Age, left atrial dimension and arterial stiffness after external cardioversion of atrial fibrillation. A vascular component in arrhythmia maintenance? Results from a preliminary study

Atrial Fibrillation and Early Vascular Aging: Clinical Implications, Methodology Issues and Open Questions-A Review from the VascAgeNet COST Action

Atrial fibrillation (AF), the most common cardiac arrhythmia, is associated with adverse CV outcomes. Vascular aging (VA), which is defined as the progressive deterioration of arterial function and structure over a lifetime, is an independent predictor of both AF development and CV events. A timing identification and treatment of early VA has therefore the potential to reduce the risk of AF incidence and related CV events. A network of scientists and clinicians from the COST Action VascAgeNet identified five clinically and methodologically relevant questions regarding the relationship between AF and VA and conducted a narrative review of the literature to find potential answers. These are: (1) Are VA biomarkers associated with AF? (2) Does early VA predict AF occurrence better than chronological aging? (3) Is early VA a risk enhancer for the occurrence of CV events in AF patients? (4) Are devices measuring VA suitable to perform subclinical AF detection? (5) Does atrial-fibrillation-related rhythm irregularity have a negative impact on the measurement of vascular age? Results showed that VA is a powerful and independent predictor of AF incidence, however, its role as risk modifier for the occurrence of CV events in patients with AF is debatable. Limited and inconclusive data exist regarding the reliability of VA measurement in the presence of rhythm irregularities associated with AF. To date, no device is equipped with tools capable of detecting AF during VA measurements. This represents a missed opportunity to effectively perform CV prevention in people at high risk. Further advances are needed to fill knowledge gaps in this field.

Should atrial fibrillation be considered a vascular disease? The need for a comprehensive vascular approach

INTRODUCTION

Atrial fibrillation (AF) cannot be considered an isolated disease. Patients with AF should be managed using a comprehensive approach that is not limited to stroke prevention.

AREAS COVERED

In this manuscript, the potential role of AF as a vascular disease that is managed as part of a holistic approach was reviewed.

EXPERT OPINION

The residual risk of stroke in patients with AF reaches 1-2% annually, despite appropriate anticoagulation therapy. Additionally, patients with AF may develop cognitive impairment through stroke-independent pathways. Furthermore, patients with AF may have a higher risk of developing atherosclerotic vascular disease in various vascular beds and chronic kidney disease; conversely, patients with atherosclerotic disease may have an increased risk of developing AF. AF should be considered a truly systemic vascular disease, since it brings together several hemodynamic and systemic changes, including inflammation, oxidative stress, activation of the renin-angiotensin-aldosterone and sympathetic systems, as well as a prothrombotic state and endothelial dysfunction. In this regard, patients with AF should be treated based on a holistic approach that is not limited to oral anticoagulation but includes complete vascular protection.

Recurrence of atrial fibrillation after pulmonary vein isolation in dependence of arterial stiffness

Background

Arterial stiffness (AS) has emerged as a strong predictor of cardiovascular (CV) diseases. Although increased AS has been described as a predictor of atrial fibrillation (AF), its role as a risk marker for AF recurrence has not yet been elucidated.

Methods

Patients with AF who underwent pulmonary vein isolation (PVI) were included in this study. Presence of AS was evaluated by measuring aortic distensibility (AD) of the descending aorta by transoesophageal echocardiography.

Results

In total, 151 patients (mean ± standard deviation (SD) age 71.9 ± 9.8 years) were enrolled and followed for a median duration of 21 months (interquartile range 15.0–31.0). During follow-up, AF recurred in 94 (62.3%) patients. AF recurrence was seen more frequently in patients with permanent AF (27% vs 46%, p = 0.03) and in those who had undergone prior PVI (9% vs 23%, p = 0.02). AD was significantly reduced in patients with AF recurrence (mean ± SD 2.6 ± 2.3 vs 1.5 ± 0.7 × 10⁻³ mm Hg⁻¹, p < 0.0001), as well as left atrial volume index (LAVI) (mean ± SD 29 ± 12 vs 44 ± 15 ml/m², p < 0.0001). Multivariable analysis revealed LAVI (odds ratio (OR) 2.9, 95% confidence interval (CI) 1.2–3.4) and AS (OR 3.6, 95% CI 2.8–4.1) as independent risk factors of AF recurrence.

Conclusion

Increased AS and left atrial size were independent predictors of AF recurrence after PVI. AD as surrogate marker of AS seemed to reflect the overall CV risk. In addition, AD was significantly correlated with left atrial size, which suggests that increased AS leads to atrial remodelling and thus to AF recurrence.

Trial registration

German registry for clinical studies (DRKS), DRKS00019007.

Supplementary Information

The online version of this article (10.1007/s12471-021-01644-w) contains supplementary material, which is available to authorized users.

Determinants of arterial stiffness in patients with atrial fibrillation

BACKGROUND

Arterial stiffness has emerged as a strong predictor of cardiovascular disease, end-organ damage and all-cause mortality. Although increased arterial stiffness has been described as a predictor of atrial fibrillation, the relationship between arterial stiffness and atrial fibrillation is uncertain.

AIM

We assessed arterial stiffness in patients with atrial fibrillation compared with that in a control group.

METHODS

We enrolled 151 patients with atrial fibrillation who underwent pulmonary vein isolation (mean age 71.1±9.8 years) and 54 control patients with similar cardiovascular risk profiles and sinus rhythm, matched for age (mean age 68.6±15.7 years) and sex. Aortic distensibility as a measure of arterial stiffness was assessed by transoesophageal echocardiography. Patients with atrial fibrillation were followed over a median of 21 (15 to 31) months.

