Obesity and the risk of new-onset atrial fibrillation

Association of adipose tissue infiltration with cardiac function: scoping review

Evidence suggests that adipose tissue (AT) infiltration in skeletal muscles may negatively influence cardiac function, yet its use as a biomarker remains unclear. This scoping review examined the relationship between AT infiltration and cardiac function in adults. A systematic search of PubMed, CINAHL and SCOPUS identified peer-reviewed studies reporting AT infiltration and cardiac function measures. Excluded were review-type studies, animal studies, abstracts and case series. Study quality was assessed using the Study Quality Assessment Tool (SQAT). Three good-quality studies were included. Findings demonstrated a negative association between AT infiltration and cardiac function parameters, including exercise capacity, left ventricular ejection fraction (LVEF) and heart failure events, in cancer survivors and healthy individuals. There is evidence supporting an association between increased AT infiltration of skeletal muscles and impaired cardiac function, highlighting the need for further research to validate AT infiltration as a potential biomarker. Despite the limited available studies, our findings highlight a distinct association between skeletal muscle AT infiltration and cardiac dysfunction, independent of general obesity.

The Therapeutic Impact of Genetic Evaluation in an Atrial Fibrillation Precision Medicine Clinic

Background and Aims

Genetic testing is recommended for select patients with atrial fibrillation (AF). The aims of this study were to define the results of genetic evaluation and its therapeutic impact for patients referred to a dedicated AF precision medicine clinic.

Methods

Patients diagnosed with AF before age 60 were candidates for referral. In addition to standard evaluation with history, physical exam, and ECG, genetic evaluation included a 3-generation pedigree, cardiac imaging, ambulatory monitoring, and clinical genetic testing with a cardiomyopathy/arrhythmia panel.

Results

264 participants were referred: the median age was 47 years (Q1, Q3: 38, 55), 77 (29%) were female, and 236 (89%) were White. Median age at AF diagnosis was 39 years (Q1, Q3: 31, 48) and median time from AF diagnosis to evaluation was 3.7 years (Q1, Q3: 0.9, 10). 242 patients (92%) underwent genetic testing, which identified a pathogenic or likely pathogenic variant in 48 (20%). The strongest predictors of positive genetic testing were history of cardiomyopathy, infranodal conduction disease, and elevated T1 or late gadolinium enhancement on cardiac MRI (all p<0.05). The strongest predictors of negative genetic testing were obstructive sleep apnea and a normal 12-lead ECG (both p<0.04). Overall, genetic testing changed clinical management in 52% of patients with positive genetic testing, highlighted by 7 new ICD placements and initiation of disease modifying therapy in 16 patients.

Conclusions

Genetic testing was positive in 20% of patients with early-onset AF referred to a dedicated AF precision medicine clinic. Genetic testing results changed clinical management in approximately half of genotype-positive patients.

STRUCTURED GRAPHICAL ABSTRACT

Key Question: Does genetic evaluation of patients with early-onset atrial fibrillation (AF) change their clinical management?Key Finding: Among 246 participants that completed genetic evaluation in a dedicated AF precision medicine clinic, 20% had positive genetic testing with identification of a pathogenic cardiomyopathy or channelopathy variant. These findings led to changes in clinical management in 52% of patients with positive genetic testing.Take-home Message: Genetic evaluation of patients with early-onset AF consists of detailed phenotyping and genetic testing to identify previously undiagnosed genetic disorders. This facilitates earlier diagnosis and clinical intervention.

Identification of a new genetic locus associated with atrial fibrillation in the Taiwanese population by genome-wide and transcriptome-wide association studies

AIMS

Genome-wide association studies (GWASs) identified common single-nucleotide polymorphisms (SNPs) in more than 100 genomic regions associated with atrial fibrillation (AF). We aimed to identify novel AF genes in Taiwanese population by multi-stage GWAS.

METHODS AND RESULTS

In exploratory stage, we did GWAS with whole-genome genotypes (4 512 191 SNPs) in 516 patients with AF from the National Taiwan University AF Registry and 5160 normal sinus rhythm controls from the Taiwan Biobank. Significant loci were replicated in 1002 independent patients and 2003 controls and in the UK Biobank. Expression quantitative trait locus (eQTL) mapping and transcriptome-wide association study (TWAS) were performed to implicate functional significance. Stage I GWAS revealed three loci associated with AF with a genome-wide significance level, including one close to PITX2 gene (chromosome 4q25, rs2723329, minor allele frequency [MAF] 0.50 vs. 0.41, P = 1.53 × 10-10), another close to RAP1A gene (also to previous KCND3; chromosome 1p13.2, rs7525578, MAF 0.17 vs. 0.07, P = 1.24 × 10-26), and one novel locus close to HNF4G gene (chromosome 8q21.13, rs2980218, MAF 0.44 vs. 0.35, P = 2.19 × 10-9). They were validated in Stage II population. The eQTL analyses showed significant colocalization of 1p13.2 locus with RAP1A gene expression in fibroblasts and 8q21.13 locus with HNF4G expression in lymphocytes. There is a significant association of RAP1A gene expression in fibroblasts and HNF4G in lymphocytes and brain with AF in TWAS.

CONCLUSION

Genome-wide association study in Taiwan revealed PITX2 and RAP1A/KCND3 loci and novel AF locus (HNF4G) with the most significant locus in the RAP1A locus. RAP1A and HNF4G genes may implicate fibrosis, metabolic, and neurogenic pathways in pathogenesis of AF.

Waist circumference and body surface area and the risk of developing new-onset atrial fibrillation: A systematic review and meta-analysis of observational studies

BACKGROUND

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia with significant health consequences. Identifying modifiable risk factors, such as obesity, is crucial. While body mass index (BMI) is linked to increased AF risk, the association between new-onset AF (NOAF) and other anthropometric measures like waist circumference (WC) and body surface area (BSA) warrants further investigation.

OBJECTIVES

This systematic review and meta-analysis aimed to compare mean WC and BSA between individuals who developed NOAF and those who did not.

METHODS

We conducted a comprehensive search up to February 2024 for studies comparing mean WC and BSA in groups with and without incident NOAF. Participants had no prior AF history. We used a random-effects model to calculate standardized mean differences (SMDs) and 95 % confidence intervals (CIs). Subgroup analyses explored NOAF occurrence following coronary artery bypass graft (CABG) surgery, in the absence of any preceding procedure, and after other cardiac procedures.

RESULTS

Our analysis of 34 studies revealed that adults with NOAF had significantly higher WC (SMD = 0.20, 95 % CI 0.01; 0.39) and BSA (SMD = 0.06, 95 % CI 0.01; 0.11) compared to those without NOAF. Subgroup analysis showed a more pronounced association in individuals developing NOAF after CABG (SMD = 0.33, 95 % CI 0.17; 0.48) and in those without any prior procedure before NOAF diagnosis (SMD = 0.23, 95 % CI 0.08; 0.38) versus those without NOAF.

CONCLUSION

Higher WC and BSA appear to be significantly associated with an increased risk of NOAF, with the relations being more pronounced in specific subgroups.

Diagnosing Heart Failure with Preserved Ejection Fraction in Obese Patients

Obesity is a current pandemic that sets all affected individuals at risk of heart failure (HF), and the majority of them will develop the clinical syndrome of HF with preserved ejection fraction (HFpEF). The diagnosis of HFpEF is challenging as it is based on the detection of subtle functional and structural remodeling of the heart that leads to diastolic dysfunction with increased left ventricular (LV) filling pressures and raised natriuretic peptides (NPs). The accurate diagnosis of HFpEF is even more challenging in patients who are obese, since the echocardiographic imaging quality may be suboptimal, the parameters for the evaluation of cardiac structure are indexed to the body surface area (BSA) and thus may underestimate the severity of the remodeling, and the NPs in patients who are obese have a lower normal threshold. Moreover, patients who are obese are prone to atrial fibrillation (AF) and pulmonary hypertension (PH), making the evaluation of diastolic dysfunction more strenuous. The current review aims to offer insights on the accurate diagnosis of HFpEF in patients who are obese in different clinical scenarios-patients who are obese in different clinical scenarios-such as in sinus rhythm, in atrial fibrillation, and in the case of pulmonary hypertension-by applying multimodality imaging and clinical diagnostic algorithms.

Cardiac neurons expressing a glucagon-like receptor mediate cardiac arrhythmia induced by high-fat diet in Drosophila

Cardiac arrhythmia leads to increased risks for stroke, heart failure, and cardiac arrest. Arrhythmic pathology is often rooted in the cardiac conduction system, but the mechanism is complex and not fully understood. For example, how metabolic diseases, like obesity and diabetes, increase the risk for cardiac arrhythmia. Glucagon regulates glucose production, mobilizes lipids from the fat body, and affects cardiac rate and rhythm, attributes of a likely key player. Drosophila is an established model to study metabolic diseases and cardiac arrhythmias. Since glucagon signaling is highly conserved, we used high-fat diet (HFD)-fed flies to study its effect on heart function. HFD led to increased heartbeat and an irregular rhythm. The HFD-fed flies showed increased levels of adipokinetic hormone (Akh), the functional equivalent to human glucagon. Both genetic reduction of Akh and eliminating the Akh producing cells (APC) rescued HFD-induced arrhythmia, whereas heart rhythm was normal in Akh receptor mutants (AkhRnull ). Furthermore, we discovered a pair of cardiac neurons that express high levels of Akh receptor. These are located near the posterior heart, make synaptic connections at the heart muscle, and regulate heart rhythm. Altogether, this Akh signaling pathway provides new understanding of the regulatory mechanisms between metabolic disease and cardiac arrhythmia.

