Chronic obstructive pulmonary disease and the development of atrial fibrillation

Macrophage IL-1β mediates atrial fibrillation risk in diabetic mice

Diabetes mellitus (DM) is an independent risk factor for atrial fibrillation (AF). The mechanisms underlying DM-associated AF are unclear. AF and DM are both related to inflammation. We investigated whether DM-associated inflammation contributed to AF risk. Mice were fed with high-fat diet to induce type II DM and were subjected to IL-1β antibodies, macrophage depletion by clodronate liposomes, a mitochondrial antioxidant (mitoTEMPO), or a cardiac ryanodine receptor 2 (RyR2) stabilizer (S107). All tests were performed at 36-38 weeks of age. DM mice presented with increased AF inducibility, enhanced mitochondrial reactive oxygen species (mitoROS) generation, and activated innate immunity in the atria, as evidenced by enhanced monocyte chemoattractant protein-1 (MCP-1) expression, macrophage infiltration, and IL-1β levels. Signs of aberrant RyR2 Ca2+ leak were observed in the atria of DM mice. IL-1β neutralization, macrophage depletion, and exposure to mitoTEMPO and S107 significantly ameliorated the AF vulnerability in DM mice. Atrial overexpression of MCP-1 increased AF occurrence in normal mice through the same mechanistic signaling cascade as observed in DM mice. In conclusion, macrophage-mediated IL-1β contributed to DM-associated AF risk through mitoROS modulation of RyR2 Ca2+ leak.

Detrimental Impact of Atrial Fibrillation among Patients Hospitalized for Acute Exacerbation of COPD: Results of a Population-Based Study in Spain from 2016 to 2021

Background/Objectives: To analyze changes in the prevalence of atrial fibrillation (AF) in patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD); to evaluate hospital outcomes according to AF status, assessing sex differences; to identify factors associated with AF presence; and to analyze variables associated with in-hospital mortality (IHM) in AE-COPD patients with AF. Methods: We used data from the Registry of Specialized Care Activity-Basic Minimum Data Set (RAE-CMBD) to select patients aged ≥40 years with COPD in Spain (2016-2021). We stratified the study population according to AF presence and sex. The propensity score matching (PSM) methodology was employed to create comparable groups based on age, admission year, and comorbidities at the time of hospitalization. Results: We identified 399,196 hospitalizations that met the inclusion criteria. Among them, 20.58% had AF. The prevalence of AF rose from 2016 to 2021 (18.26% to 20.95%), though the increase was only significant in men. The median length of hospital stay (LOHS) and IHM were significantly higher in patients with AF than in those without AF. After PSM, IHM remained significantly higher for man and women with AF. Older age, male sex, and several comorbidities were factors associated with AF. Additionally, older age, male sex, different comorbidities including COVID-19, hospitalization in the year 2020, mechanical ventilation, and intensive care unit (ICU) admission were associated with higher IHM in patients with AE-COPD and AF. Conclusions: AF prevalence was high in patients hospitalized for AE-COPD, was higher in men than in women, and increased over time. AF presence was associated with worse outcomes. The variables associated with IHM in hospitalized AE-COPD patients with AF were older age, male sex, different comorbidities including COVID-19 presence, hospitalization in the year 2020, need of mechanical ventilation, and ICU admission.

Predictive nomogram models for atrial fibrillation in COPD patients: A comprehensive analysis of risk factors and prognosis

The aim of the present study was to identify the independent risk factors and prognostic indicators for atrial fibrillation (AF) in patients with chronic obstructive pulmonary disease (COPD) and to develop predictive nomogram models. This retrospective study included a total of 286 patients with COPD who were admitted to the Second Affiliated Hospital of Guilin Medical College between January 2020 and May 2022. The average age of the patients was 77.11±8.67 years. Based on the presence or absence of AF, the patients were divided into two groups: The AF group (n=87) and the non-AF group (n=199). Logistic regression analysis was conducted to identify variables with significant differences between the two groups. Nomogram models were constructed to predict the occurrence of AF in COPD patients and to assess prognosis. Survival analysis was performed using the Kaplan-Meier method. The follow-up period for the present study extended until April 31, 2023. Survival time was defined as the duration from the date of the interview to the date the participant succumbed or the end of the follow-up period. In the present study, age, uric acid (UA) and left atrial diameter (LAD) were found to be independent risk factors for the development of AF in patients diagnosed with COPD. The stepwise logistic regression analysis revealed that age had an odds ratio (OR) of 1.072 [95% confidence interval (CI): 1.019-1.128; P=0.007], UA had an OR of 1.004 (95% CI: 1.001-1.008; P=0.010) and LAD had an OR of 1.195 (95% CI: 1.098-1.301; P<0.001). Univariate and multivariate Cox regression analysis revealed that LAD and UA were independent prognostic factors for long-term mortality in COPD patients with AF. LAD had a hazard ratio (HR) of 1.104 (95% CI: 1.046-1.165; P<0.001) and UA had an HR of 1.004 (95% CI: 1.000-1.008; P=0.042). Based on these findings, predictive nomogram models were developed for AF in COPD patients, which demonstrated good discrimination ability with an area under the curve of 0.886. The prognostic nomogram for COPD patients with AF also showed good predictive accuracy with a concordance index of 0.886 (95% CI: 0.842-0.930). These models can provide valuable information for risk assessment and prognosis evaluation in clinical practice. Age, UA and LAD are independent risk factors for AF in COPD patients. The developed nomogram models provide a reliable tool for predicting AF in COPD patients and for prognosis assessment.

Atrial cardiomyocytes contribute to the inflammatory status associated with atrial fibrillation in right heart disease

AIMS

Right heart disease (RHD), characterized by right ventricular (RV) and atrial (RA) hypertrophy, and cardiomyocytes' (CM) dysfunctions have been described to be associated with the incidence of atrial fibrillation (AF). Right heart disease and AF have in common, an inflammatory status, but the mechanisms relating RHD, inflammation, and AF remain unclear. We hypothesized that right heart disease generates electrophysiological and morphological remodelling affecting the CM, leading to atrial inflammation and increased AF susceptibility.

