elliott AD, Thomas G, Mishima RS, Pitman B, Middeldorp ME, Fitzgerald JL, Young GD, Roberts-Thomson KC, Arnolda LF, Lau DH, Sanders P. Autonomic Afferent Dysregulation in Atrial Fibrillation. JACC Clin Electrophysiol 2022; 8:152-164. [PMID: 35210071 DOI: 10.1016/j.jacep.2021.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/21/2021] [Accepted: 10/24/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES This study sought to evaluate the role of cardiac afferent reflexes in atrial fibrillation (AF). BACKGROUND Efferent autonomic tone is not associated with atrial remodeling and AF persistence. However, the role of cardiac afferents is unknown. METHODS Individuals with nonpermanent AF (n = 48) were prospectively studied (23 in the in-AF group and 25 in sinus rhythm [SR]) with 12 matched control subjects. We performed: 1) low-level lower body negative pressure (LBNP), which decreases cardiac volume, offloading predominantly cardiac afferent (volume-sensitive) low-pressure baroreceptors; 2) Valsalva reflex (predominantly arterial high-pressure baroreceptors); and 3) isometric handgrip reflex (both baroreceptors). We measured beat-to-beat mean arterial pressure (MAP) and heart rate (HR). LBNP elicits reflex vasoconstriction, estimated using venous occlusion plethysmography-derived forearm blood flow (∝1/vascular resistance), maintaining MAP. To assess reversibility, we repeated LBNP (same day) after 1-hour low-level tragus stimulation (in n = 5 in the in-AF group and n = 10 in the in-SR group) and >6 weeks post-cardioversion (n = 7). RESULTS The 3 groups were well matched for age (59 ± 12 years, 83% male), body mass index, and risk factors (P = NS). The in-AF group had higher left atrial volume (P < 0.001) and resting HR (P = 0.01) but similar MAP (P = 0.7). The normal LBNP vasoconstriction (-49 ± 5%) maintaining MAP (control subjects) was attenuated in the in-SR group (-12 ± 9%; P = 0.005) and dysfunctional in the in-AF group (+11 ± 6%; P < 0.001), in which MAP decreased and HR was unchanged. Valsalva was normal throughout. Handgrip MAP response was lowest in the in-AF group (P = 0.01). Interestingly, low-level tragus stimulation and cardioversion improved LBNP vasoconstriction (-48 ± 15%; P = 0.04; and -32 ± 9%; P = 0.02, respectively). CONCLUSIONS Cardiac afferent (volume-sensitive) reflexes are abnormal in AF patients during SR and dysfunctional during AF. This could contribute to AF progression, thus explaining "AF begets AF." (Characterisation of Autonomic function in Atrial Fibrillation [AF-AF Study]; ACTRN12619000186156).
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Affiliation(s)
- Varun Malik
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Gijo Thomas
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Ricardo S Mishima
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Bradley Pitman
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - John L Fitzgerald
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Glenn D Young
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Kurt C Roberts-Thomson
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Leonard F Arnolda
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia.
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Koh YH, Lew LZW, Franke KB, Elliott AD, Lau DH, Thiyagarajah A, Linz D, Arstall M, Tully PJ, Baune BT, Munawar DA, Mahajan R. Predictive role of atrial fibrillation in cognitive decline: a systematic review and meta-analysis of 2.8 million individuals. Europace 2022; 24:1229-1239. [PMID: 35061884 PMCID: PMC9435641 DOI: 10.1093/europace/euac003] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/04/2022] [Indexed: 12/31/2022] Open
Abstract
Aims To systematic review and meta-analyse the association and mechanistic links between atrial fibrillation (AF) and cognitive impairment. Methods and results PubMed, EMBASE, and Cochrane Library were searched up to 27 March 2021 and yielded 4534 citations. After exclusions, 61 were analysed; 15 and 6 studies reported on the association of AF and cognitive impairment in the general population and post-stroke cohorts, respectively. Thirty-six studies reported on the neuro-pathological changes in patients with AF; of those, 13 reported on silent cerebral infarction (SCI) and 11 reported on cerebral microbleeds (CMB). Atrial fibrillation was associated with 39% increased risk of cognitive impairment in the general population [n = 15: 2 822 974 patients; hazard ratio = 1.39; 95% confidence interval (CI) 1.25–1.53, I2 = 90.3%; follow-up 3.8–25 years]. In the post-stroke cohort, AF was associated with a 2.70-fold increased risk of cognitive impairment [adjusted odds ratio (OR) 2.70; 95% CI 1.66–3.74, I2 = 0.0%; follow-up 0.25–3.78 years]. Atrial fibrillation was associated with cerebral small vessel disease, such as white matter hyperintensities and CMB (n = 8: 3698 patients; OR = 1.38; 95% CI 1.11–1.73, I2 = 0.0%), SCI (n = 13: 6188 patients; OR = 2.11; 95% CI 1.58–2.64, I2 = 0%), and decreased cerebral perfusion and cerebral volume even in the absence of clinical stroke. Conclusion Atrial fibrillation is associated with increased risk of cognitive impairment. The association with cerebral small vessel disease and cerebral atrophy secondary to cardioembolism and cerebral hypoperfusion may suggest a plausible link in the absence of clinical stroke. PROSPERO CRD42018109185.
