Electrocardiographic parameters and the risk of new-onset atrial fibrillation in the general population

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): The Rotterdam Study is funded by Erasmus Medical Center and Erasmus University, Rotterdam, Netherlands Organization for the Health Research and Development (ZonMw), the Research Institute for Diseases in the Elderly (RIDE), the Ministry of Education, Culture and Science, the Ministry for Health, Welfare and Sports, the European Commission (DG XII), and the Municipality of Rotterdam. This study is further supported by the Senior Scientist Grant from Dutch Heart Foundation (03-004-2021-T050).

Background

The (shape of the) association and sex-differences between electrocardiographic parameters and new-onset atrial fibrillation (AF) remain incompletely understood.

Purpose

To investigate the association between electrocardiographic parameters and new-onset atrial fibrillation among men and women in the general population.

Methods

12,212 participants free of AF from a large population-based cohort study were included. Up to five repeated measurements of electrocardiographic parameters including PR, QRS, QT, QT corrected for heart rate (QTc), JT, RR interval, and heart rate were assessed at baseline and follow-up examinations. Cox proportional hazards models and joint models, both adjusted for cardiovascular risk factors, were used to determine the (shape of) association between baseline and longitudinal electrocardiographic parameters with new-onset AF. Additionally, we evaluated potential sex-differences.

Results

During a median follow-up of 9.3 years, 1,282 incident AF cases occurred among 12,212 participants (mean age 64.9 years, 58.2% women). Penalized cubic splines revealed that associations between baseline electrocardiographic measures and risk of new-onset AF were generally U-shaped (Figure 1). Sex-differences in terms of the shape of the various associations were most apparent for baseline PR, QT, QTc, RR, and heart rate in relation to new-onset AF. Longitudinal measures of PR (hazard ratio (HR), 95% confidence interval (CI), 1.43, 1.02-2.04, p=0.0393), and QTc interval (HR, 95% CI, 5.23, 2.18-12.45, p=0.0002) were significantly associated with new-onset AF. Sex-stratified analyses showed that the longitudinal associations were more prominent among men.

Conclusions

Baseline electrocardiographic measures and risk of new-onset AF were generally U-shaped. Longitudinal electrocardiographic measures of PR, and QTc interval were significantly associated with new-onset AF, more pronounced in men. Our findings imply that different thresholds of electrocardiographic parameters might translate to a differential risk of AF among men and women, and that treatment options targeting specific electrocardiographic parameters might prevent AF in the general population, in particular in men.

Heart rate variability and atrial fibrillation in the general population: a longitudinal and mendelian randomization study

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): The Rotterdam Study is funded by Erasmus Medical Center and Erasmus University, Rotterdam, Netherlands Organization for the Health Research and Development (ZonMw), the Research Institute for Diseases in the Elderly (RIDE), the Ministry of Education, Culture and Science, the Ministry for Health, Welfare and Sports, the European Commission (DG XII), and the Municipality of Rotterdam. This study is further supported by the Gender and prevention grant (555003017) from ZonMw.

Background

Sex-differences and the causality of the association between heart rate variability (HRV) and atrial fibrillation (AF) remain unclear.

Purpose

To investigate the sex-differences and the causality of the association between heart rate variability and atrial fibrillation.

Methods

12,334 participants free of AF from a large population-based cohort study were included. Measures of HRV including the standard deviation of normal RR-intervals (SDNN), SDNN corrected for heart rate (SDNNc), RR-interval differences (RMSSD), RMSSD corrected for heart rate (RMSSDc), and heart rate were assessed at baseline and follow-up examinations. Joint models, adjusted for cardiovascular risk factors, were used to determine the association between longitudinal measures of HRV with new-onset AF. Additionally, we evaluated sex-differences. Genetic variants for HRV were used as instrumental variables in a Mendelian randomization (MR) analysis using GWAS summary-level data.