Left atrial strain and risk of atrial fibrillation after coronary artery bypass-grafting

AIM

Postoperative Atrial Fibrillation (POAF) is a common complication following Coronary Artery Bypass Grafting (CABG), associated with increased morbidity and mortality. Aim of the study is to analyze whether the measurement of preoperative Left Atrial (LA) strain can offer advantages over conventional clinical and echocardiographic parameters to identify patients at risk of developing POAF.

METHODS AND RESULTS

We conducted a prospective study involving 100 patients undergoing isolated CABG from April 2023 to April 2024. Key parameters measured included LA strain measurements, Left Atrial Emptying Fraction (LA-EF), Left Ventricular Ejection Fraction, Left Atrial Volume index (LAVi). POAF occurred in 27 patients (27 %) with a mean latency of 3.2 ± 2.1 days. Higher preoperative serum creatinine levels were significantly associated with POAF. LA strain parameters (LA Reservoir Strain, LA Contraction Strain) and LA-EF were all significantly lower in the POAF group. Multivariate logistic regression identified LA Contraction Strain (OR: 0.73, p = 0.04), LA Reservoir Strain (OR: 0.27, p = 0.02) and preoperative serum creatinine (OR: 0.55, p = 0.01) as significant predictors of POAF. ROC curve analysis indicated that LA Reservoir Strain ≤24.5 %, LA Contraction Strain ≤9.5 %, LA-EF ≤ 43.4 % have a good accuracy in detection of POAF. Significant correlations were found between LAVi and LA Reservoir Strain, LAVi and LA-EF, and LA Reservoir Strain and LA-EF.

CONCLUSIONS

Preoperative LA analysis are significant predictors of POAF. These findings suggest that echocardiographic strain measurements offer an added value in preoperative risk assessment for POAF in CABG patients.

Plasma Concentrations of Direct Oral Anticoagulants in Patients with Nonvalvular Atrial Fibrillation and Different Degrees of Obesity

BACKGROUND

Atrial fibrillation (AF) has multiple cardio-metabolic comorbidities, including obesity. The use of direct oral anticoagulants (DOACs) in patients with AF and obesity is still uncertain owing to the concern of possible ineffective DOAC plasma concentration. We evaluated the peak and trough plasma concentrations of DOACs in AF patients with different degrees of obesity.

METHODS

Observational single-center study including patients with obesity and AF, between April 2022 and April 2024. Obesity was defined as body mass index (BMI) ≥ 30.0 kg/m2. The 2-hour peak and trough DOAC plasma concentrations were assessed. Intake of DOAC was verified on site. Multivariable logistic regression analysis was used to assess the odds ratio (OR) and 95% confidence interval (95% CI) of factors associated with below-range trough concentration (BRTC) and below-range peak concentration (BRPC).

RESULTS

In total, 160 patients (33.8% women) with a mean age of 73.2 ± 9.1 years were included. The median BMI was 32.3 kg/m2. DOACs prescribed were apixaban (46.8%), rivaroxaban (21.8%), dabigatran (16.4%), and edoxaban (15.0%); 18.1% and 14.4% had BRTC and BRPC concentrations, respectively. Patients with BRTC were more frequently treated with edoxaban and dabigatran and had a higher BMI. On multivariable logistic regression analysis, dabigatran [hazard ratio (HR) 3.039, 95% CI 1.155-7.999, p = 0.024) and BMI ≥ II class (OR 2.625, 95% CI 1.087-6.335, p = 0.032] were associated with BRTC. Dabigatran (OR 4.296, 95% CI 1.523-12.120, p = 0.006) and apixaban (OR 0.277, 95% CI 0.096-0.802, p = 0.018) were directly and inversely associated with BRPC, respectively.

CONCLUSIONS

A nonnegligible proportion of patients with obesity and AF have below-range plasma concentrations of DOACs. Assessment of DOAC plasma concentration in obesity class ≥ II may be useful in these patients.

BTKi-induced cardiovascular toxicity in CLL: Risk mitigation and management strategies

Targeted therapies, consisting of Bruton tyrosine kinase inhibitors (BTKis) or BCL-2 inhibitors, are the mainstay of contemporary treatments for chronic lymphocytic leukemia (CLL). The most common adverse effects (AEs) of BTKis are fatigue, bruising, infection, hematological and cardiovascular AEs. While AEs during treatment are usually mild (grades 1 and 2), grade 3 and 4 AEs have been detected in some patients, necessitating additional medical care and temporary or permanent drug discontinuation. In this review, we analyzed the cardiovascular effects associated with BTKi therapy for CLL and the essential practical aspects of multidisciplinary management of patients who develop cardiovascular toxicity during treatment. We particularly focus on the data and strategies for controlling cardiovascular risks associated with ibrutinib and newer BTKis (acalabrutinib, zanubrutinib and pirtobrutinib), including the development of atrial fibrillation, hypertension, ventricular arrhythmias, sudden death, heart failure, bleeding, and ischemic complications (stroke and myocardial infarction). This review highlights hematological insights underlying cardiotoxicity, an area that has received limited attention in comparison to the predominantly cardiological perspective. This review synthesizes emerging evidence on hematological biomarkers, cardiotoxic mechanisms, and therapeutic interventions, linking hematology and cardiology to enhance understanding and guide comprehensive prevention and management strategies.

The Close Link Between Obesity and Cardiovascular Disease: Current Insights and Remaining Challenges

Obesity is a global public health crisis, contributing to chronic disease development and poor prognosis. A large body of evidence consistently demonstrates that increased adiposity leads to many cardiovascular diseases (CVDs) and complications, such as coronary artery disease, heart failure, and arrhythmias, via direct and indirect mechanisms. Therefore, weight management is crucial to reduce and prevent cardiovascular risk. The recent emergence of glucose-like peptide-1 receptor agonists shows remarkable weight reduction and cardiovascular prevention. Despite the clear benefits, controversies and challenges on obesity-related CVD remain. This review aims to provide a comprehensive understanding of obesity-related CVD and explore current remaining tasks.

The Influence of Risk Factor Modification on Atrial Fibrillation Outcomes and Their Impact on the Success of Catheter Ablation

The global prevalence of atrial fibrillation (AF) is growing with a significant increase in AF burden. The pathophysiology of AF is complex and exhibits a strong relationship with modifiable lifestyle AF risk factors, such as physical inactivity, smoking, obesity, and alcohol consumption, as well as co-morbidities, such as hypertension, diabetes mellitus, and cardiovascular disease. Current evidence suggests that cardiac rehabilitation and lifestyle risk factor modification can potentially lower the overall AF burden. Additionally, AF ablation can be an effective treatment for a rhythm control strategy, but reducing AF recurrences post-catheter ablation is paramount. Thus, addressing these modifiable lifestyle risk factors and co-morbidities is critical, as the recent 2024 European Society of Cardiology AF guidance update highlights. A comprehensive approach to treating these risk factors is essential, especially given the rising prevalence of AF. This article provides a state-of-the-art update on the evidence of addressing AF-related risk factors and co-morbidities, particularly in patients undergoing AF ablation.

Obesity and Atrial Fibrillation: A Comprehensive Review

Atrial fibrillation (AF) remains the most common arrhythmia worldwide, but its pathophysiology remains complex and multifactorial. As obesity has increased over the past couple of decades, much interest has been generated about its relationship with other diseases. As a result, the interplay between AF and obesity has been rigorously investigated as risk factor modification has become more important for the management of AF. In this review, we discuss the epidemiology of AF and obesity, the pathophysiology connecting these two diseases, and how obesity affects the management of AF.

Obesity and cardiovascular disease: an ESC clinical consensus statement

The global prevalence of obesity has more than doubled over the past four decades, currently affecting more than a billion individuals. Beyond its recognition as a high-risk condition that is causally linked to many chronic illnesses, obesity has been declared a disease per se that results in impaired quality of life and reduced life expectancy. Notably, two-thirds of obesity-related excess mortality is attributable to cardiovascular disease. Despite the increasingly appreciated link between obesity and a broad range of cardiovascular disease manifestations including atherosclerotic disease, heart failure, thromboembolic disease, arrhythmias, and sudden cardiac death, obesity has been underrecognized and sub-optimally addressed compared with other modifiable cardiovascular risk factors. In the view of major repercussions of the obesity epidemic on public health, attention has focused on population-based and personalized approaches to prevent excess weight gain and maintain a healthy body weight from early childhood and throughout adult life, as well as on comprehensive weight loss interventions for persons with established obesity. This clinical consensus statement by the European Society of Cardiology discusses current evidence on the epidemiology and aetiology of obesity; the interplay between obesity, cardiovascular risk factors and cardiac conditions; the clinical management of patients with cardiac disease and obesity; and weight loss strategies including lifestyle changes, interventional procedures, and anti-obesity medications with particular focus on their impact on cardiometabolic risk and cardiac outcomes. The document aims to raise awareness on obesity as a major risk factor and provide guidance for implementing evidence-based practices for its prevention and optimal management within the context of primary and secondary cardiovascular disease prevention.