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Affiliation(s)
- Yu Han Koh
- The University of Adelaide, Adelaide, Australia
| | | | | | | | - Dennis H Lau
- The University of Adelaide, Adelaide, Australia
- Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Margaret Arstall
- The University of Adelaide, Adelaide, Australia
- Lyell McEwin Hospital, Adelaide, Australia
| | | | - Bernhard T Baune
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Victoria, Australia
- Department of Psychiatry, University of Münster, Münster, Germany
| | - Dian A Munawar
- The University of Adelaide, Adelaide, Australia
- Royal Adelaide Hospital, Adelaide, Australia
- Department of Cardiology and Vascular Medicine, University of Indonesia, Jakarta, Indonesia
| | - Rajiv Mahajan
- The University of Adelaide, Adelaide, Australia
- Lyell McEwin Hospital, Adelaide, Australia
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Nath LC, Forbes G, Elliott AD, Tomren V, Ryan A, Franklin SH. Application of an electrocardiography device (iECG) for heart rhythm analysis after exercise in Thoroughbred horses. Aust Vet J 2021; 100:114-120. [PMID: 34859419 DOI: 10.1111/avj.13137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 10/08/2021] [Accepted: 11/14/2021] [Indexed: 12/01/2022]
Abstract
AliveCor is a smartphone electrocardiography device (iECG) providing automated heart rate (HR) and rhythm determination. Atrial fibrillation (AF) in horses often is paroxysmal and rapid ECG acquisition is needed for diagnostic confirmation. iECGs were collected post-race from 15 horses with AF and 64 horses in sinus rhythm (SR). Results of manual assessment were compared to 3 commercial algorithms for HR and rhythm. Agreement between manually derived HR (HRM ) and HR derived by the AliveECG Vet (HRVET ) and Kardia version-1 (KV1 HR) and Kardia advanced (KADV HR) algorithms was quantified by the Bland-Altman limits of agreement test. Agreement between manual rhythm classification and KV1 and KADV algorithms for AF and SR was calculated by the Kappa statistical coefficient. The agreement (bias, 95% limits), between HRM and HRVET was 7.1 BPM (-29 to 43) in AF and -4.2 BPM (-38 to 30) in SR, between HRM and KV1 HR, was -0.3 BPM (-31 to 30) in AF and 0.2 BPM (-3 to 4) in SR, and between HRM and KADV HR was 7.0 BPM (-29 to 43) in AF and 0.2 BPM (-3.9 to 4.2) in SR. Agreement between manual rhythm classification and KV1 was 0.36 (0.13-0.59), and KADV was 0.84 (0.68-0.99). Sensitivity and specificity for identification of AF and SR of the KV1 algorithm were 60, 100% and 83, 100%, respectively, and of KADV was 87, 100% and 93, 100% respectively. The Kardia algorithms improved precision for HR determination in SR but not AF. The advanced algorithm accurately distinguished between AF and SR. The iECG is suitable for recording episodes of AF following exercise.
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Affiliation(s)
- L C Nath
- University of Adelaide, Roseworthy, South Australia, Australia
| | - G Forbes
- Racing Victoria, Flemington, Victoria, Australia
| | - A D Elliott
- University of Adelaide, Adelaide, South Australia, Australia
| | - V Tomren
- Racing Victoria, Flemington, Victoria, Australia
| | - A Ryan
- University of Adelaide, Roseworthy, South Australia, Australia
| | - S H Franklin
- University of Adelaide, Roseworthy, South Australia, Australia
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Ariyaratnam JP, Elliott AD, Mishima RS, Gallagher C, Lau DH, Sanders P. Heart failure with preserved ejection fraction: An alternative paradigm to explain the clinical implications of atrial fibrillation. Heart Rhythm O2 2021; 2:771-783. [PMID: 34988529 PMCID: PMC8710629 DOI: 10.1016/j.hroo.2021.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
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.
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Affiliation(s)
- Jonathan P Ariyaratnam
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Ricardo S Mishima
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
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29
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Affiliation(s)
- Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health & Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health & Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia
| | - Dominik K Linz
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health & Medical Research Institute and Royal Adelaide Hospital, Adelaide, Australia.,Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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30
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Kadhim K, Middeldorp ME, Elliott AD, Agbaedeng T, Gallagher C, Malik V, Wong CX, McEvoy RD, Kalman JM, Lau DH, Linz D, Sanders P. Prevalence and Assessment of Sleep-Disordered Breathing in Patients With Atrial Fibrillation: A Systematic Review and Meta-analysis. Can J Cardiol 2021; 37:1846-1856. [PMID: 34606918 DOI: 10.1016/j.cjca.2021.09.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In this study, we sought to estimate the prevalence of concomitant sleep-disordered breathing (SDB) in patients with atrial fibrillation (AF) and to systematically evaluate how SDB is assessed in this population. METHODS We searched Medline, Embase and Cinahl databases through August 2020 for studies reporting on SDB in a minimum 100 patients with AF. For quantitative analysis, studies were required to have systematically assessed for SDB in consecutive AF patients. Pooled prevalence estimates were calculated with the use of the random effects model. Weighted mean differences and odds ratios were calculated when possible to assess the strength of association between baseline characteristics and SDB. RESULTS The search yielded 2758 records, of which 33 studies (n = 23,894 patients) met the inclusion criteria for qualitative synthesis and 13 studies (n = 2660 patients) met the meta-analysis criteria. The pooled SDB prevalence based on an SDB diagnosis cutoff of apnea-hypopnea index (AHI) ≥ 5/h was 78% (95% confidence interval [CI] 70%-86%; P < 0.001). For moderate-to-severe SDB (AHI ≥ 15/h), the pooled SDB prevalence was 40% (95% CI 32%-48%; P < 0.001). High degrees of heterogeneity were observed (I2 = 96% and 94%, respectively; P < 0.001). Sleep testing with the use of poly(somno)graphy or oximetry was the most common assessment tool used (in 22 studies, 66%) but inconsistent diagnostic thresholds were used. CONCLUSIONS SDB is highly prevalent in patients with AF. Wide variation exists in the diagnostic tools and thresholds used to detect concomitant SDB in AF. Prospective systematic testing for SDB in unselected cohorts of AF patients may be required to define the true prevalence of SDB in this population.