METHODS AND RESULTS

Pulmonary artery banding (PAB) was surgically performed (except for sham) on male Wistar rats (225-275 g) to provoke an RHD. Twenty-one days (D21) post-surgery, all rats underwent echocardiography and electrophysiological studies (EPS). Optical mapping was performed in situ, on Langendorff-perfused hearts. The contractility of freshly isolated CM was evaluated and recorded during 1 Hz pacing in vitro. Histological analyses were performed on formalin-fixed RA to assess myocardial fibrosis, connexin-43 levels, and CM morphology. Right atrial levels of selected genes and proteins were obtained by qPCR and Western blot, respectively. Pulmonary artery banding induced severe RHD identified by RV and RA hypertrophy. Pulmonary artery banding rats were significantly more susceptible to AF than sham. Compared to sham RA CM from PAB rats were significantly elongated and hypercontractile. Right atrial CM from PAB animals showed significant augmentation of mRNA and protein levels of pro-inflammatory interleukin (IL)-6 and IL1β. Sarcoplasmic-endoplasmic reticulum Ca2+-ATPase-2a (SERCA2a) and junctophilin-2 were decreased in RA CM from PAB compared to sham rats.

CONCLUSIONS

Right heart disease-induced arrhythmogenicity may occur due to dysfunctional SERCA2a and inflammatory signalling generated from injured RA CM, which leads to an increased risk of AF.

Atrial fibrillation: comorbidities, lifestyle, and patient factors

Modern anticoagulation therapy has dramatically reduced the risk of stroke and systemic thromboembolism in people with atrial fibrillation (AF). However, AF still impairs quality of life, increases the risk of stroke and heart failure, and is linked to cognitive impairment. There is also a recognition of the residual risk of thromboembolic complications despite anticoagulation. Hence, AF management is evolving towards a more comprehensive understanding of risk factors predisposing to the development of this arrhythmia, its' complications and interventions to mitigate the risk. This review summarises the recent advances in understanding of risk factors for incident AF and managing these risk factors. It includes a discussion of lifestyle, somatic, psychological, and socioeconomic risk factors. The available data call for a practice shift towards a more individualised approach considering an increasingly broader range of health and patient factors contributing to AF-related health burden. The review highlights the needs of people living with co-morbidities (especially with multimorbidity), polypharmacy and the role of the changing population demographics affecting the European region and globally.

Impact of chronic obstructive pulmonary disease in patients with atrial fibrillation: an analysis from the GLORIA-AF registry

AIMS

Chronic obstructive pulmonary disease (COPD) may influence management and prognosis of atrial fibrillation (AF), but this relationship has been scarcely explored in contemporary global cohorts. We aimed to investigate the association between AF and COPD, in relation to treatment patterns and major outcomes.

METHODS AND RESULTS

From the prospective, global GLORIA-AF registry, we analysed factors associated with COPD diagnosis, as well as treatment patterns and risk of major outcomes in relation to COPD. The primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). A total of 36 263 patients (mean age 70.1 ± 10.5 years, 45.2% females) were included; 2,261 (6.2%) had COPD. The prevalence of COPD was lower in Asia and higher in North America. Age, female sex, smoking, body mass index, and cardiovascular comorbidities were associated with the presence of COPD. Chronic obstructive pulmonary disease was associated with higher use of oral anticoagulant (OAC) [adjusted odds ratio (aOR) and 95% confidence interval (CI): 1.29 (1.13-1.47)] and higher OAC discontinuation [adjusted hazard ratio (aHR) and 95% CI: 1.12 (1.01-1.25)]. Chronic obstructive pulmonary disease was associated with less use of beta-blocker [aOR (95% CI): 0.79 (0.72-0.87)], amiodarone and propafenone, and higher use of digoxin and verapamil/diltiazem. Patients with COPD had a higher hazard of primary composite outcome [aHR (95% CI): 1.78 (1.58-2.00)]; no interaction was observed regarding beta-blocker use. Chronic obstructive pulmonary disease was also associated with all-cause death [aHR (95% CI): 2.01 (1.77-2.28)], MACEs [aHR (95% CI): 1.41 (1.18-1.68)], and major bleeding [aHR (95% CI): 1.48 (1.16-1.88)].

CONCLUSION

In AF patients, COPD was associated with differences in OAC treatment and use of other drugs; Patients with AF and COPD had worse outcomes, including higher mortality, MACE, and major bleeding.

Association between cancer, CHA2DS2VASc risk, and in-hospital ischaemic stroke in patients hospitalized for atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is commonly encountered in cancer patients. We investigated the CHA2DS2VASc score, and its association with in-hospital ischaemic stroke in patients with cancer who were hospitalized for AF.

METHODS AND RESULTS

Using the United States National Inpatient Sample, all hospitalizations with principal diagnosis of AF between October 2015 and December 2018 were stratified by cancer diagnosis, type, and CHA2DS2VASc risk categories (low risk, low-moderate risk, moderate-high risk). In-hospital ischaemic stroke and its association with the CHA2DS2VASc risk score was assessed across the groups using hierarchical multivariable logistic regression with adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). Discrimination of CHA2DS2VASc score for in-hospital ischaemic stroke was evaluated with Receiver Operating Characteristic and Area Under the Curve (AUC). Among 1 341 870 included hospitalizations, 71 965 (5.4%) had comorbid cancer. Cancer patients had a higher proportion of moderate-high CHA2DS2VASc risk compared with their non-cancer counterparts (86.5% vs. 82.3%, P < 0.001). Compared with their low CHA2DS2VASc risk counterparts, cancer patients in low-moderate and moderate-high risk scores had similar odds of developing stroke (aOR 1.28 95% CI 0.22-7.63 and aOR 1.78 95% CI 0.41-7.66, respectively). The CHA2DS2VASc risk score had poor discrimination for ischaemic stroke in the cancer group (AUC 0.538 95% CI 0.477-0.598).

CONCLUSION

Cancer patients with AF have high CHA2DS2VASc risk. Discrimination of CHA2DS2VASc for ischaemic stroke is lower in cancer than non-cancer patients, and CHA2DS2VASc may not be adequate in determining ischaemic risk in cancer population.

Repurposing catheter ablation work-up to detect expiratory airflow limitation in patients with atrial fibrillation

Background

In atrial fibrillation (AF) patients, presence of expiratory airflow limitation may negatively impact treatment outcomes. AF patients are not routinely screened for expiratory airflow limitation, but existing examinations can help identify at-risk individuals. We aimed to assess the diagnostic value of repurposing existing assessments from the pre-ablation work-up to identify and understand the characteristics of affected patients.