Recurrent atrial fibrillation markers post radiofrequency catheter ablation

Atrial fibrillation (AF), the most common type of heart arrhythmia, is recognized as an independent risk factor for stroke. Fortunately, catheter ablation (CA) offers an effective treatment option for AF patients. However, numerous studies have reported suboptimal outcomes, as AF recurrence rates often remain elevated even after CA. Consequently, there exists a need for early identification of patients prone to recurrence, necessitating anti-inflammatory and/or antiarrhythmic treatment post-CA. The discovery and application of markers associated with AF recurrence could significantly aid in this early identification process. In this review, we present an overview of AF recurrence markers from three distinct perspectives (biochemical, imaging, and electrocardiographic markers).

Proarrhythmic Lipid Inflammatory Mediators: Mechanisms in Obesity Arrhythmias

The prevalence of obesity and associated metabolic disorders such as diabetes is rapidly increasing; therefore, concerns regarding their cardiovascular consequences, including cardiac arrhythmias, are rising. As obesity progresses, the excessively produced lipids accumulate in unconventional areas such as the epicardial adipose tissue (EAT) around the myocardium. Metabolic alterations in obesity contribute to the transformation of these ectopic fat deposits into arrhythmogenic substrates. However, despite advances in therapeutic approaches, particularly in lowering EAT volume and thickness through sodium-glucose co-transporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists, obese and diabetic patients still suffer from fatal arrhythmias that may lead to sudden cardiac death. Therefore, an investigation into how unappreciated underlying pathways such as lipid mediators contribute to the transformation of adipose tissues into proinflammatory and arrhythmogenic substrates is of significance. Leukotriene B4 (LTB4) is an eicosanoid derived from arachidonic acid and acts as a lipid mediator. LTB4 has recently been identified to be associated with cardiac ion channel modulations and arrhythmogenic conditions in diabetes. LTB4 increases circulatory free fatty acids (FFAs) and has been associated with adipocyte hypertrophy. LTB4 also interferes with insulin signaling pathways, instigating insulin resistance (IR). In addition, LTB4, as a potent chemoattractant, contributes to the mobilization of circulatory immune cells such as monocytes and promotes inflammatory macrophage polarization and macrophage dysfunction. Thus, this review provides a comprehensive overview of LTB4's underlying pathways in obesity; illustrates how these pathways might lead to alterations in cardiac ion channels, currents, and cardiac arrhythmias; and shows how they might pose a therapeutic target for metabolic-associated arrhythmias.

Atrial Fibrillation Prediction Model Following Aortic Valve Replacement Surgery

(1) Background: Postoperative atrial fibrillation (POAF) is the most common complication following cardiac surgery. It leads to increased perioperative morbidity and costs. Our study aimed to determine the incidence of new-onset POAF in patients undergoing isolated aortic valve replacement (AVR) and develop a multivariate model to identify its predictors. (2) Methods: We conducted a retrospective study including all consecutive patients who underwent isolated AVR at our institution between January 2010 and December 2022. Patients younger than 18, with a history of atrial fibrillation, previous cardiac surgery, or those who underwent concomitant procedures were excluded. Patients were dichotomized into POAF and No POAF groups. Multivariate logistic regression with backward elimination was utilized for predictive modeling. (3) Results: This study included 1108 patients, of which 297 (27%) developed POAF. The final multivariate model identified age, larger valve size, cardiopulmonary bypass time, delayed sternal closure, ventilation time, and intensive care unit stay as predictors of POAF. The model exhibited fair predictive ability (AUC = 0.678, p < 0.001), with the Hosmer-Lemeshow test confirming good model fit (p = 0.655). The overall correct classification percentage was 65.6%. (4) Conclusions: A POAF prediction model offers personalized risk estimates, allowing for tailored management strategies with the potential to enhance patient outcomes and optimize healthcare costs.

Exploring Anti-Inflammatory Treatment as Upstream Therapy in the Management of Atrial Fibrillation

Inflammation has been widely recognized as one of the major pathophysiological drivers of the development of atrial fibrillation (AF), which works in tandem with other risk factors of AF including obesity, diabetes, hypertension, and heart failure (HF). Our current understanding of the role of inflammation in the natural history of AF remains elusive; however, several key players, including the NLRP3 (NLR family pyrin domain containing 3) inflammasome, have been acknowledged to be heavily influential on chronic inflammation in the atrial myocardium, which leads to fibrosis and eventual degradation of its electrical function. Nevertheless, our current methods of pharmacological modalities with reported immunomodulatory properties, including well-established classes of drugs e.g., drugs targeting the renin-angiotensin-aldosterone system (RAAS), statins, and vitamin D, have proven effective in reducing the overall risk of developing AF, the onset of postoperative atrial fibrillation (POAF), and reducing overall mortality among patients with AF. This might bring hope for further progress in developing new treatment modalities targeting cellular checkpoints of the NLRP3 inflammasome pathway, or revisiting other well-known anti-inflammatory drugs e.g., colchicine, vitamin C, nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticosteroids, and antimalarial drugs. In our review, we aim to find relevant upstream anti-inflammatory treatment methods for the management of AF and present the most current real-world evidence of their clinical utility.

Left atrial functional impairment as a predictor of atrial fibrillation: insights from cardiac CT

OBJECTIVES

A strong association exists between left atrial (LA) structural remodeling and the development of atrial fibrillation (AF). The role of LA function in AF prediction remains unclear. We studied the relationship between LA function and incident AF using cardiac CT.

MATERIALS AND METHODS

We retrospectively analyzed patients who underwent multiphasic cardiac CT. LA volumes and parameters of LA global, reservoir and booster function were calculated. The association between measures of LA function and incident AF was analyzed using multivariable Cox regression adjusting for clinical variables, LA volume and left ventricular function.

RESULTS

1025 patients (age 64 years ± 14) were evaluated. Over a median of 3.9 years, 90 patients developed AF. There was a significant association between LA total emptying fraction (adjusted hazard ratio (HR) 1.05; 95% CI: 1.02-1.05 per 1% decrease, p < 0.001), LA reservoir function (HR 1.04; 95% CI: 1.02-1.06 per 1 mL/m2 decrease in LA expansion index, p < 0.001) and passive LA emptying (HR 1.08; 95% CI: 1.03-1.13 per 1% decrease in LA passive emptying fraction, p < 0.001) with incident AF, but no association with LA booster function. Incorporating LA function into predictive models improved risk stratification beyond clinical variables and LA volume. Mediation analysis demonstrated that 46% of the effect of LA volume on AF was mediated via LA dysfunction.

CONCLUSION

LA functional impairment is common even in patients with normal LA volume and provides additional prognostic information for AF risk. The findings underscore the significance of LA mechanical dysfunction in the pathogenesis of AF.

KEY POINTS

Question A strong association exists between left atrial structural remodeling and incident atrial fibrillation. The role of left atrial function in atrial fibrillation prediction remains unclear. Findings Left atrial reservoir and passive emptying function (but not booster function) predict incident atrial fibrillation independent of left atrial volume and clinical risk factors. Clinical relevance Left atrial functional impairment precedes the development of atrial fibrillation. Measures of left atrial reservoir and passive emptying function are independent predictors of incident atrial fibrillation.

Integrated Management of Persistent Atrial Fibrillation

The global incidence of atrial fibrillation is on the rise. Atrial fibrillation, a complex disease, heightens the likelihood of heart failure, stroke, and mortality, necessitating careful attention. Controlling heart rate and rhythm, addressing risk factors, and preventing strokes are fundamental in treating atrial fibrillation. Catheter ablation stands out as the primary approach for atrial fibrillation rhythm control. Nevertheless, the limited success rates pose a significant challenge to catheter ablation, particularly for persistent atrial fibrillation. Various adjunctive ablation techniques are currently under investigation to enhance the effectiveness of catheter ablation. This review provides an overview of the current state of the art and the latest optimized treatments for persistent atrial fibrillation in the areas of rhythm control, heart rate control, and risk factor management.

Atrial Cardiomyopathy: From Diagnosis to Treatment

With a better understanding of the susceptibility to atrial fibrillation (AF) and the thrombogenicity of the left atrium, the concept of atrial cardiomyopathy (ACM) has emerged. The conventional viewpoint holds that AF-associated hemodynamic disturbances and thrombus formation in the left atrial appendage are the primary causes of cardiogenic embolism events. However, substantial evidence suggests that the relationship between cardiogenic embolism and AF is not so absolute, and that ACM may be an important, underestimated contributor to cardiogenic embolism events. Chronic inflammation, oxidative stress response, lipid accumulation, and fibrosis leading to ACM form the foundation for AF. Furthermore, persistent AF can exacerbate structural and electrical remodeling, as well as mechanical dysfunction of the atria, creating a vicious cycle. To date, the relationship between ACM, AF, and cardiogenic embolism remains unclear. Additionally, many clinicians still lack a comprehensive understanding of the concept of ACM. In this review, we first appraise the definition of ACM and subsequently summarize the noninvasive and feasible diagnostic techniques and criteria for clinical practice. These include imaging modalities such as echocardiography and cardiac magnetic resonance imaging, as well as electrocardiograms, serum biomarkers, and existing practical diagnostic criteria. Finally, we discuss management strategies for ACM, encompassing "upstream therapy" targeting risk factors, identifying and providing appropriate anticoagulation for patients at high risk of stroke/systemic embolism events, and controlling heart rhythm along with potential atrial substrate improvements.