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Affiliation(s)
- Kadhim Kadhim
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Thomas Agbaedeng
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Varun Malik
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Christopher X Wong
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - R Doug McEvoy
- Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University and Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, and Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Dominik Linz
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia.
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Tu SJ, Elliott AD, Hanna-Rivero N, Gallagher C, Mishima RS, Lyrtzis E, Wlochowicz D, Clarke NA, Roberts-Thomson KC, Stokes MB, Emami M, Lau DH, Sanders P, Wong CX. Rationale and design of the IRON-AF study: a double-blind, randomised, placebo-controlled study to assess the effect of intravenous ferric carboxymaltose in patients with atrial fibrillation and iron deficiency. BMJ Open 2021; 11:e047642. [PMID: 34373301 PMCID: PMC8354291 DOI: 10.1136/bmjopen-2020-047642] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is associated with significantly impaired quality-of-life. Iron deficiency (ID) is prevalent in patients with AF. Correction of ID in other patient populations with intravenous iron supplementation has been shown to be a safe, convenient and effective way of improving exercise tolerance, fatigue and quality-of-life. The IRON-AF (Effect of Iron Repletion in Atrial Fibrillation) study is designed to assess the effect of iron repletion with intravenous ferric carboxymaltose in patients with AF and ID. METHODS AND ANALYSIS The IRON-AF study is a double-blind, randomised controlled trial that will recruit at least 84 patients with AF and ID. Patients will be randomised to receive infusions of either ferric carboxymaltose or placebo, given in repletion and then maintenance doses. The study will have follow-up visits at weeks 4, 8 and 12. The primary endpoint is change in peak oxygen uptake from baseline to week 12, as measured by cardiopulmonary exercise testing (CPET) on a cycle ergometer. Secondary endpoints include changes in quality-of-life and AF disease burden scores, blood parameters, other CPET parameters, transthoracic echocardiogram parameters, 6-minute walk test distance, 7-day Holter/Event monitor burden of AF, health resource utilisation and mortality. ETHICS AND DISSEMINATION The study protocol has been approved by the Central Adelaide Local Health Network Human Research Ethics Committee, Australia. The results of this study will be disseminated through publications in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12620000285954).
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Affiliation(s)
- Samuel J Tu
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nicole Hanna-Rivero
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ricardo S Mishima
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ellen Lyrtzis
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Danielle Wlochowicz
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nicholas Ar Clarke
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Kurt C Roberts-Thomson
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michael B Stokes
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mehrdad Emami
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Christopher X Wong
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Thiyagarajah A, Griffin A, Elliott AD, Emami M, O'Shea CJ, Wong CX, Ariyaratnam JP, Malik V, Fitzgerald JL, Lau DH, Sanders P. B-PO04-067 INCIDENCE OF NEW-ONSET ATRIAL FIBRILLATION AFTER CAVOTRICUSPID ISTHMUS ABLATION FOR ISOLATED ATRIAL FLUTTER: A SYSTEMATIC REVIEW AND META-ANALYSIS. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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O'Shea C, Middeldorp ME, Thomas G, Harper C, Elliott AD, Ray N, Campbell KR, Lau DH, Sanders P. B-PO04-051 DEVICE-DETECTED ATRIAL FIBRILLATION DURING THE COVID-19 PANDEMIC. Heart Rhythm 2021. [PMCID: PMC8559532 DOI: 10.1016/j.hrthm.2021.06.747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mishima RS, Elliott AD, Ariyaratnam JP, Malik V, Pitman BM, Lau DH, Sanders P. B-PO03-144 LOWER CARDIORESPIRATORY FITNESS IS ASSOCIATED WITH LOWER RESTING LEFT ATRIAL STRAIN IN ATRIAL FIBRILLATION. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Malik V, Elliott AD, Thomas G, Mishima RS, Pitman BM, Middeldorp ME, Ariyaratnam J, Roberts-Thomson KC, Young GD, Arnolda LF, Lau DH, Sanders P. B-PO05-138 CATHETER ABLATION OF ATRIAL FIBRILLATION IS NOT ASSOCIATED WITH DESTRUCTION OF CARDIAC AFFERENTS DRIVING VOLUME-REGULATING AUTONOMIC REFLEXES. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.1057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Malik V, Elliott AD, Thomas G, Sadashi Mishima R, Pitman BM, Middeldorp ME, Leonard Fitzgerald J, Roberts-Thomson KC, Young GD, Arnolda LF, Lau DH, Sanders P. B-YIA1-01 ABNORMAL CARDIAC VOLUME-SENSITIVE REFLEX IN PATIENTS WITH AF: IMPACT OF RHYTHM AND IMPLICATIONS ON ATRIAL REMODELING. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Tu SJ, Gallagher C, Elliott AD, Linz, Pitman BM, Hendriks JM, Lau DH, Sanders P, Wong CX. B-PO02-004 TOTAL AND BEVERAGE-SPECIFIC ALCOHOL CONSUMPTION AND INCIDENT ATRIAL FIBRILLATION. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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O'Shea CJ, Middeldorp ME, Thomas G, Harper C, Elliott AD, Ray N, Campbell K, Lau DH, Sanders P. Atrial fibrillation burden during the coronavirus disease 2019 pandemic. Europace 2021; 23:1493-1501. [PMID: 34077513 PMCID: PMC8195127 DOI: 10.1093/europace/euab099] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/30/2021] [Indexed: 01/14/2023] Open
Abstract
Aims The aim of this study is to determine the association between the coronavirus disease 2019 (COVID-19) pandemic and atrial fibrillation (AF) occurrence in individuals with cardiac implantable electronic devices (CIEDs). Method and results Multi-centre, observational, cohort study over a 100-day period during the COVID-19 pandemic (COVID-19) in the USA. Remote monitoring was used to assess AF episodes in patients with a CIED (pacemaker or defibrillator; 20 centres, 13 states). For comparison, the identical 100-day period in 2019 was used (Control). The primary outcomes were the AF burden during the COVID-19 pandemic, and the association of the pandemic with AF occurrence, as compared with 1 year prior. The secondary outcome was the association of AF occurrence with per-state COVID-19 prevalence. During COVID-19, 10 346 CIEDs with an atrial lead were monitored. There were 16 570 AF episodes of ≥6 min transmitted (16 events per 1000 patient days) with a significant increase in proportion of patients with AF episodes in high COVID-19 prevalence states compared with low prevalence states [odds ratio 1.34, 95% confidence interval (CI) 1.21–1.48, P < 0.001]. There were significantly more AF episodes during COVID-19 compared with Control [incident rate ratio (IRR) 1.33, 95% CI 1.25–1.40, P < 0.001]. This relationship persisted for AF episodes ≥1 h (IRR 1.65, 95% CI 1.53–1.79, P < 0.001) and ≥6 h (IRR 1.54, 95% CI 1.38–1.73, P < 0.001). Conclusion During the first 100 days of COVID-19, a 33% increase in AF episodes occurred with a 34% increase in the proportion of patients with AF episodes observed in states with higher COVID-19 prevalence. These findings suggest a possible association between pandemic-associated social disruptions and AF in patients with CIEDs. Clinical TRIAL registration Australian New Zealand Clinical Trial Registry: ACTRN12620000692932.