Methods

We screened 110 consecutive AF patients scheduled for catheter ablation with handheld spirometry. Routine pre-ablation work-up included cardiac computed tomographic angiography (CCTA), transthoracic echocardiography and polygraphy. CCTA was analyzed qualitatively for emphysema and airway abnormalities. Multivariate logistic regression analysis was performed to determine predictors of expiratory airflow limitation.

Results

We found that 25 % of patients had expiratory airflow limitation, which was undiagnosed in 86 % of these patients. These patients were more likely to have pulmonary abnormalities on CCTA, including emphysema (odds ratio [OR] 4.2, 95 % confidence interval [CI] 1.12-15.1, p < 0.05) and bronchial wall thickening (OR 2.6, 95 % CI 1.0-6.5, p < 0.05). The absence of pulmonary abnormalities on CCTA accurately distinguished patients with normal lung function from those with airflow limitation (negative predictive value: 85 %). Echocardiography and polygraphy did not contribute significantly to identifying airflow limitation.

Conclusions

In conclusion, routine pre-ablation CCTA can detect pulmonary abnormalities in AF patients with airflow limitation, guiding further pulmonary assessment. Future studies should investigate its impact on ablation procedure success.

Spirometry in atrial fibrillation: what's the catch?

INTRODUCTION

People with COPD rarely have COPD alone, and the commonest co-morbidities occurring with COPD are cardiovascular. Whilst multiple studies have explored the association between major cardiovascular events and COPD, less attention has been paid to arrhythmias, specifically atrial fibrillation (AF). AF and COPD frequently occur together, posing challenges in diagnosis and management. In this review, we describe the relationship between AF and COPD epidemiologically and physiologically, demonstrating the role of spirometry as a diagnostic and disease management tool.

AREAS COVERED

We provide epidemiological evidence that COPD and AF are independent risk factors for one another, that either disease is highly prevalent amongst people with the other, and that they have shared risk factors; all of which contribute to adverse prognostic. We elucidated common pathophysiological mechanisms implicated in AF-COPD. We ultimately present the epidemiological and physiological evidence with a view to highlight specific areas where we feel spirometry is of value in the management of AF-COPD.

EXPERT OPINION

AF and COPD commonly co-occur, there is often diagnostic delay, increased risk of reduced cardioversion success, and missed opportunity to intervene to reduce stroke risk. Greater awareness and timelier diagnosis and guideline directed management may improve outcomes for people with both diseases.

Combining bioinformatics and machine learning to identify common mechanisms and biomarkers of chronic obstructive pulmonary disease and atrial fibrillation

Background

Patients with chronic obstructive pulmonary disease (COPD) often present with atrial fibrillation (AF), but the common pathophysiological mechanisms between the two are unclear. This study aimed to investigate the common biological mechanisms of COPD and AF and to search for important biomarkers through bioinformatic analysis of public RNA sequencing databases.

Methods

Four datasets of COPD and AF were downloaded from the Gene Expression Omnibus (GEO) database. The overlapping genes common to both diseases were screened by WGCNA analysis, followed by protein-protein interaction network construction and functional enrichment analysis to elucidate the common mechanisms of COPD and AF. Machine learning algorithms were also used to identify key biomarkers. Co-expression analysis, “transcription factor (TF)-mRNA-microRNA (miRNA)” regulatory networks and drug prediction were performed for key biomarkers. Finally, immune cell infiltration analysis was performed to evaluate further the immune cell changes in the COPD dataset and the correlation between key biomarkers and immune cells.

Results

A total of 133 overlapping genes for COPD and AF were obtained, and the enrichment was mainly focused on pathways associated with the inflammatory immune response. A key biomarker, cyclin dependent kinase 8 (CDK8), was identified through screening by machine learning algorithms and validated in the validation dataset. Twenty potential drugs capable of targeting CDK8 were obtained. Immune cell infiltration analysis revealed the presence of multiple immune cell dysregulation in COPD. Correlation analysis showed that CDK8 expression was significantly associated with CD8+ T cells, resting dendritic cell, macrophage M2, and monocytes.

Conclusions

This study highlights the role of the inflammatory immune response in COPD combined with AF. The prominent link between CDK8 and the inflammatory immune response and its characteristic of not affecting the basal expression level of nuclear factor kappa B (NF-kB) make it a possible promising therapeutic target for COPD combined with AF.

How, when and why to establish preoperative surgical risk in thoracic surgery

PURPOSE OF REVIEW

Emphasizing a systems-based approach, we discuss the timing for referral for perioperative surgical consultation. This review then highlights several types of comorbidities that may complicate thoracic procedures, and references recent best practices for their management.

RECENT FINDINGS

Patients requiring thoracic surgeries present some of the most challenging cases for both intraoperative and postoperative management. The recent SARS-CoV-2 pandemic has only exacerbated these concerns. Effective preoperative optimization, however, provides for identification of patient comorbidities, allowing for mitigation of surgical risks. This kind of planning is multidisciplinary by nature. We believe patients benefit from early engagement of a dedicated preoperative clinic experienced for caring for complex surgical patients.

SUMMARY

Optimizing patients for thoracic surgery can be challenging for small and large health systems alike. Implementation of evidence-based guidelines can improve care and mitigate risk. As surgical techniques evolve, future research is needed to ensure that perioperative care continues to progress.

Sex-specific and age-specific incidence of ischaemic heart disease, atrial fibrillation and heart failure in community patients with chronic obstructive pulmonary disease

OBJECTIVE

To estimate the incidence of ischaemic heart disease, atrial fibrillation and heart failure in community patients with or without chronic obstructive pulmonary disease (COPD).

METHODS

For this population-based study, we used primary care data of the Julius General Practitioners' Network. Eligible participants were aged 40-80 years old and contributed data between January 2014 and February 2019. Participants were divided into groups according to COPD status and were followed up for new ischaemic heart disease, atrial fibrillation and/or heart failure. Age-specific and sex-specific incidence and incidence rate ratios were calculated for patients with and without COPD.

RESULTS

Mean follow-up was 3.9 years, 6223 patients were included in the COPD group, and 137 028 individuals in the background group without COPD. Incidence rates of all three heart diseases increased with age and were higher in males, independent of presence of COPD. Incidence rate ratios for patients with COPD, adjusted for age and sex, were 1.69 (95% CI 1.49 to 1.92) for ischaemic heart disease, 1.56 (95% CI 1.38 to 1.77) for atrial fibrillation and 2.96 (95% CI 2.58 to 3.40) for heart failure.