Predictors of atrial fibrillation recurrence after pulmonary vein ablation: Clinical and radiological risk factors

BACKGROUND AND OBJECTIVE

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide. Previous studies have described that certain clinical characteristics such as age, obesity, the type of AF, and imaging-based factors, such as left atrial (LA) volume, mean density (calculated as the average of Hounsfield Units values in a certain región of interest), and volume of cardiac adipose tissue, may increase the risk of recurrence following pulmonary vein ablation. However, there have been contradictory results regarding radiological variables in previous studies. The objective of this study was to evaluate these clinical and radiological risk factors obtained from computed tomography (CT) studies.

MATERIALS AND METHODS

This retrospective case-control study included all patients with AF who underwent initial radiofrequency or cryoablation of pulmonary veins after undergoing contrast-enhanced CT between 2017 and 2021. Clinical variables such as age, gender, comorbidities, medications used after ablation, type of AF, and radiological variables obtained from volumetric segmentation of CT studies were collected. Radiological variables included LA volume, mean density, and volume of epicardial, periatrial, and interatrial adipose tissue. The occurrence or absence of AF recurrence within 12 months after ablation was also recorded. These variables were subjected to univariate and multivariate analysis to evaluate the risk of recurrence.

RESULTS

Among the total number of included patients, 40 had paroxysmal AF and 12 had persistent AF. During the follow-up period, 12 patients (23.1%) experienced AF recurrence, while 40 patients (76.9%) remained in sinus rhythm. There were statistically significant differences in LA volume based on the type of AF, with higher volumes observed in patients with persistent AF (119.16 +/- 32.38 cc) compared to the rest (90.99 +/- 28.34 cc). Regarding the differences between patients with and without recurrence after ablation, only LA volume (p < 0.05) and periatrial adipose tissue volume (p < 0.01) were significantly higher in patients with recurrence.

CONCLUSION

The type of atrial fibrillation, increased left atrial volume, and increased periatrial adipose tissue volume are risk factors for recurrence in patients with atrial fibrillation undergoing pulmonary vein ablation using cryoablation or radiofrequency.

Combination of Body Mass Index and Waist Circumference Burden Determines the Risk of Atrial Fibrillation

Background

There is limited evidence regarding the significance of the combination or cumulative burden of waist circumference (WC) with body mass index (BMI) to predict future atrial fibrillation (AF) risks.

Objectives

The authors investigated the impact of the cumulative burden of BMI and WC and their combination on the incident AF risk.

Methods

We included subjects 20 years of age and older who underwent 4 consecutive national health check-ups annually (between 2009 and 2013), excluding those with previous AF. The 4-year cumulative burden of BMI and WC was categorized as a burden-score, derived from the sum of the BMI and WC scores from yearly check-ups. Incident nonvalvular AFs were identified using claims data from the Korean National Health Insurance Service (median 5.2 years of follow-up).

Results

A total of 3,726,172 subjects (age 44.5 ± 11.1 years, men 69.5% [n = 2,590,986 of 3,726,172]) were analyzed. Compared to a zero burden score, maximum burden score of BMI increased AF risk with an incidence rate of 1.56 of 1,000 person-years (adjusted HR: 1.32; 95% CI: 1.27-1.37). The risk of AF was markedly increased for those with the highest WC burden-score (incidence rate: 2.26/1,000 person-years; adjusted HR = 1.52; 95% CI: 1.46-1.58). Different BMI burdens within the same WC burden group did not affect the risk of AF, whereas increasing WC burden within each BMI burden group significantly elevated the AF risk. AF risk was particularly high in individuals with a moderate BMI burden with a high WC burden.

Conclusions

The cumulative burden of WC was a more potent indicator of AF risk than either a single BMI measurement or the overall BMI burden.

Association of left pulmonary vein trunk and subclinical atrial fibrillation in patients with cardiac implantable electronic device

The relationship between subclinical atrial fibrillation (SCAF) and left pulmonary vein anatomy is unknown. This study sought to investigate whether left pulmonary vein trunk predict the development of SCAF in patients with cardiac implantable electronic device (CIED). We also examined the relationship between the duration of SCAF and left pulmonary vein trunk. We retrospectively enrolled 162 patients who underwent implantation of dual-chamber CIEDs and follow-up by remote monitoring system. Computed tomography was used to measure the length of the left pulmonary vein. During median follow up of 2.7 years, the episodes of > 6 min and > 24 h SCAF were observed in 61 (37.7%) and 24 (14.8%) patients, respectively. The diagnosis of sinus node disease (HR: 3.66 [2.06-6.52], P < 0.01 and HR: 2.68 [1.09-6.62], P = 0.04) and left atrial diameter (HR: 1.04 [1.00-1.07], P = 0.04 and HR: 1.05 [1.00-1.10], P = 0.04) were independent predictors for > 6 min and > 24 h SCAF, respectively. Length of the left pulmonary vein trunk was an independent predictor for > 6 min SCAF (HR: 1.06 [1.02-1.10], P < 0.01), but not for > 24 h SCAF (P = 0.06). Sinus node disease, size of the left atrium and length of the left pulmonary vein trunk were related to SCAF. The left pulmonary vein trunk might especially contribute as a trigger rather than as a driver of development of atrial fibrillation.

Impact of lifestyle risk factors on atrial fibrillation: Mechanisms and prevention approaches - A narrative review

Both the development and progression of atrial fibrillation (AF) are affected by a range of modifiable lifestyle risk factors. These key modifiable risk factors encompass obesity, hypertension, hypercholesterolemia, diabetes mellitus, smoking, chronic obstructive pulmonary disease, alcohol consumption, exercise, sedentary lifestyle and obstructive sleep apnoea. These lifestyle-dependent factors rarely exist in isolation, but rather exist together, exerting a complex influence on the development of AF. This comprehensive review elucidates the interplay and interdependency of these lifestyle factors in the arrhythmogenesis of AF, by exploring their role in AF substrate formation, modulating properties and triggering mechanisms. We emphasize the importance of targeted prevention strategies by discussing available literature on the effectiveness of treatment strategies targeting multiple risk factors. Additionally, the clinical impacts of integrated care, nurse-led care and mobile health are discussed in the context of lifestyle improvement. These management strategies have favourable applicability in both paroxysmal and persistent AF, and are also beneficial for patients receiving AF ablation. Despite the challenges accompanying lifestyle and prevention strategies, substantial benefits are apparent, such as improved quality of life and better ablation outcomes. This review further emphasizes the essential nature of awareness of appropriate lifestyle modifications as fundamental pillars in the management of individuals with AF.

Bariatric surgery in patients with preoperative therapeutic anticoagulation: a 2015-2021 MBSAQIP database study

BACKGROUND

The link between obesity and adverse cardiovascular events is well-established. With the rising prevalence of metabolic and bariatric surgery (MBS), a greater number of patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) may present with preoperative therapeutic anticoagulation (AC).

OBJECTIVES

This study evaluated perioperative outcomes of SG and RYGB in patients on preoperative AC.

SETTING

Patients reported to the 2015-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

METHODS

Adults undergoing primary SG or RYGB with and without preoperative anticoagulation (SG-AC or RYGB-AC and non-SG-AC or non-RYGB-AC, respectively) were analyzed from the 2015-2021 MBSAQIP database. Differences in baseline characteristics by AC status for each MBS were adjusted using entropy-balanced weights. Multivariable logistic and linear regressions were developed to analyze the independent association between AC and outcomes of interest.

RESULTS

Of 1,178,090 patients included, 72.0% (n = 850,682) had SG and 28.0% (n = 327,408) had RYGB, of which 1.8% (n = 15,021) and 1.9% (n = 6201) had AC, respectively. Compared to non-SG-AC and non-RYGB-AC, both SG-AC and RYGB-AC encountered higher absolute 30-day rates of anastomotic leak, deep vein thrombosis and gastrointestinal bleeding. Following multivariable adjustment, SG-AC was associated with significantly greater odds of adverse cardiovascular events, anastomotic leak, gastrointestinal bleeding, and greater operative length and length of stay. RYGB-AC was associated with higher odds of readmission, unplanned ICU admission, and ED visit.

CONCLUSIONS

While preoperative AC may confer distinct outcomes between SG and RYGB, this 7-year study of MBSAQIP demonstrated an overall association with greater postoperative morbidity. Management of MBS patients with preoperative AC requires consideration of thrombohemorrhagic risks.

Predictors of arrhythmias in the population hospitalized for SARS-CoV-2

BACKGROUND

Studies exploring predictors of arrhythmias in the population primarily hospitalized for SARS-CoV-2 (COVID-19) are scarce. Understanding this is crucial for risk stratification and appropriate management.

METHODS

Using the 2020 National Inpatient Sample (NIS) database, we identified primary admissions for COVID-19. A 'greedy neighbor' 1:1 propensity-score matching (PSM) accounted for baseline differences. Then, multivariable logistic regression models were employed to account for confounders and estimate the probability of arrhythmia.

RESULTS

There were a total of 1,058,815 admissions for COVID-19 (mean age 64.3 years ±16.8), 47.2% female, 52.5% (107698) White, 18.5% (37973) Blacks, and 20.7% (42,447) Hispanics. Atrial fibrillation was the most prevalent arrhythmia, 15.1% (31,942). After PSM, 166,405 arrhythmia hospitalizations were matched to 166,405 hospitalizations without arrhythmia. Sick sinus syndrome 4.9 (4.4-5.5), dyslipidemia 1.2 (1.2-1.3), cardiac arrest 1.3 (1.1-1.4), invasive mechanical ventilation 1.9 (1.8-2.0) and obesity 1.3 (1.2-1.4), (p<0.0001, all) were all independent predictors of arrhythmias.