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Affiliation(s)
- Catherine J O'Shea
- Centre for Heart Rhythm Disorders, University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia.,Department of Cardiology, Port Road, Adelaide, South Australia, 5000, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia.,Department of Cardiology, Port Road, Adelaide, South Australia, 5000, Australia
| | - Gijo Thomas
- Centre for Heart Rhythm Disorders, University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia
| | | | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia
| | | | - Kevin Campbell
- Centre for Heart Rhythm Disorders, University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia.,Pacemate, Bradenton, FL, USA
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia.,Department of Cardiology, Port Road, Adelaide, South Australia, 5000, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia.,Department of Cardiology, Port Road, Adelaide, South Australia, 5000, Australia
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Gallagher C, Fitzgerald JL, Stokes MB, Noubiap JJ, Elliott AD, Hendriks JM, Middeldorp ME, Sanders P, Lau DH. Risk Factor Management in Atrial Fibrillation: How to Deliver a Successful Clinic. Curr Cardiovasc Risk Rep 2021. [DOI: 10.1007/s12170-021-00671-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Mishima RS, Elliott AD, Ariyaratnam JP, Jones D, Nguyen O, Martin L, Noubiap JJ, Malik V, Mahajan R, Lau DH, Sanders P. Cardiorespiratory fitness and electroanatomical remodelling in patients with atrial fibrillation. Eur J Prev Cardiol 2021. [DOI: 10.1093/eurjpc/zwab061.458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
Atrial fibrillation (AF) is the most common clinically-relevant arrhythmia. Its initiation and maintenance is linked to the presence cardiovascular risk factors such as hypertension and obesity. Higher cardiorespiratory fitness (CRF) has been associated with a better prognosis. However, specific electroanatomical features associated with baseline CRF have not been described.
Purpose
Compare electroanatomical substrate across exercise capacity levels in patients with AF
Methods
Patients referred for de novo AF radiofrequency ablation at the Centre for Heart Rhythm Disorders from August 2017 until June 2020 were screened for inclusion and CRF was evaluated in metabolic equivalents (METs) by a symptom-limited maximal treadmill exercise test using the standard Bruce protocol prior to ablation. Predicted CRF was calculated based on established equations and patients were categorized according to the percentage of predicted CRF achieved; low (<85%), adequate (85-100%) and high (>100%). Total mean and regional peak-to-peak bipolar voltages, percent of low voltage areas (% LVA), conduction velocity (CV) and percent of complex fractionated electrograms (% CFE) in sinus rhythm were compared across groups.
Results
There were no between-group differences in baseline characteristics, medication use or echocardiographic features. Total mean voltage was significantly lower in the low CRF group compared to both adequate and high CRF. Compared to the high CRF group, roof (3.25 ± 1.2 mV vs 1.9 ± 1.3 mV, p < 0.05), posterior (3.8 ± 1.8 mV vs 1.7 ± 0.9 mV, p < 0.001) and inferior mean voltages (3.4 ± 2 mV vs 1.6 ± 0.7 mV, p < 0.05) were significantly lower in the low CRF group (figure 1A). Furthermore, compared with the adequate CRF group, mean voltages were significantly lower in the posterior (3.7 ± 1.5 mV vs 1.7 ± 0.9 mV, p < 0.001), inferior (3.4 ± 1 mV vs 1.6 ± 0.7 mV, p < 0.001) and lateral (4.2 ± 2.2 mV vs 2.1 ± 1.4 mV, p < 0.05) walls of the low CRF group. Anterior and septal mean voltages were not significantly different across CRF groups (P for trend = 0.07, 0.3 and 0.15, respectively). Conduction velocities were not significantly different across groups. The inferior %LVA was significantly higher in the low CRF (5.6 ± 6%) compared to adequate CRF group (23 ± 18%) (p < 0.05) (figure 1B). Total and regional % CFE was higher in the low CRF compared to adequate and high CRF.
Conclusion
Participants in the lower baseline CRF category showed significant reductions in regional voltages along with higher fractionation with preserved conduction velocities. Research on the effect of physical activity and CRF on left atrial arrhythmogenic substrate is required.