Results

During a median follow-up of 9.4 years, 1,302 incident AF cases occurred. In joint models, higher SDNN (hazard ratio (HR), 95% confidence interval (CI), 1.24, 1.04-1.47, p=0.0213), and higher RMSSD (HR, 95% CI, 1.33, 1.13-1.54, p=0.0010) were significantly associated with new-onset AF. Sex-stratified analyses showed that the associations were mostly prominent among women. In MR analyses, genetically determined decreases in SDNN (odds ratio (OR), 95% CI, 1.60, 1.27-2.02, p=8.36x10-05), and RMSSD (OR, 95% CI, 1.56, 1.31-1.86, p= 6.32x10-07) were significantly associated with increased AF risk.

Conclusions

Longitudinal measures of uncorrected HRV were significantly associated with new-onset AF, in particular among women. MR analyses supported the causal relationship between uncorrected measures of HRV with AF. Our findings indicate that measures to modulate HRV might prevent AF in the general population, especially among women.

The association of coagulation and hemostasis with atrial fibrillation: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): - Erasmus MC MRace grant- The Netherlands Organization for the Health Research and Development (ZonMw)

Background

Atrial fibrillation (AF) is a highly prevalent cardiac tachyarrhythmia. Recent literature suggests that AF induces a prothrombotic state, ultimately leading to thrombotic events. It is also hypothesized that coagulation underlies AF development through coagulation.

Purpose

We aimed to assess the associations between selected coagulation factors with AF in both longitudinal and cross-sectional studies, to give further insight on the interaction of coagulation and AF.

Methods

Through a systematic search of large databases, including Embase, Medline ALL, and Web of Science Core Collection, all longitudinal cohort studies and cross-sectional studies published before 25th of May, 2021 were reviewed. For longitudinal studies, pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated through log-transformed HRs and 95% CIs using the generic inverse variance method. For cross-sectional studies the pooled standardized mean differences (SMD) were calculated through inverse variance weighting.

Results

16 longitudinal studies and 44 cross-sectional studies were included. In the longitudinal studies, using complex multivariable models, we found significant associations between fibrinogen (HR1.06, 95% CI 1.01-1.12), Plasminogen activator inhibitor 1 (PAI-1) (HR 1.06, 95% CI 1.00-1.12), and D-dimer (HR 1.10, 95% CI 1.02-1.19), with AF incidence. In cross-sectional studies, we found significant differences between AF patients and controls for fibrinogen (SMD 0.47), D-dimer (SMD 1.74), P-selectin (SMD 0.31), von Willebrand factor (SMD 0.96), PAI-1 (SMD 1.73), ß-thromboglobulin (SMD 0.82), and Platelet Factor 4 (SMD 0.42).

Conclusions

Atrial fibrillation is associated with higher levels of coagulation factors. These associations are most pronounced in cross-sectional analyses, but limited studies are available investigating a prothrombotic state underlying AF initiation. These results further support the hypothesis of "AF begets AF".

Imaging-based body fat depots and new-onset atrial fibrillation in general population

Background

Obesity is a well-established risk factor for incident atrial fibrillation (AF). Whether different body fat depots differentially associate with AF development remains largely unknown.

Purpose

We aimed to investigate the associations between various body fat depots and the risk of new-onset AF among middle-aged and elderly individuals from general population.

Methods

In the prospective population-based cohort study, body composition was assessed using dual-energy X-ray absorptiometry (DXA) and total body mass, lean mass, fat mass, android and gynoid fat were analyzed (N=3468). Liver fat and epicardial fat were assessed using computed tomography (CT) (N=2145). A body fat score was defined by adding tertiles of each fat depot. All participants were followed for the occurrence of AF until 1st Jan. 2014. Principle component analysis was conducted to identify body fat distribution patterns. Time-to-event analyses were performed using Cox proportional hazards regression analysis. Hazard ratios (HR) and 95% confidence-intervals (95% CI), adjusted for cardiovascular risk factors, were calculated.