CONCLUSIONS

Our analysis revealed a notable proportion of hospitalized COVID-19 patients with arrhythmias. Dyslipidemia, obesity, sick sinus syndrome, invasive mechanical ventilation, and cardiac arrest were independent predictors of arrhythmias.

Bariatric surgery partially reverses subclinical proarrhythmic structural, electrophysiological, and autonomic changes in obesity

BACKGROUND

Obesity confers higher risks of cardiac arrhythmias. The extent to which weight loss reverses subclinical proarrhythmic adaptations in arrhythmia-free obese individuals is unknown.

OBJECTIVE

The purpose of this study was to study structural, electrophysiological, and autonomic remodeling in arrhythmia-free obese patients and their reversibility with bariatric surgery using electrocardiographic imaging (ECGi).

METHODS

Sixteen arrhythmia-free obese patients (mean age 43 ± 12 years; 13 (81%) female participants; BMI 46.7 ± 5.5 kg/m2) had ECGi pre-bariatric surgery, of whom 12 (75%) had ECGi postsurgery (BMI 36.8 ± 6.5 kg/m2). Sixteen age- and sex-matched lean healthy individuals (mean age 42 ± 11 years; BMI 22.8 ± 2.6 kg/m2) acted as controls and had ECGi only once.

RESULTS

Obesity was associated with structural (increased epicardial fat volumes and left ventricular mass), autonomic (blunted heart rate variability), and electrophysiological (slower atrial conduction and steeper ventricular repolarization time gradients) remodeling. After bariatric surgery, there was partial structural reverse remodeling, with a reduction in epicardial fat volumes (68.7 cm3 vs 64.5 cm3; P = .0010) and left ventricular mass (33 g/m2.7 vs 25 g/m2.7; P < .0005). There was also partial electrophysiological reverse remodeling with a reduction in mean spatial ventricular repolarization gradients (26 mm/ms vs 19 mm/ms; P = .0009), although atrial activation remained prolonged. Heart rate variability, quantified by standard deviation of successive differences in R-R intervals, was also partially improved after bariatric surgery (18.7 ms vs 25.9 ms; P = .017). Computational modeling showed that presurgical obese hearts had a larger window of vulnerability to unidirectional block and had an earlier spiral-wave breakup with more complex reentry patterns than did postsurgery counterparts.

CONCLUSION

Obesity is associated with adverse electrophysiological, structural, and autonomic remodeling that is partially reversed after bariatric surgery. These data have important implications for bariatric surgery weight thresholds and weight loss strategies.

Can Obesity Serve as a Barrier to Minimally Invasive Mitral Valve Surgery? Overcoming the Limitations-A Multivariate Logistic Regression Analysis

Background/Objectives: Over the past two decades, significant advancements in mitral valve surgery have focused on minimally invasive techniques. Some surgeons consider obesity as a relative contraindication for minimally invasive mitral valve surgery (MIMVS). The aim of this study is to evaluate whether the specific characteristics of obese patients contribute to increased surgical complexity and whether this, in turn, leads to worse clinical outcomes compared to non-obese patients. Furthermore, we aim to explore whether these findings could substantiate the consideration of limiting this treatment option for obese patients. We investigated the outcomes of MIMVS in obese and non-obese patients at a high-volume center in Germany staffed by an experienced surgical team well-versed in perioperative management. Methods: A total of 934 MIMVS were performed in our high-volume center in Germany from 2011 to 2023. Of these, 196 patients had a BMI of 30 or higher (obese group), while 738 patients had a BMI below 30 (non-obese group), all of whom underwent MIMVS by right minithoracotomy. Demographic information, echocardiographic assessments, surgical data, and clinical outcome parameters were collected for all patients. Results: There was no significant difference in in-hospital, 30-day, and late mortality between groups (obese vs. non-obese: 6 [3.0%] vs. 14 [1.8%], p = 0.40; 6 [3.0%] vs. 14 [1.8%], p = 0.40; 13 [6.6%] vs. 39 [5.3%], p = 0.48, respectively). Respiratory insufficiency and arrhythmia occurred more frequently in the obese group (obese vs. non-obese: 25 [12.7%] vs. 35 [4.7%], p < 0.001; 35 [17.8%] vs. 77 [10.4%], p = 0.006). Conclusions: Obesity was not associated with increased early or late mortality in patients undergoing MIMVS. However, obese patients experienced higher incidences of postoperative complications, including respiratory insufficiency, arrhythmias, delirium, and wound dehiscence. Nonetheless, a multivariate logistic regression analysis indicated that obesity itself does not contraindicate MIMVS and should not be viewed as a barrier to offering this minimally invasive approach to obese patients.

A randomized controlled trial of a "Small Changes" behavioral weight loss treatment delivered in cardiac rehabilitation for patients with atrial fibrillation and obesity: study protocol for the BE-WEL in CR-AF study

BACKGROUND

Atrial fibrillation (AF) represents a global epidemic. Although international AF practice guidelines indicate weight loss for patients with AF and comorbid obesity (BMI ≥ 30 kg/m2) to alleviate symptom burden and improve prognosis, few cardiac rehabilitation (CR) programs include targeted weight loss treatment.

AIMS

This RCT protocol will evaluate the efficacy of a "Small Changes" behavioral weight loss treatment (BWLT) to produce clinically relevant (≥ 10%) weight loss among patients with AF and obesity undergoing CR, relative to CR alone. Secondary aims are to establish efficacy of CR + BWLT for improving AF symptoms, AF risk factors, and health-related quality of life.

METHODS

Adults (18 +) with AF and obesity will be recruited and randomized to receive CR + BWLT (intervention) or CR-only (control). Controls will receive CR consisting of supervised exercise and risk factor self-management for 12 weeks. The intervention group will receive CR plus BWLT (12 weekly, group-based virtual sessions, followed by 12 weeks of follow-up support). Weight and AF-risk factors will be assessed at pre-randomization, 12 weeks, 24 weeks, and 52 weeks. AF burden will be assessed using 30-s ECGs recorded bidaily and with AF symptoms. The primary endpoint of weight loss will be calculated from baseline to 52 weeks as a percentage of starting weight. Intention-to-treat analyses will compare the proportion in each group achieving ≥ 10% weight loss. Assuming success rates of 5% and 30% among controls and intervention groups, respectively, and a 30% loss to follow-up, 120 patients (60 per group) will provide 80% power to detect a difference using a two-sided independent test of proportions (alpha = 5%).

IMPACT

This clinical trial will be the first to demonstrate that adding BWLT to CR promotes clinically meaningful weight loss among patients with AF and comorbid obesity. Findings will inform design and execution of a large efficacy trial of long-term (e.g., 5-year) clinical endpoints (e.g., AF severity, mortality). Implementing weight control interventions designed to target the AF substrate in CR could dramatically reduce morbidity and enhance quality of life among patients living with AF in Canada.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT05600829. Registered October 31, 2022.

Obesity and cardiovascular disease: an ESC clinical consensus statement

The global prevalence of obesity has more than doubled over the past four decades, currently affecting more than a billion individuals. Beyond its recognition as a high-risk condition that is causally linked to many chronic illnesses, obesity has been declared a disease per se that results in impaired quality of life and reduced life expectancy. Notably, two-thirds of obesity-related excess mortality is attributable to cardiovascular disease. Despite the increasingly appreciated link between obesity and a broad range of cardiovascular disease manifestations including atherosclerotic disease, heart failure, thromboembolic disease, arrhythmias, and sudden cardiac death, obesity has been underrecognized and sub-optimally addressed compared with other modifiable cardiovascular risk factors. In the view of major repercussions of the obesity epidemic on public health, attention has focused on population-based and personalized approaches to prevent excess weight gain and maintain a healthy body weight from early childhood and throughout adult life, as well as on comprehensive weight loss interventions for persons with established obesity. This clinical consensus statement by the European Society of Cardiology discusses current evidence on the epidemiology and aetiology of obesity; the interplay between obesity, cardiovascular risk factors and cardiac conditions; the clinical management of patients with cardiac disease and obesity; and weight loss strategies including lifestyle changes, interventional procedures, and anti-obesity medications with particular focus on their impact on cardiometabolic risk and cardiac outcomes. The document aims to raise awareness on obesity as a major risk factor and provide guidance for implementing evidence-based practices for its prevention and optimal management within the context of primary and secondary cardiovascular disease prevention.

Clinical features between paroxysmal and nonparoxysmal atrial fibrillation: a comparative analysis in eastern China

BACKGROUND

Atrial fibrillation (AF) has emerged as a notable public health issue in China due to the aging population and rapid urbanization. This study aimed to describe the characteristics of patients with AF (paroxysmal and nonparoxysmal) and investigate the association between left ventricular ejection fraction (LVEF) levels and AF subtypes to facilitate early prevention in patients with AF.

METHOD

Patients with AF who presented at the cardiology department of the First People's Hospital of Yancheng were recruited in this study. In univariate and multivariate logistic regression analyses, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to evaluate the relationships between each dependent variable and nonparoxysmal AF. The restricted cubic splines (RCS) curve was employed to explore the linear relationship between LVEF and nonparoxysmal AF on a continuous scale. Subgroup analysis was applied to examine the stability of the results.