CONCLUSION

The incidence of all major cardiovascular diseases is higher in patients with COPD, with the highest incidence rate ratio observed for heart failure.

Progressive and Simultaneous Right and Left Atrial Remodeling Uncovered by a Comprehensive Magnetic Resonance Assessment in Atrial Fibrillation

Background Left atrial structural remodeling contributes to the arrhythmogenic substrate of atrial fibrillation (AF), but the role of the right atrium (RA) remains unknown. Our aims were to comprehensively characterize right atrial structural remodeling in AF and identify right atrial parameters predicting recurrences after ablation. Methods and Results A 3.0 T late gadolinium enhanced-cardiac magnetic resonance was obtained in 109 individuals (9 healthy volunteers, 100 patients with AF undergoing ablation). Right and left atrial volume, surface, and sphericity were quantified. Right atrial global and regional fibrosis burden was assessed with validated thresholds. Patients with AF were systematically followed after ablation for recurrences. Progressive right atrial dilation and an increase in sphericity were observed from healthy volunteers to patients with paroxysmal and persistent AF; fibrosis was similar among the groups. The correlation between parameters recapitulating right atrial remodeling was mild. Subsequently, remodeling in both atria was compared. The RA was larger than the left atrium (LA) in all groups. Fibrosis burden was higher in the LA than in the RA of patients with AF, whereas sphericity was higher in the LA of patients with persistent AF only. Fibrosis, volume, and surface of the RA and LA, but not sphericity, were strongly correlated. Tricuspid regurgitation predicted right atrial volume and shape, whereas diabetes was associated with right atrial fibrosis burden; sex and persistent AF also predicted right atrial volume. Fibrosis in the RA was mostly located in the inferior vena cava-RA junction. Only right atrial sphericity is significantly associated with AF recurrences after ablation (hazard ratio, 1.12 [95% CI, 1.01-1.25]). Conclusions AF progression associates with right atrial remodeling in parallel with the LA. Right atrial sphericity yields prognostic significance after ablation.

Are cardiovascular comorbidities always associated with a worse prognosis in patients with lung cancer?

Many factors contribute to mortality in lung cancer, including the presence of concomitant cardiovascular disease. In the treatment of early stage of lung cancer, the presence of comorbidities and occurence of cardiotoxicity may be prognostic. The effect of cardiotoxicity of radiotherapy and chemoradiotherapy on overall survival has been documented. Acute arterial and venous thromboembolic events seem to correlate with the degree of the histological malignancy, its clinical advancement, and even with optimal cardiac treatment, they may influence the survival time. In the case of high-grade and advanced lung cancer stage especially in an unresectable stadium, the prognosis depends primarily on the factors related to the histopathological and molecular diagnosis. Electrocardiographic and echocardiographic abnormalities may be prognostic factors, as they seem to correlate with the patient's performance status as well as tumor localization and size.

Emergency department cardiovascular disease encounters and associated mortality in patients with cancer: A study of 20.6 million records from the USA

BACKGROUND

there is limited data on Emergency department (ED) cardiovascular disease (CVD) presentations and outcomes amongst cancer patients.

OBJECTIVES

The present study aimed to describe the clinical characteristics, prevalence, and clinical outcomes of the most common cardiovascular ED admissions in patients with cancer.

METHODS

All ED encounters with a primary CVD diagnosis from the US Nationwide Emergency Department Sample between January 2016 to December 2018 were stratified by cancer type as well as metastatic status. Multivariable logistic regression was performed to determine the adjusted odds ratios of in-hospital mortality in different groups.

RESULTS

From a total of 20,737,247 ED encounters with a primary CVD diagnosis, cancer was present in 3.4%. In patients with cancer the most common CVDs were DVT/PE (20%), hypertensive heart or kidney disease (14.7%), and AF/flutter (11.2%). The distribution of CVDs varied by cancer type, with AF/flutter most common in patients with lung cancer, AMI most common in patients with prostate cancer, heart failure most common in those with haematological malignancies, and patients with colorectal cancer having the greatest frequency of DVT/PE. Cancer status was independently associated with significantly higher risk of mortality in almost all CVD categories, consistent across all the cancer types, amongst which lung cancer patients had the highest risk of mortality across all CVD categories, except intracranial haemorrhage and hypertensive crisis.

CONCLUSIONS

Cardiovascular presentations to the ED varied by cancer subtype. Across all cancer subtypes, patients presenting with cardiovascular presentations carried a significantly increased risk of mortality compared to patients with no cancer.

Impact of COPD or Asthma on the Risk of Atrial Fibrillation: A Systematic Review and Meta-Analysis

Background:

Respiratory diseases related to chronic pulmonary ventilation dysfunction are mainly composed of chronic obstructive pulmonary disease (COPD) and asthma. Our meta-analysis aimed to illustrate the association of COPD or asthma with risk of atrial fibrillation (AF).

Methods

We systematically searched the databases of the PubMed, Embase, and Cochrane library until December 2021 for studies focusing on the relationship between COPD or asthma and AF risk. Due to the potential heterogeneity across studies, the random-effects model was used to pool the studies.

Results

Our meta-analysis included 14 studies. Based on the random-effects model, the pooled analysis showed that COPD (risk ratio[RR] = 1.74, 95% confidence interval [CI]: 1.70–1.79) and asthma (RR = 1.08, 95% CI: 1.04–1.12) were significantly associated with an increased risk of AF. The results did not change after each study was excluded.

Conclusion

Our current data suggested that COPD or asthma with associated with an increased risk of AF.

New-Onset Atrial Fibrillation Is a Risk Factor of Ischemic Stroke in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) induces atrial fibrillation (AF) and stroke, and COPD with AF increased ischemic stroke (IS) in a cross-sectional study. Therefore, healthcare providers must be concerned and well-informed about this particular situation. For this study, inpatient data were obtained from the Taiwan National Health Insurance Database in 2010. We identified patients who were hospitalized with COPD (International Classification of Disease, Ninth Revision, Clinical Modification [ICD-9-CM] is 491, 492, and 496). Patients who experienced AF (ICD-9-CM to 427.3) during the same admission or after COPD hospitalization were discharged and defined as new-onset AF. The outcome was IS (ICD-9-CM as 433–437). The factors related to IS after COPD were used for multivariate logistic regression. There were 4177/62163 (6.72%) patients with incident IS. The risk of IS after COPD hospitalization was shown to have an adjusted odds ratio of 1.749 (95% CI: 1.584–1.93, p < 0.001) for patients with new-onset AF. Other factors included advanced age, atherosclerosis factors, comorbidity severity, sepsis and lower-level hospital admission. In conclusion, COPD patients suffering from new-onset AF had an increased incidence of IS in the population observation study. New-onset AF was an omit risk factor for IS in COPD in the Chinese population.