Abstract Figure. Global and regional mV and % LVA by CRF
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Affiliation(s)
- RS Mishima
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - AD Elliott
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - JP Ariyaratnam
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - D Jones
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - O Nguyen
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - L Martin
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - JJ Noubiap
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - V Malik
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - R Mahajan
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - DH Lau
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - P Sanders
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
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Mishima RS, Ariyaratnam JP, Malik V, Pitman BM, Elliott AD, Sanders P. Cardiorespiratory fitness and left atrial strain in atrial fibrillation: A comparative study. Eur J Prev Cardiol 2021. [DOI: 10.1093/eurjpc/zwab061.457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Atrial fibrillation (AF) is the most common clinically relevant arrhythmia, and its occurrence is associated with pathological left atrial (LA) remodelling. In these patients, low cardiorespiratory fitness (CRF) is associated with increased AF recurrence. Speckle tracking derived LA strain (LAS) permits chamber function quantification and provides angle-independent and highly reproducible measurements of chamber deformation. However, the relationship between CRF and LA function, amongst AF patients is poorly understood.
Purpose
To compare LA function amongst AF patients stratified by cardiorespiratory fitness.
Methods
Consecutive AF patients referred for treadmill exercise stress test (EST) and transthoracic echocardiogram (TTE) between March and December 2020 were screened for inclusion. Treadmill EST was symptom limited and age and gender predicted CRF was calculated with conventional formulas. Speckle tracking software was used to obtain LAS from apical 4 and 2 chamber views and mean measurements for LASr and LASb were calculated. Those achieving <100% (low CRF) and ≥100% (high CRF) of predicted CRF were compared.
Results
After exclusions, 141 patients in sinus rhythm were included in the analysis. Baseline characteristics were not significantly different between groups. Ejection fraction (63.6 ± 4.7% vs 64.8 ± 8.4%, p = 0.3) and LA volume index (33.1 ± 6.9 vs 31.4 ± 9.4 mL/m2, p = 0.3) were not different between groups. Both LASr (22.9% ± 7.4% vs 27.6% ± 11.4%, p = 0.02) and LASb (8.2% ± 4.7% vs 12.1% ± 6.8%, p = 0.004) (figure 1) were significantly higher in the fitter group.
Conclusion
Patients with higher CRF showed improved LA function as per strain measurement in the absence of AF. The relationship between CRF and left atrial function warrants further research.
Abstract Figure. LASr and LASb by CRF
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Affiliation(s)
- RS Mishima
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - JP Ariyaratnam
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - V Malik
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - BM Pitman
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - AD Elliott
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - P Sanders
- University of Adelaide, Centre for Heart Rhythm Disorders, Adelaide, Australia
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Nath LC, Elliott AD, Weir J, Curl P, Rosanowski SM, Franklin S. Incidence, recurrence, and outcome of postrace atrial fibrillation in Thoroughbred horses. J Vet Intern Med 2021; 35:1111-1120. [PMID: 33604980 PMCID: PMC7995445 DOI: 10.1111/jvim.16063] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 01/25/2021] [Accepted: 02/02/2021] [Indexed: 12/23/2022] Open
Abstract
Background Atrial fibrillation (AF) impacts performance and horse and jockey safety. Understanding the outcomes of AF identified postrace will better inform regulatory policy. Hypothesis/Objectives To investigate the outcomes after episodes of AF identified postrace and determine whether affected horses are at increased risk of additional episodes compared to the general racing population. Animals Total of 4684 Thoroughbred racehorses. Methods Race records for Thoroughbred horses racing in Hong Kong from 2007 to 2017 were reviewed. Horses that performed below expectation were examined by cardiac auscultation and ECG. Incidence and recurrence of AF were compared between horses with and without a history of AF and between horses with paroxysmal and persistent episodes using Fisher's exact test. Results There were 96 135 race starts during the study. Atrial fibrillation was identified in 4.9% of horses, with an overall incidence of 2.7 episodes per 1000 starts. The incidence of AF in horses after any previous episode (12.8 per 1000 starts) was higher than for horses with no previous episode (2.4 per 1000 starts; odds ratio [OR], 5.3; 95% confidence interval [CI], 3.8‐7.6). Recurrence was seen in 64% of horses previously treated for persistent AF, which was higher than recurrence in horses with paroxysmal AF (23%; OR, 5.9; 95% CI, 1.6‐21.2). Median duration between episodes was 343 days (range, 34‐1065). Conclusions and Clinical Importance Thoroughbreds are at increased risk of recurrent AF after both paroxysmal and persistent episodes, but the duration of time between episodes varies widely. These findings support a substantial burden of AF among individual Thoroughbred racehorses.