RESULTS

The study included a total of 2054 patients who were diagnosed with AF. 652 (31.74%) patients had paroxysmal AF, and 1402 (68.26%) had nonparoxysmal AF. Multivariate logistic regression analyses indicated that compared to those with paroxysmal AF, patients with nonparoxysmal AF tended to have a higher prevalence of coronary artery disease, lower levels of LVEF, and an elevated heart rate. Additionally, RCS curves also showed that LVEF was negatively and linearly associated with the nonparoxysmal AF. Furthermore, the association between LVEF and nonparoxysmal AF was stronger among patients with hypertension and obesity (P for interaction < 0.05).

CONCLUSIONS

Patients with nonparoxysmal AF have a more advanced AF burden and the transition from paroxysmal to nonparoxysmal AF should be recognized in time, especially to treat the corresponding comorbidities (including hypertension and obesity) more consistently.

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

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

Managing elderly patients with atrial fibrillation and multimorbidity: call for a systematic approach

INTRODUCTION

Atrial fibrillation (AF) is often accompanied by comorbidities. Not only cardiovascular but also non-cardiovascular comorbidities have been associated with AF. Multimorbidity is therefore a common finding in patients with AF, especially in elderly patients. Multimorbidity is associated with adverse outcomes, adds complexity to AF management, and poses a significant burden on healthcare costs. It is expected that the prevalence of elderly patients with multimorbidity will increase significantly. It is therefore crucial to outline implications for clinical practice and guide comprehensive multimorbidity management.

AREAS COVERED

This perspective article outlines multimorbidity in AF and the importance of comprehensive comorbidity management. It addresses current clinical practice guided by international guidelines and the need for integrated care including a patient-centered focus, comprehensive AF management, coordinated multidisciplinary care, and supporting technology. Moreover, it proposes a novel model of care delivery following a systematic approach to multimorbidity management.

EXPERT OPINION

Providing comprehensive care by means of a multidisciplinary team and patient engagement is crucial to provide optimal personalized care for elderly patients with AF and multimorbidity. A systematic integrated care approach seems promising, but further studies are needed to investigate the feasibility of a systematic approach and prioritization of comorbidity management in patients with multimorbidity.

The Prevalence of Arrhythmias, Including Premature Supraventricular and Ventricular Beats and Other Electrocardiographic Patterns, in 24-Hour Holter Monitoring in Patients with Overweight and Obesity

OBJECTIVES

this study aims to evaluate the prevalence of various arrhythmias and other electrocardiographic patterns within the group of individuals with overweight and obesity.

METHODS

One hundred eighty-one adults (90 females and 91 males) were qualified for inclusion in the experimental group. All participants had a body mass index (BMI) exceeding 25 kg/m2 (98 patients with obesity and 83 with overweight). The mean BMI in the obesity group was 33.6 kg/m2, and all participants had class 1 obesity. The control group comprised 69 individuals (56 females and 13 males) with normal BMI. The basic measurements were performed, and the participants filled out questionnaires describing their health conditions and lifestyles. Each participant underwent an electrocardiographic (ECG) examination and a 24 h Holter ECG examination.

RESULTS

In patients with class 1 obesity compared to the control patients, the average numbers of premature ventricular beats (PVBs) and premature supraventricular beats (SPBs) were statistically significantly higher (p = 0.030 and p = 0.042). There was a positive correlation between body weight and PVB (p = 0.028) and between body weight and SPB (p = 0.028). Moreover, BMI and waist circumference were correlated with SPB (p = 0.043 and p = 0.031). In the backward stepwise multivariate regression model considering 24 h Holter ECG monitoring, concerning SPB as the dependent variable, it was observed that BMI (especially obesity class 1), type 2 diabetes, and thyroid disease exhibited the highest regression coefficients.

CONCLUSIONS

obesity, even in class 1, might be a factor in a more frequent occurrence of abnormalities in electrocardiographic tests.

Obesity

Obesity is a complex, multifactorial disease that is highly prevalent in the United States. Obesity is typically classified by body mass index and the US Preventive Services Task Force recommends screening all patients 6 years or older for obesity. Evaluation includes a thorough history and physical examination as well as laboratory tests including hemoglobin A1c, comprehensive metabolic panel, lipid panel, and thyroid-stimulating hormone. Treatment involves a multidisciplinary approach including nutrition, physical activity, and behavioral therapy as well as pharmacotherapy and bariatric surgery when appropriate.

Global, regional, and national burden of atrial fibrillation/flutter related to metabolic risks over three decades: estimates from the global burden of disease study 2019

AIMS

Atrial fibrillation/atrial flutter (AF/AFL) remains a significant public health concern on a global scale, with metabolic risks playing an increasingly prominent role. This study aimed to investigate comprehensive epidemiological data and trends concerning the metabolic risks related-AF/AFL burden based on the data from the Global Burden of Disease study in 2019.

METHODS AND RESULTS

The analysis of disease burden focused on numbers, age-standardized rates of deaths, disability-adjusted life years (DALYs), and estimated annual percentage change, while considering factors of age, sex, sociodemographic index (SDI), and locations. In 2019, there was a culmination of 137 179 deaths and 4 099 146 DALYs caused by metabolic risks related-AF/AFL worldwide, with an increase of 162.95% and 120.30%, respectively from 1990. High and high-middle SDI regions predominantly carried the burden of AF/AFL associated with metabolic risks, while a shift towards lower SDI regions had been occurring. Montenegro had the highest recorded death rate (7.6 per 100 000) and DALYs rate (146.3 per 100 000). An asymmetrically inverted V-shaped correlation was found between SDI and deaths/DALYs rates. Moreover, females and the elderly exhibited higher AF/AFL burdens, and young adults (over 40 years old) also experienced an annual increase.

CONCLUSION

The global AF/AFL burden related to metabolic risks has significantly increased over the past three decades, with considerable spatiotemporal, gender-based, and age-related heterogeneity. These findings shed valuable light on the trends in the burden of metabolic risks related-AF/AFL and offered insights into corresponding strategies.

Paradoxical SERCA dysregulation contributes to atrial fibrillation in a model of diet-induced obesity

Obesity is a major risk factor for atrial fibrillation (AF) the most common serious cardiac arrhythmia, but the molecular mechanisms underlying diet-induced AF remain unclear. In this study, we subjected mice to a chronic high-fat diet and acute sympathetic activation ('two-hit' model) to study the mechanisms by which diet-induced obesity promotes AF. Surface electrocardiography revealed that diet-induced obesity and sympathetic activation synergize during intracardiac tachypacing to induce AF. At the cellular level, diet-induced obesity and acute adrenergic stimulation facilitate the formation of delayed afterdepolarizations in atrial myocytes, implicating altered Ca2+ dynamics as the underlying cause of AF. We found that diet-induced obesity does not alter the expression of major Ca2+-handling proteins in atria, including the sarcoplasmic reticulum Ca2+-ATPase (SERCA), a major component of beat-to-beat Ca2+ cycling in the heart. Paradoxically, obesity reduces phospholamban phosphorylation, suggesting decreased SERCA activity, yet atrial myocytes from obese mice showed a significantly increased Ca2+ transient amplitude and SERCA-mediated Ca2+ uptake. Adrenergic stimulation further increases the Ca2+ transient amplitude but does not affect Ca2+ reuptake in atrial myocytes from obese mice. Transcriptomics analysis showed that a high-fat diet prompts upregulation of neuronatin, a protein that has been implicated in obesity and is known to stimulate SERCA activity. We propose a mechanism in which obesity primes SERCA for paradoxical activation, and adrenergic stimulation facilitates AF conversion through a Ca2+-induced Ca2+ release gain in atrial myocytes. Overall, this study links obesity, altered Ca2+ signaling, and AF, and targeting this mechanism may prove effective for treating obesity-induced AF.

Effect of Obesity on the Use of Antiarrhythmics in Adults With Atrial Fibrillation: A Narrative Review

BACKGROUND

Atrial fibrillation (AF) and obesity coexist in approximately 37.6 million and 650 million people globally, respectively. The anatomical and physiological changes in individuals with obesity may influence the pharmacokinetic properties of drugs.

AIM

This review aimed to describe the evidence of the effect of obesity on the pharmacokinetics of antiarrhythmics in people with AF.

METHODS

Three databases were searched from inception to June 2023. Original studies that addressed the use of antiarrhythmics in adults with AF and concomitant obesity were included.

RESULTS

A total of 4549 de-duplicated articles were screened, and 114 articles underwent full-text review. Ten studies were included in this narrative synthesis: seven cohort studies, two pharmacokinetic studies, and a single case report. Samples ranged from 1 to 371 participants, predominately males (41%-85%), aged 59-75 years, with a body mass index (BMI) of 23-66 kg/m2. The two most frequently investigated antiarrhythmics were amiodarone and dofetilide. Other drugs investigated included diltiazem, flecainide, disopyramide, propafenone, dronedarone, sotalol, vernakalant, and ibutilide. Findings indicate that obesity may affect the pharmacokinetics of amiodarone and sodium channel blockers (e.g., flecainide, disopyramide, and propafenone). Factors such as drug lipophilicity may also influence the pharmacokinetics of the drug and the need for dose modification.

DISCUSSION

Antiarrhythmics are not uniformly affected by obesity. This observation is based on heterogeneous studies of participants with an average BMI and poorly controlled confounding factors such as multimorbidity, concomitant medications, varying routes of administration, and assessment of obesity. Controlled trials with stratification at the time of recruitment for obesity are necessary to determine the significance of these findings.