Electrocardiographic Abnormalities in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Objective: The objective of this article was to determine the frequency of different electrocardiographic (ECG) abnormalities in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD).

Design: This is a cross-sectional study.

Place and duration: The study was conducted at the medicine department at Civil Hospital Karachi, Pakistan, between November 2018 and May 2019.

Method: Both female and male participants aged 18-60 years with acute exacerbation of COPD (as per the operational definition) for more than three days who did not receive any treatment for exacerbation were included in the study. Twelve-lead ECG was recorded (Schiller AG, Baar, Switzerland) for 10 minutes after the supine rest, with a 50 mm/s of paper speed, 10 mm/mV of gain, and filter default settings.

Results: In total, 140 participants (male: n = 124 [88.6%] and female: n = 16 [11.4%]) were included the research. The mean age of the participants was 40.43 ± 11.51 years. In terms of severity, 46 (32.95) patients presented with mild, 46 (32.9%) with moderate, and 48 (34.4%) with severe exacerbation. Moreover, 33 (23.65%) participants had ECG abnormalities, i.e., 13 (9.3%) patients presented with right atrial enlargement, and eight (5.7%) with right ventricular hypertrophy. Patients with a longer smoking duration (years) were likely to present with ECG abnormalities.

Conclusion: Patients with COPD who had severe acute exacerbation and a long smoking duration have a high prevalence of ECG abnormalities. Hence, ECG may be a valuable tool for detecting ischemic abnormalities among patients with COPD, independent of previously known heart disease, in clinical settings.

Association of Chronic Obstructive Pulmonary Disease With Arrhythmia Risks: A Systematic Review and Meta-Analysis

Background: A large number of studies have shown that the arrhythmia risks may be the potential causes of death among chronic obstructive pulmonary disease (COPD) patients. However, the association of COPD with risks of arrhythmias has never been systematically reviewed. Therefore, we performed a meta-analysis to assess the relationship between COPD and arrhythmia risks.

Methods: An updated systematic retrieval was carried out within the databases of Embase and PubMed until June 27, 2021.The random-effects model was used to pool studies due to the potential heterogeneity across the included studies. The risk ratios (RRs) with 95% confidence intervals (CIs) were regarded as effect estimates.

Results: A total of 21 studies were included in our meta-analysis. In the pooled analysis by the random-effects model, the results showed that COPD was significantly related to the risk of atrial fibrillation (AF) (RR = 1.99, 95% CI: 1.46–2.70), ventricular arrhythmias (VA) (RR = 2.01, 95% CI: 1.42–2.85), and sudden cardiac death (SCD) (RR = 1.68, 95% CI: 1.28–2.21). The corresponding results were not changed after exclusion one study at a time. The pooled results were also stable when we re-performed the analysis using the fixed-effects model.

Conclusions: Our current data suggested that COPD was associated with increased risks of AF, VA, and SCD.

Switching to nebulised short acting bronchodilators does not increase the risk of arrhythmia in patients hospitalized with a COPD exacerbation

If short acting β2-agonists and muscarinic antagonists (SABA/SAMA) may have proarrhythmic effects during acute COPD exacerbations (AECOPD) is still unknown. The primary objective of the study was to investigate the incidence of new onset arrhythmias in hospitalized patients shifted to SABA/SAMA during an AECOPD compared with continuing chronic inhaled therapy. Secondary objectives were to assess the clinical characteristics of patients shifted to SABA/SAMA and risk factors for arrhythmia. This was a retrospective, observational, study enrolling consecutive patients hospitalized with an AECOPD. Incidence of arrhythmias was obtained reviewing digital records. Patients with chronic arrhythmias or home-treated with SABA/SAMA were excluded. 235 patients (63.8% males) were included, and 10/182 patients shifted to SABA/SAMA experienced arrhythmias, while no events were observed in patients on chronic inhaled therapy (p = 0.122). Shifted patients had a more severe AECOPD and history of paroxysmal atrial fibrillation was an independent risk factor for arrhythmia (OR 14.010, IC95%: 2.983-65.800; p = 0.001). In conclusion, shifting patients to SABA/SAMA appears not to increase the risk for arrhythmia during severe AECOPD. However, the pharmacological approach in patients with a history of paroxysmal arrhythmia should be carefully evaluated and monitored.

Trends in Incidence, and Mortality of Acute Exacerbation of Chronic Obstructive Pulmonary Disease in the United States Emergency Department (2010-2018)

Literature regarding trends of incidence, mortality, and complications of acute exacerbation of chronic obstructive pulmonary disease (COPD) in the emergency departments (ED) is limited. What are trends of COPD exacerbation in ED? Data were obtained from the Nationwide Emergency Department Sample (NEDS) that constitutes a 20% sample of hospital-owned EDs and inpatient sample in the US. All ED encounters were included in the analysis. Complications of AECOPD were obtained by using ICD codes. Out of 1.082 billion ED encounters, 5,295,408 (mean age 63.31 ± 12.63 years, females 55%) presented with COPD exacerbation. Among these patients, 353,563(6.7%) had AECOPD-plus (features of pulmonary embolism, acute heart failure and/or pneumonia) while 4,941,845 (93.3%) had exacerbation without associated features or precipitating factors which we grouped as AECOPD. The AECOPD-plus group was associated with statistically significantly higher proportion of cardiovascular complications including AF (5.6% vs 3.5%; p < 0.001), VT/VF (0.14% vs 0.06%; p < 0.001), STEMI (0.22% vs 0.11%; p < 0.001) and NSTEMI (0.65% vs 0.2%; p < 0.001). The in-hospital mortality rates were greater in the AECOPD-plus population (0.7% vs 0.1%; p < 0.001). The incidence of both AECOPD and AECOPD-plus had worsened (p-trend 0.004 and 0.0003) and the trend of mortality had improved (p-trend 0.0055 and 0.003, respectively). The prevalence of smoking for among all COPD patients had increased (p-value 0.004), however, the prevalence trend of smoking among AECOPD groups was static over the years 2010-2018. There was an increasing trend of COPD exacerbation in conjunction with smoking; however, mortality trends improved significantly. Moreover, the rising burden of AECOPD would suggest improvement in diagnostics and policy making regarding management.