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Affiliation(s)
- Laura C Nath
- School of Animal & Veterinary Sciences, University of Adelaide, Roseworthy, South Australia, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Joe Weir
- Hong Kong Jockey Club, Veterinary Clinical Services, Equine Hospital, Hong Kong SAR, Hong Kong
| | - Peter Curl
- Veterinary Regulation, Hong Kong Jockey Club, Hong Kong SAR, Hong Kong
| | | | - Samantha Franklin
- School of Animal & Veterinary Sciences, University of Adelaide, Roseworthy, South Australia, Australia
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O’Shea CJ, Thomas G, Middeldorp ME, Harper C, Elliott AD, Ray N, Lau DH, Campbell K, Sanders P. Ventricular arrhythmia burden during the coronavirus disease 2019 (COVID-19) pandemic. Eur Heart J 2021; 42:520-528. [PMID: 33321517 PMCID: PMC7953962 DOI: 10.1093/eurheartj/ehaa893] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/18/2020] [Accepted: 10/13/2020] [Indexed: 12/17/2022] Open
Abstract
AIMS Our objective was to determine the ventricular arrhythmia burden in implantable cardioverter-defibrillator (ICD) patients during COVID-19. METHODS AND RESULTS In this multicentre, observational, cohort study over a 100-day period during the COVID-19 pandemic in the USA, we assessed ventricular arrhythmias in ICD patients from 20 centres in 13 states, via remote monitoring. Comparison was via a 100-day control period (late 2019) and seasonal control period (early 2019). The primary outcome was the impact of COVID-19 on ventricular arrhythmia burden. The secondary outcome was correlation with COVID-19 incidence. During the COVID-19 period, 5963 ICD patients underwent remote monitoring, with 16 942 episodes of treated ventricular arrhythmias (2.8 events per 100 patient-days). Ventricular arrhythmia burden progressively declined during COVID-19 (P < 0.001). The proportion of patients with ventricular arrhythmias amongst the high COVID-19 incidence states was significantly reduced compared with those in low incidence states [odds ratio 0.61, 95% confidence interval (CI) 0.54-0.69, P < 0.001]. Comparing patients remotely monitored during both COVID-19 and control periods (n = 2458), significantly fewer ventricular arrhythmias occurred during COVID-19 [incident rate ratio (IRR) 0.68, 95% CI 0.58-0.79, P < 0.001]. This difference persisted when comparing the 1719 patients monitored during both the COVID-19 and seasonal control periods (IRR 0.69, 95% CI 0.56-0.85, P < 0.001). CONCLUSIONS During COVID-19, there was a 32% reduction in ventricular arrhythmias needing device therapies, coinciding with measures of social isolation. There was a 39% reduction in the proportion of patients with ventricular arrhythmias in states with higher COVID-19 incidence. These findings highlight the potential role of real-life stressors in ventricular arrhythmia burden in individuals with ICDs. TRIAL REGISTRATION Australian New Zealand Clinical Trial Registry; URL: https://www.anzctr.org.au/; Unique Identifier: ACTRN12620000641998.
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Affiliation(s)
- Catherine J O’Shea
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Gijo Thomas
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | | | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | | | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Kevin Campbell
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- PaceMate, USA
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
- Corresponding author. Centre for Heart Rhythm Disorders, Department of Cardiology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. Tel: +61 883139000, Fax: +61 883622273,
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Tu SJ, Hanna-Rivero N, Elliott AD, Clarke N, Huang S, Pitman BM, Gallagher C, Linz D, Mahajan R, Lau DH, Sanders P, Wong CX. Associations of anemia with stroke, bleeding, and mortality in atrial fibrillation: A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2021; 32:686-694. [PMID: 33476452 DOI: 10.1111/jce.14898] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/31/2020] [Accepted: 01/10/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anemia frequently coexists with atrial fibrillation (AF) and has been variably associated with worse outcomes. We performed a systematic review and meta-analysis to comprehensively assess the effect of anemia on mortality, stroke/systemic thromboembolism, and bleeding events in patients with AF. METHODS MEDLINE and Embase were searched from inception until May 2020. Studies examining associations of anemia with the above outcomes in AF patients were included, and maximally adjusted hazard ratios (HRs) meta-analysed. PROSPERO registration number CRD42020171113. RESULTS Twenty-eight studies involving 365 484 patients (41% female, mean age 74.7 years) were included. The average study follow-up ranged from 0.2 to 4.0 years, and the prevalence of anemia was 16%. Anemia was associated with a 78% increase in all-cause mortality (HR, 1.78; 95% confidence interval [CI], 1.44-2.20), 60% increase in cardiovascular mortality (HR, 1.60; 95% CI, 1.17-2.19), 134% increase in noncardiovascular mortality (HR, 2.34; 95% CI, 1.58-3.47) 15% increase in stroke/systemic thromboembolism (HR, 1.15; 95% CI, 1.01-1.31), 78% increase in major bleeding (HR, 1.78; 95% CI, 1.54-2.05), and 77% increase in gastrointestinal bleeding (HR, 1.77; 95% CI, 1.23-2.55). Sensitivity analyses including studies that reported odds ratios did not result in any material change. CONCLUSION Anemia is a frequently observed comorbidity in patients with AF, and is associated with an increased risk of all-cause, cardiovascular and noncardiovascular mortality, stroke/systemic thromboembolism, and major and gastrointestinal bleeding. Future studies are required to explore the causes of anemia in AF, and whether investigation and treatment may be clinically beneficial in affected individuals.
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Affiliation(s)
- Samuel J Tu
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nicole Hanna-Rivero
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adrian D Elliott
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nicholas Clarke
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Sonia Huang
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Bradley M Pitman
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Celine Gallagher
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dominik Linz
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Rajiv Mahajan
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dennis H Lau
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Prashanthan Sanders
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Christopher X Wong
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Elliott AD, Verdicchio CV, Gallagher C, Linz D, Mahajan R, Mishima R, Kadhim K, Emami M, Middeldorp ME, Hendriks JM, Lau DH, Sanders P. Factors Contributing to Exercise Intolerance in Patients With Atrial Fibrillation. Heart Lung Circ 2020; 30:947-954. [PMID: 33341399 DOI: 10.1016/j.hlc.2020.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/24/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Reduced exercise capacity and exercise intolerance are commonly reported by individuals with atrial fibrillation (AF). Our objectives were to evaluate the contributing factors to reduced exercise capacity and describe the association between subjective measures of exercise intolerance versus objective measures of exercise capacity. METHODS Two hundred and three (203) patients with non-permanent AF and preserved ejection fraction undergoing cardiopulmonary exercise testing (CPET) were recruited. Clinical characteristics, AF-symptom evaluation, and transthoracic echocardiography measures were collected. Peak oxygen consumption (VO2peak) was calculated during CPET as an objective measure of exercise capacity. We assessed the impact of 16 pre-defined clinical features, comorbidities and cardiac functional parameters on VO2peak. RESULTS Across this cohort (Age 66±11 years, 40.4% female and 32% in AF), the mean VO2peak was 20.3±6.3 mL/kg/min. 24.9% of patients had a VO2peak considered low (<16 mL/kg/min). In multivariable analysis, echocardiography-derived estimates of elevated left ventricular (LV) filling pressure (E/E') and reduced chronotropic index were significantly associated with lower VO2peak. The presence of AF at the time of testing was not significantly associated with VO2peak but was associated with elevated minute ventilation to carbon dioxide production indicating impaired ventilatory efficiency. There was a poor association between VO2peak and subjectively reported exercise intolerance and exertional dyspnoea. CONCLUSION Reduced exercise capacity in AF patients is associated with elevated LV filling pressure and reduced chronotropic response rather than rhythm status. Subjectively reported exercise intolerance is not a sensitive assessment of reduced exercise capacity. These findings have important implications for understanding reduced exercise capacity amongst AF patients and the approach to management in this cohort. (ACTRN12619001343190).