The impact of lifestyle factors on atrial fibrillation

Atrial fibrillation (AF), with its significant associated morbidity and mortality contributes to significant healthcare utilisation and expenditure. Given its progressively rising incidence, strategies to limit AF development and progression are urgently needed. Lifestyle modification is a potentially potent but underutilised weapon against the AF epidemic. The purpose of this article is to review the role of lifestyle factors as risk factors for AF, outline potential mechanisms of pathogenesis and examine the available evidence for lifestyle intervention in primary and secondary AF prevention. It will also highlight the need for investment by physicians, researchers, health services and governments in order to facilitate delivery of the comprehensive, multidisciplinary AF care that is required to manage this complex and multifactorial disease.

Exploring the bidirectional relationship between sleep disorders and atrial fibrillation: implications for risk stratification and management

BACKGROUND

Atrial fibrillation (AF) is characterized by the absence of p-waves on ECG and irregular rhythm. It often presents with palpitations either palpitations may occur acutely over a short period or intermittently over several years. Other cardinal symptoms of atrial fibrillation include fatigue, dyspnea, and lightheadedness; it is important however to note that most affected individuals are asymptomatic. Concurrently, sleep disorders such as obstructive sleep apnea (OSA), insomnia, narcolepsy, and circadian rhythm disorders which are a group of conditions associated with the body's internal clock that affect the timing of sleep and alertness, are raising concerns due to their potential associations to arrhythmias. This review explores the bidirectional relationship between AF and sleep disorders, highlighting their implications for risk stratification and management strategies.

MAIN BODY

The narrative approach of this review synthesizes evidence from numerous studies obtained through meticulous literature searches. Specific sleep disorders with a bidirectional relationship with AF are the focus, with scrutiny on the prevalence of this connection. The examination delves into the pathophysiology of sleep-related autonomic dysregulation and inflammation, emphasizing potential management modalities. Various meta-analysis cohorts have highlighted a strong connection between sleep disorders and atrial fibrillation (AF). Patients with sleep disorders, especially OSA, have a higher likelihood of developing AF, and conversely, those with AF are more prone to sleep disorders. This impact is not limited to development, as sleep disorders also contribute to the progression of AF, with AF, in turn, negatively impacting sleep duration and quality. Sleep disorders may play an important role in atrial remodeling as well as electrophysiological abnormalities, rendering the atrial tissue more susceptible to arrhythmogenesis. The narrative review suggests that treating sleep disorders could not only improve sleep quality but also reduce risk factors associated with atrial fibrillation. The effective management of sleep disorders emerges as a potential challenge in preventing and treating atrial fibrillation.

CONCLUSION

In conclusion, this narrative study highlights the bidirectional relationship between sleep disorders and atrial fibrillation. There is a positive correlation, affecting the development, progression, and management of atrial fibrillation. The detrimental impact of sleep disorders on atrial remodeling and electrophysiological abnormalities underscores the significance of their diagnosis and treatment. Education about the importance of sleep and the benefits of sleep disorder treatment becomes imperative for patients with AF and sleep disorders.

Left Atrial Volume Index Predicts Atrial Fibrillation Recurrence after Catheter Ablation Only in Obese Patients-Brief Report

BACKGROUND

It has been shown that obesity and a higher body mass index (BMI) are associated with a higher recurrence rate of atrial fibrillation (AF) after successful catheter ablation (CA). The same has been proven for the left atrial volume index (LAVI). It has also been shown that there is a correlation between LAVI and BMI. However, whether the LAVI's prognostic impact on AF recurrence is BMI-independent remains unclear.

METHODS

We prospectively included 62 patients with paroxysmal AF who were referred to our institution for CA. All patients underwent radiofrequency CA with standard pulmonary veins isolation. Transthoracic 2-D echocardiography was performed one day after CA to obtain standard measures of cardiac function and morphology. Recurrence was defined as documented AF within 6 months of the follow-up period. Patients were also instructed to visit our outpatient clinic earlier in case of symptoms suggesting AF recurrence.

RESULTS

We observed AF recurrence in 27% of patients after 6 months. The mean BMI in our cohort was 29.65 ± 5.08 kg/cm2 and the mean LAVI was 38.04 ± 11.38 mL/m2. We further divided patients into two groups according to BMI. Even though the LAVI was similar in both groups, we found it to be a significant predictor of AF recurrence only in obese patients (BMI ≥ 30) and not in the non-obese group (BMI < 30). There was also no significant difference in AF recurrence between both cohorts. The significance of the LAVI as an AF recurrence predictor in the obesity group was also confirmed in a multivariate model.

CONCLUSIONS

According to our results, the LAVI tends to be a significant predictor of AF recurrence after successful catheter ablation in obese patients, but not in normal-weight or overweight patients. This would suggest different mechanisms of AF in non-obese patients in comparison to obese patients. Further studies are needed in this regard.

Sodium-glucose cotransporter-2 inhibitors and the risk of atrial fibrillation in patients with type 2 diabetes: a population-based cohort study

AIMS

Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) have a direct cardiac effect that is likely to be independent of its glucose lowering renal effect. Previous research has shown that SGLT2-is mitigate heart failure and prevent arrhythmic cardiac death. Our objective is to determine whether SGLT-2is reduce atrial fibrillation (AF) in comparison to other second-to third-line antidiabetic drugs in type 2 diabetes.

METHODS AND RESULTS

We conducted a population-based, new-user active comparator cohort study using data from the UK Clinical Practice Research Datalink. We identified a cohort of patients initiating a new antidiabetic drug class between January 2013 and September 2020. This cohort included patients initiating their first ever non-insulin antidiabetic drug, as well as those who switched to or added-on an antidiabetic drug class not previously used in their treatment history. Individuals with a diagnosis of AF or atrial flutter at any time before cohort entry were excluded. Cox regression analysis with time-dependent covariates was used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) of AF comparing SGLT-2-is with other second-line to third-line antidiabetic drugs. Stratified analyses were performed according to sex, diabetes duration (<5 or ≥ 5 years), body mass index (BMI), HbA1c, and presence of heart failure.The cohort comprised 142 447 patients. SGLT-2is were associated with a statistically significant reduced hazard of AF compared to other second-line to third-line antidiabetic drugs (adjusted HR: 0.77 [95% CI: 0.68-0.88]). This reduced risk was present in both sexes but was more prominently among women (adjusted HRwomen: 0.60 [95% CI: 0.45-0.79]; HRmen: 0.85 [95% CI: 0.73-0.98]; P-value interaction: 0.012). There was no evidence for effect modification when stratifying on duration of diabetes, BMI, HbA1c, or presence of heart failure.

CONCLUSION

SGLT-2is were associated with a reduced risk of AF in patients with type 2 diabetes compared to other second-line to third-line antidiabetic drugs. This reduced risk occurs in both sexes but more prominently among women.

Multidimensional Analysis of the Adult Human Heart in Health and Disease Using Hierarchical Phase-Contrast Tomography

Background Current clinical imaging modalities such as CT and MRI provide resolution adequate to diagnose cardiovascular diseases but cannot depict detailed structural features in the heart across length scales. Hierarchical phase-contrast tomography (HiP-CT) uses fourth-generation synchrotron sources with improved x-ray brilliance and high energies to provide micron-resolution imaging of intact adult organs with unprecedented detail. Purpose To evaluate the capability of HiP-CT to depict the macro- to microanatomy of structurally normal and abnormal adult human hearts ex vivo. Materials and Methods Between February 2021 and September 2023, two adult human donor hearts were obtained, fixed in formalin, and prepared using a mixture of crushed agar in a 70% ethanol solution. One heart was from a 63-year-old White male without known cardiac disease, and the other was from an 87-year-old White female with a history of multiple known cardiovascular pathologies including ischemic heart disease, hypertension, and atrial fibrillation. Nondestructive ex vivo imaging of these hearts without exogenous contrast agent was performed using HiP-CT at the European Synchrotron Radiation Facility. Results HiP-CT demonstrated the capacity for high-spatial-resolution, multiscale cardiac imaging ex vivo, revealing histologic-level detail of the myocardium, valves, coronary arteries, and cardiac conduction system across length scales. Virtual sectioning of the cardiac conduction system provided information on fatty infiltration, vascular supply, and pathways between the cardiac nodes and adjacent structures. HiP-CT achieved resolutions ranging from gross (isotropic voxels of approximately 20 µm) to microscopic (approximately 6.4-µm voxel size) to cellular (approximately 2.3-µm voxel size) in scale. The potential for quantitative assessment of features in health and disease was demonstrated. Conclusion HiP-CT provided high-spatial-resolution, three-dimensional images of structurally normal and diseased ex vivo adult human hearts. Whole-heart image volumes were obtained with isotropic voxels of approximately 20 µm, and local regions of interest were obtained with resolution down to 2.3-6.4 µm without the need for sectioning, destructive techniques, or exogenous contrast agents. Published under a CC BY 4.0 license Supplemental material is available for this article. See also the editorial by Bluemke and Pourmorteza in this issue.

Dual vs Single Cardioversion of Atrial Fibrillation in Patients With Obesity: A Randomized Clinical Trial

Importance

Atrial fibrillation and obesity are common, and both are increasing in prevalence. Obesity is associated with failure of cardioversion of atrial fibrillation using a standard single set of defibrillator pads, even at high output.

Objective

To compare the efficacy and safety of dual direct-current cardioversion (DCCV) using 2 sets of pads, with each pair simultaneously delivering 200 J, with traditional single 200-J DCCV using 1 set of pads in patients with obesity and atrial fibrillation.