FEV1 is independently related with impaired left atrial strain in chronic obstructive pulmonary disease patients: A speckle tracking study

BACKGROUND

Atrial fibrillation (AF) is common in chronic obstructive pulmonary disease (COPD) patients. It is known that impaired forced expiratory volume in 1 s (FEV1) is one of the risk factors of cardiovascular disease. Two-dimensional speckle tracking echocardiography (2D-STE) can detect deterioration of left atrial mechanical functions in the subclinical stage. We hypothesized that reduced lung functions, measured by FEV1 in COPD patients, may be associated with impaired left atrial (LA) mechanical functions.

OBJECTIVES

Present study included 127 consecutive COPD patients. We divided study population into two groups: patients with normal LA strain (n = 20) or with impaired LA strain (n = 107).

RESULTS

In univariate logistic regression analysis, age (p: 0.001), FEV1% (p < 0.001), FEV1 (p < 0.001), FEV1/forced vital capacity (FVC) (p: 0.014), white blood cell (p: 0.012), LA Max vol (p: 0.026), C-reactive protein (p :0.001), arterial oxygen pressure (PaO₂ ) (p: 0.019), arterial oxygen saturation (SO₂ ) (p: 0.021), left ventricle ejection fraction (LVEF) (p: 0.042), and mitral A-wave velocity (p: 0.017) were associated with impaired LA-strain. In multivariate logistic regression analysis, age (p: 0.043), FEV1 (p < 0.001), LA Max vol (p: 0.004), and LVEF (p: 0.004) were independently associated with impaired LA strain.

CONCLUSION

FEV1 is associated with impaired left atrial strain independently of arterial blood gas and left ventricular diastolic dysfunction parameters in COPD patients with preserved left ventricular systolic function.

Impact of cancer diagnosis on causes and outcomes of 5.9 million US patients with cardiovascular admissions

INTRODUCTION

There are limited data on causes of cardiovascular (CV) admissions and associated outcomes among patients with different cancers.

METHODS

All CV admissions from the US National Inpatient Sample between October 2015 to December 2017 were stratified by cancer type as well as metastatic status. Multivariable logistic regression was performed to determine the adjusted odds ratios (aOR) of in-hospital mortality in different groups.

RESULTS

From 5,936,014 eligible CV admissions, cancer was present in 265,221 (4.5%) hospitalizations. There was significant variation in the admission diagnoses among the different cancers, with hematological malignancies being principally associated with heart failure (HF), lung cancer with atrial fibrillation (AF), and colorectal and prostate cancer with acute myocardial infarction (AMI). Admission with haemorrhagic stroke has the highest associated mortality across cancers (20.0-38.4%). In-hospital mortality was higher in cancer than non-cancer patients across most CV admissions (P < 0.001) with AF having the worst prognosis. Compared to group without any cancer, the greatest aOR of mortality was associated with lung cancer in AMI (aOR 2.32, 95% CI 2.18-2.47), ischemic stroke (aOR 2.21, 95%CI 2.08-2.34), AF (aOR 4.69, 95%CI 4.32-5.10) and HF (aOR 2.07, 95%CI 1.89-2.27).

CONCLUSIONS

The most common causes of CV admission to hospital vary in patients with different types of cancer, with AMI being most common in patients with colon cancer, HF in patients with hematological malignancies and AF in patients with lung cancer. Patients with cancer, particularly lung cancer, have greater mortality than non-cancer patients after admissions with a CV cause.

Dose-response relationship among body mass index, abdominal adiposity and atrial fibrillation in patients undergoing cardiac surgery: a meta-analysis of 35 cohorts

Background

Whether overweight increases the risk of postoperative atrial fibrillation (POAF) is unclear, and whether adiposity independently contributes to POAF has not been comprehensively studied. Thus, we conducted a meta-analysis to clarify the strength and shape of the exposure-effect relationship between adiposity and POAF.

Methods

The PubMed, Cochrane Library, and EMBASE databases were searched for revelant studies (randomized controlled trials (RCTs), cohort studies, and nest-case control studies) reporting data regarding the relationship between adiposity and the risk of POAF.

Results

Thirty-five publications involving 33,271 cases/141,442 patients were included. Analysis of categorical variables showed that obesity (RR: 1.39, 95% CI [1.21–1.61]; P < 0.001), but not being underweight (RR: 1.44, 95% CI [0.90–2.30]; P = 0.13) or being overweight (RR: 1.03, 95% CI [0.95–1.11]; P = 0.48) was associated with an increased risk of POAF. In the exposure-effect analysis (BMI) was 1.09 (95% CI [1.05–1.12]; P < 0.001) for the risk of POAF. There was a significant linear relationship between BMI and POAF (P_nonlinearity = 0.44); the curve was flat and began to rise steeply at a BMI of approximately 30. Notably, BMI levels below 30 (overweight) were not associated with a higher risk of POAF. Additionally, waist obesity or visceral adiposity index was associated with the risk of POAF.

Conclusion

Based on the current evidence, our findings showed that high body mass index or abdominal adiposity was independently associated with an increased risk of POAF, while underweight or overweight might not significantly increase the POAF risk.

Detection of Atrial Fibrillation After Central Retinal Artery Occlusion

[Figure: see text].