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Affiliation(s)
- Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide, and the Royal Adelaide Hospital, Adelaide, SA, Australia.
| | - Christian V Verdicchio
- Centre for Heart Rhythm Disorders, University of Adelaide, and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, University of Adelaide, and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dominik Linz
- Centre for Heart Rhythm Disorders, University of Adelaide, and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders, University of Adelaide, and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Ricardo Mishima
- Centre for Heart Rhythm Disorders, University of Adelaide, and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kadhim Kadhim
- Centre for Heart Rhythm Disorders, University of Adelaide, and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Mehrdad Emami
- Centre for Heart Rhythm Disorders, University of Adelaide, and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jeroen M Hendriks
- Centre for Heart Rhythm Disorders, University of Adelaide, and the Royal Adelaide Hospital, Adelaide, SA, Australia; College of Nursing & Health Sciences, Finders University, Adelaide, SA, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide, and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, and the Royal Adelaide Hospital, Adelaide, SA, Australia
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Wells R, Malik V, Brooks AG, Linz D, Elliott AD, Sanders P, Page A, Baumert M, Lau DH. Cerebral Blood Flow and Cognitive Performance in Postural Tachycardia Syndrome: Insights from Sustained Cognitive Stress Test. J Am Heart Assoc 2020; 9:e017861. [PMID: 33280488 PMCID: PMC7955388 DOI: 10.1161/jaha.120.017861] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background The physiology underlying "brain fog" in the absence of orthostatic stress in postural tachycardia syndrome (POTS) remains poorly understood. Methods and Results We evaluated cognitive and hemodynamic responses (cardiovascular and cerebral: heart rate, blood pressure, end‐tidal carbon dioxide, and cerebral blood flow velocity (CBFv) in the middle cerebral artery at baseline, after initial cognitive testing, and after (30‐minutes duration) prolonged cognitive stress test (PCST) whilst seated; as well as after 5‐minute standing in consecutively enrolled participants with POTS (n=22) and healthy controls (n=18). Symptom severity was quantified with orthostatic hypotensive questionnaire at baseline and end of study. Subjects in POTS and control groups were frequency age‐ and sex‐matched (29±11 versus 28±13 years; 86 versus 72% women, respectively; both P≥0.4). The CBFv decreased in both groups (condition, P=0.04) following PCST, but a greater reduction in CBFv was observed in the POTS versus control group (−7.8% versus −1.8%; interaction, P=0.038). Notably, the reduced CBFv following PCST in the POTS group was similar to that seen during orthostatic stress (60.0±14.9 versus 60.4±14.8 cm/s). Further, PCST resulted in greater slowing in psychomotor speed (6.1% versus 1.4%, interaction, P=0.027) and a greater increase in symptom scores at study completion (interaction, P<0.001) in the patients with POTS, including increased difficulty with concentration. All other physiologic responses (blood pressure and end‐tidal carbon dioxide) did not differ between groups after PCST (all P>0.05). Conclusions Reduced CBFv and cognitive dysfunction were evident in patients with POTS following prolonged cognitive stress even in the absence of orthostatic stress.
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Affiliation(s)
- Rachel Wells
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Medicine Royal Adelaide Hospital Adelaide Australia
| | - Varun Malik
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide Australia
| | - Anthony G Brooks
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia
| | - Dominik Linz
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide Australia
| | - Amanda Page
- Centre for Nutrition and Gastrointestinal Diseases The University of Adelaide Adelaide Australia
| | - Mathias Baumert
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,School of Electrical and Electronic Engineering The University of Adelaide Adelaide Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders The University of Adelaide Adelaide Australia.,Department of Cardiology Royal Adelaide Hospital Adelaide Australia
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Malik V, Mishima R, D Elliott A, H Lau D, Sanders P. The "Road" to Atrial Fibrillation: The Role of the Cardiac Autonomic Nervous System. J Atr Fibrillation 2020; 13:2400. [PMID: 33024501 DOI: 10.4022/jafib.2400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/16/2020] [Accepted: 03/18/2020] [Indexed: 01/04/2023]
Abstract
At the population level, there is a parallel escalation in the healthcare burden of both, atrial fibrillation (AF) as well its risk factors. Compounding this relationship, AF is associated with escalating burden at an individual level, due its self-perpetuating and progressive nature. The mechanisms by which these risk factors interact to produce atrial remodelling and subsequent AF are unclear. This intersection is critical to the development of strategies to combat this disease at both the individual and population-level. It is well known that AF can manifest from disturbances in autonomic activity. At the population level, there is growing data to suggest a role of the autonomic nervous system in the future incidence of AF. Here, we provide an overview of the association of cardiac autonomic dysfunction with the incidence of AF, review the role of the autonomic nervous system (ANS) as an intermediary between risk factors and the development of AF and finally, we discuss the bidirectional relationship between AF and cardiac autonomic nervous system dysfunction; to determine whether this is implicated in the progression of AF.