RESULTS

Compared with control patients, patients with atrial fibrillation had significantly lower aortic distensibility (1.8±1.1 vs. 2.1±1.1 10^-3mmHg^-1; P=0.02). Age (hazard ratio 0.67, 95% confidence interval 0.003 to 0.03; P=0.02) and pulse pressure (hazard ratio -1.35, 95% confidence interval -0.07 to -0.03; P<0.0001) were the strongest predictors of decreased aortic distensibility in the study cohort. This effect was independent of the type of atrial fibrillation (paroxysmal/persistent). During follow-up, decreased aortic distensibility was a predictor of cardiovascular and all-cause hospitalizations, as well as recurrences of atrial fibrillation, with a higher incidence rate of events in patients in the lowest aortic distensibility quartile (P=0.001).

CONCLUSIONS

Aortic distensibility was significantly reduced in patients with atrial fibrillation, with age and pulse pressure showing the strongest correlation, independent of the type of atrial fibrillation. Additionally, decreased aortic distensibility was associated with cardiovascular and all-cause hospitalizations, as well as recurrences of atrial fibrillation, which showed a quartile-dependent occurrence.

Arterial stiffness and left ventricular performance in elderly patients with persistent atrial fibrillation

BACKGROUND

The prevalence of atrial fibrillation (AF) and arterial stiffness (AS) increases with age.

AIMS

To evaluate if AS is correlated to longitudinal strain (LS), a marker of left ventricular (LV) function, in elderly AF patients with preserved ejection fraction (EF) undergoing external cardioversion.

METHODS

AS was measured using the cardio-ankle vascular index (CAVI), LS was calculated from echocardiographic data of three consecutive cardiac cycles.

RESULTS

We enrolled 38 patients (age 76 ± 8 years; men 60.5%; EF 65 ± 7%). LS and CAVI were, respectively, - 17.7 ± 3.7% and 9.7 ± 1.3. Multivariate analysis showed that LV performance was inversely related to height (p < 0.001) and to the presence of AF-related symptoms (p = 0.008). LS grew with increasing values of CAVI (p = 0.038).

CONCLUSIONS

In elderly AF patients with preserved systolic function, LV performance is directly associated with AS. This link could influence atrium remodeling and the incidence of arrhythmia relapse.

Left Atrial Mechanical Function and Aortic Stiffness in Middle-aged Patients with the First Episode of Atrial Fibrillation

Background:

In the early stages of atrial remodeling, aortic stiffness might be an indication of an atrial myopathy, in particular, atrial fibrosis. This study aimed to investigate the association between left atrial (LA) mechanical function, assessed by two-dimensional speckle tracking echocardiography, and aortic stiffness in middle-aged patients with the first episode of nonvalvular atrial fibrillation (AF).

Methods:

This prospective study included 34 consecutive patients with the first episode of AF, who were admitted to Kartal Koşuyolu Research and Training Hospital between May 2013 and October 2015, and 31 age- and gender-matched healthy controls. During the 1^st month (mostly in the first 2 weeks) following their first admission, 34 patients underwent the first pulse wave measurements. Then, 21 patients were recalled for their second pulse wave measurement at 11.8 ± 6.0 months following their initial admission. Echocardiographic and pulse wave findings were compared between these 34 patients and 31 healthy controls. We also compared the pulse wave and echocardiographic findings between the first and second measurements in 21 patients.

Results:

Pulse wave analysis showed no significant differences between the AF patients and healthy controls with respect to PWV (10.2 ± 2.5 m/s vs. 9.7 ± 2.1 m/s; P = 0.370), augmentation pressure (9.6 ± 7.4 mmHg vs. 9.1 ± 5.7 mmHg; P = 0.740), and aortic pulse pressure (AoPP; 40.4 ± 14.0 mmHg vs. 42.1 ± 7.6 mmHg, P = 0.550). The first LA positive peak of strain was inversely related to the augmentation pressure (r = −0.30; P = 0.02) and aortic systolic pressure (r = −0.26, P = 0.04). Comparison between the two consecutive pulse wave measurements in 21 patients showed similar results, except for AoPP. In 21 patients, the AoPP at the second measurement (45.1 ± 14.1 mmHg) showed a significant increase compared with AoPP at the first measurement (39.0 ± 10.6 mmHg, P = 0.028), which was also higher than that of healthy controls (42.1 ± 7.6 mmHg, P = 0.000).

Conclusion:

The association between aortic stiffness with reduced atrial strain and the key role of AoPP in the development of AF should be considered when treating nonvalvular AF patients with normal LA sizes.

Atrial fibrillation after electrical cardioversion in elderly patients: a role for arterial stiffness? Results from a preliminary study

Background and aims

Atrial fibrillation (AF) is the most frequent arrhythmia of the elderly, and electrical cardioversion (ECV) is a common procedure, although incidence of recurrences remains high. We evaluated the possible association between arterial stiffness (AS) and the persistence or recurrence of AF in elderly patients after ECV.

Methods

We enrolled all subjects undergoing ECV over a 9-month period. AS was evaluated with the cardio-ankle vascular index (CAVI). Patients were then visited at follow-up (on average at 6 months).

Results

Thirty-one patients (age 78 ± 7 years; men 67.7 %; CHA₂DS₂-VASc 4.1 ± 1.6; AF length >2 months 51.6 %; CAVI 9.9 ± 1.6) underwent ECV. At follow-up, sinus rhythm was recorded in 16 (51.6 %) patients. At multivariate analysis, the presence of AF was directly associated with CHA₂DS₂-VASc score and CAVI. Amiodarone therapy reduced the risk of relapsed AF.

Conclusions

In elderly AF patients treated with ECV, AS at baseline seems to predict AF at follow-up.