Chronic obstructive pulmonary disease and atrial fibrillation: an interdisciplinary perspective

Chronic obstructive pulmonary disease (COPD) is highly prevalent among patients with atrial fibrillation (AF), shares common risk factors, and adds to the overall morbidity and mortality in this population. Additionally, it may promote AF and impair treatment efficacy. The prevalence of COPD in AF patients is high and is estimated to be ∼25%. Diagnosis and treatment of COPD in AF patients requires a close interdisciplinary collaboration between the electrophysiologist/cardiologist and pulmonologist. Differential diagnosis may be challenging, especially in elderly and smoking patients complaining of unspecific symptoms such as dyspnoea and fatigue. Routine evaluation of lung function and determination of natriuretic peptides and echocardiography may be reasonable to detect COPD and heart failure as contributing causes of dyspnoea. Acute exacerbation of COPD transiently increases AF risk due to hypoxia-mediated mechanisms, inflammation, increased use of beta-2 agonists, and autonomic changes. Observational data suggest that COPD promotes AF progression, increases AF recurrence after cardioversion, and reduces the efficacy of catheter-based antiarrhythmic therapy. However, it remains unclear whether treatment of COPD improves AF outcomes and which metric should be used to determine COPD severity and guide treatment in AF patients. Data from non-randomized studies suggest that COPD is associated with increased AF recurrence after electrical cardioversion and catheter ablation. Future prospective cohort studies in AF patients are needed to confirm the relationship between COPD and AF, the benefits of treatment of either COPD or AF in this population, and to clarify the need and cost-effectiveness of routine COPD screening.

Left Ventricular Diastolic Dysfunction Is Associated With the Prevalence of Paroxysmal Atrial Fibrillation Determined on the Latest Echocardiographic Criteria

Background: The relationship between left ventricular diastolic dysfunction (LVDD) and paroxysmal atrial fibrillation (PAF) remains unclear because of a lack of standard measures to evaluate LVDD. Accordingly, we examined the association between the prevalence of PAF and each LVDD grade determined according to the latest American Society of Echocardiography guidelines.

Methods and Results: In all, 2,063 patients without persistent AF who underwent echocardiography at Saitama Municipal Hospital from July 2016 to June 2017 were included in the study. Patients were divided into LVDD 6 categories: No-LVDD (n=1,107), Borderline (n=392), Grade 1 (n=204), Indeterminate (n=62), Grade 2 (n=254), and Grade 3 (n=44). PAF was documented in 111 (10.0%), 81 (20.7%), 28 (13.7%), 6 (9.7%), 52 (20.5%), and 24 (54.5%) patients in the No-LVDD, Borderline, Grade 1, Indeterminate, Grade 2, and Grade 3 categories, respectively. PAF prevalence was higher in patients with Grade 3 LVDD across the whole study population. Subgroup analyses showed that the prevalence of PAF increased with increased LVDD grade in patients with reduced left ventricular ejection fraction. This relationship was significant in multivariate analysis including various patient characteristics.

Conclusions: LVDD severity determined on the basis of the latest echocardiographic criteria was associated with the prevalence of PAF. The present findings shed light on the development of new therapeutic markers for PAF.

Transient Receptor Potential Ankyrin Type-1 Channels as a Potential Target for the Treatment of Cardiovascular Diseases

Cardiovascular disease is one of the chronic conditions with the highest mortality rate in the world. Underlying conditions such as hypertension, metabolic disorders, and habits like smoking are contributors to the manifestation of cardiovascular diseases. The treatment of cardiovascular diseases is inseparable from the development of drugs. Consequently, this has led to many researchers to focus on the search for effective drug targets. The transient receptor potential channel Ankyrin 1 (TRPA1) subtype is a non-selective cation channel, which belongs to the transient receptor potential (TRP) ion channel. Previous studies have shown that members of the TRP family contribute significantly to cardiovascular disease. However, many researchers have not explored the role of TRPA1 as a potential target for the treatment of cardiovascular diseases. Furthermore, recent studies revealed that TRPA1 is commonly expressed in the vascular endothelium. The endothelium is linked to the causes of some cardiovascular diseases, such as atherosclerosis, myocardial fibrosis, heart failure, and arrhythmia. The activation of TRPA1 has a positive effect on atherosclerosis, but it has a negative effect on other cardiovascular diseases such as myocardial fibrosis and heart failure. This review introduces the structural and functional characteristics of TRPA1 and its importance on vascular physiology and common cardiovascular diseases. Moreover, this review summarizes some evidence that TRPA1 is correlated to cardiovascular disease risk factors.

Increased One-Year Recurrent Ischemic Stroke after First-Ever Ischemic Stroke in Males with Benign Prostatic Hyperplasia

(1) Background: Patients with benign prostatic hyperplasia (BPH) were questioned about quality of life and sleep. Most BPH patients were treated with alpha-1 adrenergic receptor antagonists, which could improve cerebral blood flow for 1–2 months. Patients with ischemic stroke (IS) could experience cerebral autoregulation impairment for six months. The relationship between BPH and recurrent IS remains unclear. The aim of this study was to determine the risk of one-year recurrent IS conferred by BPH. (2) Methods: We used data from the Taiwanese National Health Insurance Database to identify newly diagnosed IS cases entered from 1 January 2008 to 31 December 2008. Patients were followed until the recurrent IS event or 365 days after the first hospitalization. The risk factors associated with one-year recurrent IS were assessed using Cox proportional hazards regression. (3) Results: Patients with BPH had a higher risk of recurrent IS (12.11% versus 8.15%) (adjusted hazard ratio (HR): 1.352; 95% confidence interval (CI): 1.028–1.78, p = 0.031). Other risk factors included hyperlipidemia (adjusted HR: 1.338; 95% CI: 1.022–1.751, p = 0.034), coronary artery disease (adjusted HR: 1.487; 95% CI: 1.128–1.961, p = 0.005), chronic obstructive pulmonary disease (adjusted HR: 1.499; 95% CI: 1.075–2.091, p = 0.017), and chronic kidney disease (adjusted HR: 1.523; 95% CI: 1.033–2.244, p = 0.033). (4) Conclusion: Patients with BPH who had these risk factors had an increased risk of one-year recurrent IS. The modification of risk factors may prevent recurrent IS.

Objectives, design and main findings until 2020 from the Rotterdam Study

The Rotterdam Study is an ongoing prospective cohort study that started in 1990 in the city of Rotterdam, The Netherlands. The study aims to unravel etiology, preclinical course, natural history and potential targets for intervention for chronic diseases in mid-life and late-life. The study focuses on cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, otolaryngological, locomotor, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. Since 2016, the cohort is being expanded by persons aged 40 years and over. The findings of the Rotterdam Study have been presented in over 1700 research articles and reports. This article provides an update on the rationale and design of the study. It also presents a summary of the major findings from the preceding 3 years and outlines developments for the coming period.

Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation: A Scientific Statement From the American Heart Association

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is associated with substantial morbidity, mortality, and healthcare use. Great strides have been made in stroke prevention and rhythm control strategies, yet reducing the incidence of AF has been slowed by the increasing incidence and prevalence of AF risk factors, including obesity, physical inactivity, sleep apnea, diabetes mellitus, hypertension, and other modifiable lifestyle-related factors. Fortunately, many of these AF drivers are potentially reversible, and emerging evidence supports that addressing these modifiable risks may be effective for primary and secondary AF prevention. A structured, protocol-driven multidisciplinary approach to integrate lifestyle and risk factor management as an integral part of AF management may help in the prevention and treatment of AF. However, this aspect of AF management is currently underrecognized, underused, and understudied. The purpose of this American Heart Association scientific statement is to review the association of modifiable risk factors with AF and the effects of risk factor intervention. Implementation strategies, care pathways, and educational links for achieving impactful weight reduction, increased physical activity, and risk factor modification are included. Implications for clinical practice, gaps in knowledge, and future directions for the research community are highlighted.

Mortality of Cardiovascular Events in Patients With COPD and Preceding Hospitalization for Acute Exacerbation

BACKGROUND

Acute exacerbation (AE) of COPD may be accompanied by the deterioration of cardiovascular comorbidities, as evidenced by the increased incidence of acute cardiovascular events.

RESEARCH QUESTION

The goal of this study was to determine whether preceding AE might be associated with mortality of cardiovascular events.

STUDY DESIGN AND METHODS

Using a health insurance research database in Taiwan, patients with COPD were identified who experienced first-time acute myocardial infarction (AMI; n = 26,442), ischemic stroke (n = 54,959), and intracranial hemorrhage (ICH; n = 14,893) over a 13-year period. In each cohort, 4,356, 6,655, and 1,727 patients, respectively, had been hospitalized for AE within the previous year prior to the index cardiovascular events, and patients with COPD but without hospitalization for AEs constituted the control subjects. ORs of 90-day mortality and hazard ratios (HRs) of overall mortality during follow-up in relation to hospitalization for an AE and the frequency of hospitalization for AEs (ie, 1 and ≥ 2 hospitalizations for AEs) were estimated with adjustment for potential confounders.

RESULTS

Hospitalization for an AE was independently associated with 90-day mortality of AMI (OR, 1.33; 95% CI, 1.24-1.43), ischemic stroke (OR, 1.46; 95% CI, 1.36-1.56), and ICH (OR, 1.19; 95% CI, 1.06-1.32). Hospitalization for an AE was associated with overall mortality of AMI (HR, 1.23; 95% CI, 1.19-1.27), ischemic stroke (HR, 1.29; 95% CI, 1.26-1.33), and ICH (HR, 1.19; 95% CI, 1.13-1.26). In addition, compared with control subjects, patients with more frequent hospitalizations for AEs exhibited significant trends at higher risk of 90-day and overall mortality of AMI, ischemic stroke, and ICH. Finally, these results were consistent with propensity score matching-based estimates.

INTERPRETATION

Preceding hospitalization for AEs is associated with 90-day and overall mortality of cardiovascular events in COPD.

Effect of Bronchodilator and Steroid Use on Heart Disease and Stroke Risks in a Bronchiectasis-Chronic Obstructive Pulmonary Disease Overlap Cohort: A Propensity Score Matching Study

Background: To determine the effects of bronchodilator, steroid, and anti-arrhythmia drug use on the risk of heart disease/stroke (HDS) in patients with bronchiectasis–chronic obstructive pulmonary disease overlap syndrome (BCOS).

Methods: We retrospectively enrolled patients with BCOS (BCOS cohort, n = 1,493) and patients without bronchiectasis and chronic obstructive pulmonary disease (COPD) (non-BCOS cohort, n = 5,972). The cumulative incidence of HDS was analyzed through Cox proportional regression. We calculated adjusted hazard ratios (aHRs) and their 95% confidence intervals (CIs) for HDS after adjustments for sex, age, comorbidities, long-acting β2-agonist or long-acting muscarinic antagonist (LABAs/LAMAs) use, short-acting β2-agonist or short-acting muscarinic antagonist (SABAs/SAMAs) use, oral steroid (OSs) or inhaled corticosteroid steroid (ICSs) use, and anti-arrhythmia drugs use.

Results: The aHR (95% CI) for HDS was 1.08 (0.28–4.06) for patients using LAMAs compared with those not using drugs. Regarding drug use days, the aHRs (95% CIs) were 32.2 (1.79–773.0), 1.85 (1.01–3.39), and 31.1 (3.25–297.80) for those with recent SABAs use, past ICSs use, and past anti-arrythmia drugs use, respectively. Regarding cumulative drug dose, the aHRs (95% CIs) were 2.12 (1.46–3.10), 3.48 (1.13–10.6), 3.19 (2.04–4.99), 28.1 (1.42–555.7), 2.09 (1.32–3.29), 2.28 (1.53–3.40), and 1.93 (1.36–2.74) for those with a low dose of SABAs, medium dose of SABAs, low dose of SAMAs, low dose of ICSs, medium dose of ICSs, low dose of OSs, and medium dose of OSs, respectively.

Conclusions: Compared with patients without bronchiectasis and COPD, BCOS patients with recent SABAs, past ICSs, and past anti-arrhythmia drugs use; a low or medium SABAs ICSs, and OSs dose; and a low SAMAs dose had a higher risk of HDS. LAMAs were not associated with HDS.

Catheter ablation of atrial fibrillation-A key role in heart failure therapy?

Atrial fibrillation (AF) and heart failure (HF) are epidemic cardiac diseases and are often detected in the same patient. Recent evidence suggests that this is not a mere coincidence but that the strategy of AF treatment may impact HF development. This review comprehensively summarizes current trial data on rhythm and rate control strategies in atrial fibrillation with a special focus on catheter ablation of AF in HF patients. For a long time, rate and rhythm control strategies for AF have been regarded as equal regarding long term mortality. Decision making has been based on the symptoms of patients. Current trials, however, show that the treatment strategy of AF and its effectiveness may significantly impact survival of HF patients. The benefits of rhythm control in HF patients may have been masked by side effects of antiarrhythmic drugs. If rhythm control, however, is achieved by catheter ablation, a reduction of HF related mortality can be observed. As catheter ablation of AF may reduce mortality in HF patients, AF ablation should be preferred over medical treatment in HF patients. In general, HF patients may profit most from rigorous AF treatment.