Results

Mean (standard deviation) of age for participants in DXA study and CT study was 74.42 (6.85) and 68.66 (6.41) years, respectively. AF incidence rate was 13.1 per 1000 person-years during a median follow-up time of 9.62 years. In the adjusted model, fat mass (HR; 95% CI: 1.33; 1.05–1.68), lean mass (1.40; 1.15–1.72), gynoid fat mass (1.36; 1.12–1.65), and total body mass (1.51; 1.21–1.89) were significantly associated with new-onset AF. Of note, android-to-gynoid fat ratio was inversely associated with incident AF (HR; 95% CI: 0.81; 0.70–0.94). Larger body fat score was associated with increased risk of incident AF (P for trend <0.01). Two fat distribution patterns were identified. Adherence to the fat- and gynoid fat- pattern (P for trend = 0.035), but not muscle- and visceral fat- pattern (P for trend = 0.35), was significantly associated with larger risk of new-onset AF.

Conclusions

Various body fat depots were associated with new-onset AF. Larger values of total body mass carried the highest risk for incident AF. The inverse association between android to gynoid fat ratio with AF presents a novel finding. A significant dose-response relationship between body fat accumulation and risk of new-onset AF was observed, implying a collective impact of fat depots on AF development. Findings also suggest that various fat depots, characterized by different fat distribution patterns, may exert differential combined effect on the risk of incident AF.

Funding Acknowledgement

Type of funding sources: None. Fat depots and atrial fibrillation

Distribution and risk profile of atrial fibrillation patterns among women and men from the general population

Background

In a clinical setting, atrial fibrillation (AF) subgroups are defined, including paroxysmal, persistent, and permanent AF. These subgroups differ in terms of clinical characteristics, management strategy, and long-term outcomes. Application of clinical classifications in population-based settings is challenging as they are based on the duration of symptoms, recurrence, and treatment.

Purpose

We aim to develop an objective and standardized classification for AF patterns in the general population and examine the associated cardiovascular risk profiles and outcomes for the identified AF patterns.

Methods

Participants with only one reported AF episode were categorized as single-documented AF, if at least two separate AF episodes were reported as multiple-documented AF and as longstanding persistent AF if at least two consecutive ECG's at the research center showed AF, not followed by an ECG showing sinus rhythm. We fitted mixed effect models with age as time scale to characterize sex-specific cardiovascular risk factor trajectories preceding each AF pattern. We further used Cox proportional hazard modelling to describe the risk of coronary heart disease (CHD), heart failure (HF), stroke, and all-cause mortality following AF.

Results

We included 14,620 men and women aged ≥45 years. 1137 participants were categorized as single-documented AF, 208 as multiple-documented AF, and 57 as longstanding persistent AF. We identified significant differences in the preceding trajectories of weight, body mass index, systolic blood pressure, diastolic blood pressure, waist circumference, hip circumference, and waist-hip ratio with various AF patterns. In general, both men and women with persistent-elevated levels of these risk factors were prone to longstanding persistent AF.

AF was associated with a large risk for subsequent CHD, HF, stroke, and mortality in the general population. Among the different AF patterns, single-documented AF conferred the largest risk of CHD [hazard ratio, 95% confidence interval: 1.92 (1.19–3.03)] and mortality [1.70 (1.41–2.07)] as compared to multiple-documented AF, and as compared to longstanding persistent AF [1.45 (0.72–2.90) and 3.66 (2.25–5.95), respectively].

Conclusion

We developed a classification for AF patterns within a general population. We identified differences in risk factor trajectories preceding each AF pattern, which implies differences in pathophysiological mechanisms underlying AF. Participants with single-documented AF showed worse prognosis than those with multiple AF episodes. This might be due to the subgroup definition, since participants should live for a longer period of time to be categorized in the multiple-documented AF and longstanding persistent AF groups. This can also imply that participants suffering from multiple AF episodes are more frequently monitored, and treated for other risk factors. However, this could also suggest that singular AF episodes are not as innocent as commonly thought.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): - Erasmus MC Mrace grant. - Netherlands Organization for the Health Research and Development (ZonMw) Figure 1Figure 2. Progosis of various AF patterns