Design, Setting, and Participants

This was a prospective, investigator-initiated, patient-blinded, randomized clinical trial spanning 3 years from August 2020 to 2023. As a multicenter trial, the setting included 3 sites in Louisiana. Eligibility criteria included body mass index (BMI) of 35 or higher (calculated as weight in kilograms divided by height in meters squared), age 18 years or older, and planned nonemergent electrical cardioversion for atrial fibrillation. Patients who met inclusion criteria were randomized 1:1. Exclusions occurred due to spontaneous cardioversion, instability, thrombus, or BMI below threshold.

Interventions

Dual DCCV vs single DCCV.

Main Outcomes and Measures

Return to sinus rhythm, regardless of duration, immediately after the first cardioversion attempt of atrial fibrillation, adverse cardiovascular events, and chest discomfort after the procedure.

Results

Of 2079 sequential patients undergoing cardioversion, 276 met inclusion criteria and were approached for participation. Of these, 210 participants were randomized 1:1. After exclusions, 200 patients (median [IQR] age, 67.6 [60.1-72.4] years; 127 male [63.5%]) completed the study. The mean (SD) BMI was 41.2 (6.5). Cardioversion was successful more often with dual DCCV compared with single DCCV (97 of 99 patients [98%] vs 87 of 101 patients [86%]; P = .002). Dual cardioversion predicted success (odds ratio, 6.7; 95% CI, 3.3-13.6; P = .01). Patients in the single cardioversion cohort whose first attempt failed underwent dual cardioversion with all subsequent attempts (up to 3 total), all of which were successful: 12 of 14 after second cardioversion and 2 of 14 after third cardioversion. There was no difference in the rating of postprocedure chest discomfort (median in both groups = 0 of 10; P = .40). There were no cardiovascular complications.

Conclusions and Relevance

In patients with obesity (BMI ≥35) undergoing electrical cardioversion for atrial fibrillation, dual DCCV results in greater cardioversion success compared with single DCCV, without any increase in complications or patient discomfort.

Trial Registration

ClinicalTrials.gov Identifier: NCT04539158.

Clinical outcomes of obese and nonobese patients with atrial fibrillation according to associated metabolic abnormalities: A report from the COOL-AF registry

BACKGROUND

The primary objective was to determine the influence of obesity and associated metabolic status on clinical outcomes of Asian patients with atrial fibrillation (AF).

METHODS

This study was based on a prospective multicenter of patients with nonvalvular AF. Patients were classified as obese and nonobese and being metabolic unhealthy was defined as having at least one of the three cardiovascular risk factors including dyslipidemia, hypertension, or diabetes mellitus. Outcomes were a primary composite outcome of all-cause death, ischemic stroke/systemic embolism (SSE), acute myocardial infarction (MI), and heart failure (HF), as well as the individual end points.

RESULTS

There were a total of 3141 enrolled patients (mean age 67.4 ± 11.1 years; 41.0% female), of whom 1566 (49.9%) were obese and 2564 (81.6%) were metabolic unhealthy. During a mean follow-up of 32.2 ± 8.3 months, the incidence rate of the composite outcome, all-cause death, SSE, MI, and HF were 7.21 (6.63-7.82), 3.86 (3.45-4.30), 1.48 (1.23-1.77), 0.47 (0.33-0.64), and 2.84 (2.48-3.23) per 100 person-years, respectively. Metabolic unhealthy nonobese subjects were at higher risk of the composite outcomes than metabolic unhealthy obese subjects with hazard ratio (HR) 1.39, 95% confidence interval (CI) 1.17-1.66, p < .001. Metabolic unhealthy obese subjects tend to have an increased risk of the composite outcomes compared to those metabolic healthy obese (HR 1.36, 95% CI 0.91-2.02, p = .133). Metabolic healthy obese subjects were not associated with increased risk.

CONCLUSIONS

Metabolic unhealthy obese subjects were associated with an increased risk of adverse outcomes in AF patients, whereas metabolically healthy obesity was not associated with an increased risk.

Factor Xa Inhibitors versus warfarin in patients with morbid obesity and atrial fibrillation

PURPOSE

Factor Xa Inhibitors have emerged as a first-line agent in the management of non-valvular atrial fibrillation (NVAF), but there is a need for additional data surrounding their use in the morbidly obese population. The purpose of this study was to evaluate whether Factor Xa Inhibitors are as safe and effective as warfarin for the treatment of NVAF in individuals with a BMI ≥ 40 kg/m2 and/or weight ≥ 120 kg.

METHODS

This was a multi-center retrospective cohort study comparing the use of Factor Xa Inhibitors (apixaban and rivaroxaban) to warfarin for the management of NVAF in adult patients with a BMI ≥ 40 kg/m2 and/or weight ≥ 120 kg. The primary outcomes were stroke or systemic embolism and major bleeding within 12 months.

RESULTS

A total of 3,156 patients were included in the final analysis; 1,396 in the warfarin group and 1760 in the Factor Xa Inhibitor group. The mean weight and BMI of the overall cohort was 134.1 kg and 44.7 kg/m2, respectively. There was no difference in stroke or systemic embolism (OR 1.21, 95% CI 0.78-1.85) or major bleeding (OR 0.99, 95% CI 0.65 - 1.53) with Factor Xa Inhibitors compared to warfarin after controlling for covariates.

CONCLUSION

This analysis of real-world data suggests no difference in bleeding or thrombotic outcomes for severely obese patients with NVAF taking Factor Xa Inhibitors compared to warfarin. Overall, our study adds further data to support the use of Factor Xa Inhibitors as an alternative to warfarin in severely obese patients with NVAF.

Efficacy and Safety of Direct Oral Anticoagulants versus Warfarin in Obese Patients (BMI ≥ 30 kg/m2) with Atrial Fibrillation or Venous Thromboembolism: An Updated Systematic Review and Meta-Analysis

Background: Real-world data show limited utilization of direct oral anticoagulants (DOACs) in obese patients (body mass index [BMI] ≥ 30 kg/m2) due to concerns regarding their efficacy and safety in this demographic. Aim: This review aimed to consolidate current evidence on the efficacy and safety of DOACs versus warfarin in obese patients with non-valvular atrial fibrillation (AF) or venous thromboembolism (VTE). The primary efficacy outcome assessed a composite of all-cause mortality, stroke, systemic embolism (SE), and myocardial infarction (MI). Methods: A systematic search was conducted in MEDLINE, SCOPUS, and Cochrane databases from inception to December 28, 2023. Data were synthesized using random-effects meta-analysis. Results: A total of 35 studies involving 434,320 participants were analyzed. DOAC use was associated with a significant reduction in the risk of the composite outcome (RR = 0.80, 95% CI [0.65, 0.98], I2 = 95%), hemorrhagic stroke (RR = 0.58, 95% CI [0.38, 0.88], I2 = 92%), major bleeding (RR = 0.76, 95% CI [0.63, 0.92], I2 = 94%), gastrointestinal bleeding (RR = 0.59, 95% CI [0.49, 0.72], I2 = 88%), and intracranial bleeding (RR = 0.45, 95% CI [0.34, 0.60], I2 = 44%) compared to warfarin. A non-significant benefit of DOACs was observed for all-cause mortality, MI, the composite of stroke or SE, ischemic stroke, SE, VTE, and minor bleeding compared to warfarin. Subgroup analysis indicated no significant effect modification based on the indication for anticoagulation or study design. Conclusions: DOACs demonstrated a favorable efficacy and safety profile in obese individuals compared to warfarin.

Childhood maltreatment, genetic risk, and subsequent risk of arrhythmias: a prospective cohort study

Background: Emerging evidence has linked childhood maltreatment with cardiovascular disease risk; however, the association between childhood maltreatment and cardiac arrhythmias remains unclear. Moreover, any genetic predispositions to atrial fibrillation (AF), a common cardiac arrhythmia associated with an elevated risk of stroke, heart failure, and mortality, that modify such associations have been undocumented.Purpose: To examine the associations between childhood maltreatment and incident arrhythmias, and whether a genetic predisposition to arrhythmias modifies these associations.Methods: This prospective analysis included 151,741 participants from the UK Biobank (mean age 55.8 years, 43.4% male). Childhood maltreatment, including five types, was measured using the Childhood Trauma Screener (CTS). Incident arrhythmias (AF, ventricular arrhythmias [VA], and bradyarrhythmia [BA]) were documented through linked hospital admission and death registry. Weighted AF genetic risk score was calculated. Cox proportional hazard models were conducted to test for associations between childhood maltreatment and incident arrhythmias.Results: During a median follow-up of 12.21 years (interquartile range, 11.49-12.90 years), 6,588 AF, 2,093 BA, and 742 VA events occurred. Compared with the absence of childhood maltreatment, having 3-5 types of childhood maltreatment was associated with an increased risk of incident AF (HR, 1.23; 95%CI 1.09-1.37), VA (HR, 1.39; 95%CI 1.03-1.89), and BA (HR, 1.32; 95%CI 1.09-1.61) after adjusting demographic, socioeconomic and lifestyle factors. The associations between cumulative type of childhood maltreatment and the risk of AF (Poverall < .001; Pnonlinear = .674) and BA (Poverall = .007; Pnonlinear = .377) demonstrated a linear pattern. There was a gradient association between childhood maltreatment and AF risks across the intermediate and high genetic risk groups (both Ptrend < .05) but not within the low genetic risk group (Ptrend = .378), irrespective of non-significant interaction effect (Pinteraction = .204).Conclusion: Childhood maltreatment was associated with higher risks of incident arrhythmias, especially AF and BA. Genetic risk of AF did not modify these associations.