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Affiliation(s)
- Varun Malik
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Ricardo Mishima
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
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48
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Middeldorp ME, Elliott AD, Gallagher C, Linz D, Hendriks JML, Mahajan R, Lau DH, Sanders P. Late-onset thyrotoxicosis after the cessation of amiodarone. Indian Pacing Electrophysiol J 2020; 20:265-268. [PMID: 32745519 PMCID: PMC7691770 DOI: 10.1016/j.ipej.2020.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/19/2020] [Accepted: 07/30/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction Amiodarone is a highly effective antiarrhythmic-drug with well recognized toxic side-effects. The effects of the drug late in patients with atrial fibrillation (AF) is not well described. Methods and results We present a single centre prospectively collected series of patients with thyrotoxicosis occurring late after the cessation of amiodarone. Between 2006 and 2018, 8 patients were identified with amiodarone induced thyrotoxicosis (AIT). Amiodarone was prescribed for AF in 7 patients and ventricular tachycardia in 1 patient. Mean duration of therapy was 329 [42–1092] days, mean dose of 200 ± 103.5 mg/day. Amiodarone use was short term (<140 days) in 4 of the 8 cases, with one treated for 42 days. Patients presented with symptoms including weight loss, tremors, palpitations, AF, sweats all indicative of AIT at a median of 347 [60–967] days post cessation. Thyroid function testing confirmed suppressed thyroid stimulating hormone and elevated T levels in all patients. Nuclear thyroid imaging in all cases demonstrated low uptake of iodine indicative of Type II AIT. All patients recovered following pharmaceutical treatment with Carbimazole and Prednisolone. Conclusions We describe a series of patients with late thyrotoxicosis after exposure to amiodarone. Our findings highlight the need for a high-index of clinical suspicion for AIT regardless of treatment duration or time after cessation of amiodarone.
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Affiliation(s)
- Melissa E Middeldorp
- Centre for Heart Rhythm Disorders (CHRD), University of Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders (CHRD), University of Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders (CHRD), University of Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Dominik Linz
- Centre for Heart Rhythm Disorders (CHRD), University of Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Jeroen M L Hendriks
- Centre for Heart Rhythm Disorders (CHRD), University of Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders (CHRD), University of Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders (CHRD), University of Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders (CHRD), University of Adelaide, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia.
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Wells R, Hissaria P, Elliott AD, Sanders P, Page A, Baumert M, Lau DH. Plasma Exchange Therapy in Postural Tachycardia Syndrome: A Novel Long-Term Approach? Am J Med 2020; 133:e157-e159. [PMID: 31715171 DOI: 10.1016/j.amjmed.2019.10.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/03/2019] [Accepted: 10/03/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Rachel Wells
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Department of Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Pravin Hissaria
- Department of Immunology, Royal Adelaide Hospital, Adelaide, South Australia, Australia; SA Pathology, Adelaide, South Australia, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Amanda Page
- Department of Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Centre for Nutrition and Gastrointestinal Diseases, University of Adelaide, Adelaide, South Australia, Australia
| | - Mathias Baumert
- School of Electrical and Electronic Engineering, University of Adelaide, Adelaide, South Australia, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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Malik V, Gallagher C, Linz D, Elliott AD, Emami M, Kadhim K, Mishima R, Hendriks JML, Mahajan R, Arnolda L, Sanders P, Lau DH. Atrial Fibrillation Is Associated With Syncope and Falls in Older Adults: A Systematic Review and Meta-analysis. Mayo Clin Proc 2020; 95:676-687. [PMID: 32247342 DOI: 10.1016/j.mayocp.2019.09.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/21/2019] [Accepted: 09/30/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To examine the potential association of atrial fibrillation (AF) to syncope and falls, we undertook a systematic review and meta-analysis given the increasing prevalence of AF in older adults as well as emerging data that it is a risk factor for dementia. PATIENTS AND METHODS CENTRAL, PubMed, and EMBASE databases were searched from inception to January 31, 2019, to retrieve relevant studies. Search terms consisted of MeSH, tree headings, and keywords relating patients with "AF," "falls," "syncope," and "postural hypotension." When possible; results were pooled using a random-effects model. RESULTS A total of 10 studies were included, with 7 studies (36,444 patients; mean ± SD age, 72±10 years) reporting an association between AF and falls and 3 studies (6769 patients; mean ± SD age, 65±3 years) reporting an association between AF and syncope. Pooled analyses demonstrate that AF is independently associated with falls (odds ratio, 1.19; 95% CI, 1.07-1.33; P=.001) and syncope (odds ratio, 1.88; 95% CI, 1.20-2.94; P=.006). There was overall moderate bias and low-moderate heterogeneity (I2=37%; P=.11) for falls and moderate bias with low statistical heterogeneity (I2=0%; P=.44) for syncope. Persistent AF, but not paroxysmal AF, was associated with orthostatic intolerance in 1 study (4408 patients; mean ± SD age, 66±6 years). CONCLUSION AF is independently associated with syncope and falls in older adults. Further studies are needed to delineate mechanistic links and to guide management to improve outcomes in these patients. TRIAL REGISTRATION PROSPERO: trial identifier: CRD4201810721.
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Affiliation(s)
- Varun Malik
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia
| | - Dominik Linz
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia
| | - Mehrdad Emami
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia
| | - Kadhim Kadhim
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia
| | - Ricardo Mishima
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia
| | - Jeroen M L Hendriks
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia
| | - Leonard Arnolda
- Illawarra Health and Medical Research Institute, University of Wollongong, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia.
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