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Roberts JD, Chalazan B, Andrade JG, Macle L, Nattel S, Tadros R. Clinical Genetic Testing for Atrial Fibrillation: Are We There Yet? Can J Cardiol 2024; 40:540-553. [PMID: 38551553 DOI: 10.1016/j.cjca.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/17/2023] [Accepted: 11/19/2023] [Indexed: 04/13/2024] Open
Abstract
Important progress has been made toward unravelling the complex genetics underlying atrial fibrillation (AF). Initial studies were aimed to identify monogenic causes; however, it has become increasingly clear that the most common predisposing genetic substrate for AF is polygenic. Despite intensive investigations, there is robust evidence for rare variants for only a limited number of genes and cases. Although the current yield for genetic testing in early onset AF might be modest, there is an increasing appreciation that genetic culprits for potentially life-threatening ventricular cardiomyopathies and channelopathies might initially present with AF. The potential clinical significance of this recognition is highlighted by evidence that suggests that identification of a pathogenic or likely pathogenic rare variant in a patient with early onset AF is associated with an increased risk of death. These findings suggest that it might be warranted to screen patients with early onset AF for these potentially more sinister cardiac conditions. Beyond facilitating the early identification of genetic culprits associated with potentially malignant phenotypes, insight into underlying AF genetic substrates might improve the selection of patients for existing therapies and guide the development of novel ones. Herein, we review the evidence that links genetic factors to AF, then discuss an approach to using genetic testing for early onset AF patients in the present context, and finally consider the potential value of genetic testing in the foreseeable future. Although further work might be necessary before recommending uniform integration of genetic testing in cases of early onset AF, ongoing research increasingly highlights its potential contributions to clinical care.
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Affiliation(s)
- Jason D Roberts
- Population Health Research Institute, McMaster University, and Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Brandon Chalazan
- Division of Biochemical Genetics, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason G Andrade
- Centre for Cardiovascular Innovation and Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Laurent Macle
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Stanley Nattel
- Department of Medicine and Research Center, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Rafik Tadros
- Cardiovascular Genetics Center, Montreal Heart Institute, Faculty of Medicine, Université de Montréal, Montreal, Québec, Canada
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2
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Chen HY, Darbar D. Sample size determination for adaptive crossover trial in detecting gene-drug interactions. Stat Methods Med Res 2023; 32:1680-1693. [PMID: 37431594 DOI: 10.1177/09622802231181704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
Parallel design and crossover design are two of the most frequently used designs for studying drug-gene interactions. Due to the concerns of statistical power and ethics, it is often more prudent to use the crossover design while allowing the patients to have choices of not switching the treatment if the first stage treatment is effective. This complicates the calculation of the required sample size to achieve pre-specified statistical power. We propose a method to determine the required sample size with a closed-form formula. The proposed approach is applied to determine the sample size of an adaptive crossover trial in studying gene-drug interaction in treating atrial fibrillation, the most common cardiac arrhythmia in clinical practice. Our simulation study confirms the power achieved by the sample size determined using the proposed approach. Issues related to the adaptive crossover trial are also discussed and practical guidelines are provided.
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Affiliation(s)
- Hua Yun Chen
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, IL, USA
| | - Dawood Darbar
- Division of Cardiology, Department of Medicine, University of Illinois Chicago, Chicago, IL, USA
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Kany S, Al-Taie C, Roselli C, Pirruccello JP, Borof K, Reinbold C, Suling A, Krause L, Reissmann B, Schnabel RB, Zeller T, Zapf A, Wegscheider K, Fabritz L, Ellinor PT, Kirchhof P. Association of genetic risk and outcomes in patients with atrial fibrillation: interactions with early rhythm control in the EAST-AFNET4 trial. Cardiovasc Res 2023; 119:1799-1810. [PMID: 37264683 PMCID: PMC10405565 DOI: 10.1093/cvr/cvad027] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 06/03/2023] Open
Abstract
AIMS The randomized Early Treatment of Atrial Fibrillation for Stroke Prevention Trial found that early rhythm control reduces cardiovascular events in patients with recently diagnosed atrial fibrillation (AF) compared with usual care. How genetic predisposition to AF and stroke interacts with early rhythm-control therapy is not known. METHODS AND RESULTS Array genotyping and imputation for common genetic variants were performed. Polygenic risk scores (PRS) were calculated for AF (PRS-AF) and ischaemic stroke risk (PRS-stroke). The effects of PRS-AF and PRS-stroke on the primary outcome (composite of cardiovascular death, stroke, and hospitalization for acute coronary syndrome or worsening heart failure), its components, and recurrent AF were determined.A total of 1567 of the 2789 trial patients were analysed [793 randomized to early rhythm control; 774 to usual care, median age 71 years (65-75), 704 (44%) women]. Baseline characteristics were similar between randomized groups. Early rhythm control reduced the primary outcome compared with usual care [HR 0.67, 95% CI: (0.53, 0.84), P < 0.001]. The randomized intervention, early rhythm control, did not interact with PRS-AF (interaction P = 0.806) or PRS-stroke (interaction P = 0.765). PRS-AF was associated with recurrent AF [HR 1.08 (01.0, 1.16), P = 0.047]. PRS-stroke showed an association with the primary outcome [HR 1.13 (1.0, 1.27), P = 0.048], driven by more heart failure events [HR 1.23 (1.05-1.43), P = 0.010] without differences in stroke [HR 1.0 (0.75, 1.34), P = 0.973] in this well-anticoagulated cohort. In a replication analysis, PRS-stroke was associated with incident AF [HR 1.16 (1.14, 1.67), P < 0.001] and with incident heart failure in the UK Biobank [HR 1.08 (1.06, 1.10), P < 0.001]. The association with heart failure was weakened when excluding AF patients [HR 1.03 (1.01, 1.05), P = 0.001]. CONCLUSIONS Early rhythm control is effective across the spectrum of genetic AF and stroke risk. The association between genetic stroke risk and heart failure calls for research to understand the interactions between polygenic risk and treatment. REGISTRATION ISRCTN04708680, NCT01288352, EudraCT2010-021258-20, www.easttrial.org.
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Affiliation(s)
- Shinwan Kany
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20248 Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Hamburg/Kiel/Lübeck, Germany
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Christoph Al-Taie
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20248 Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Hamburg/Kiel/Lübeck, Germany
| | - Carolina Roselli
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - James P Pirruccello
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Division of Cardiology, University of California San Francisco, San Francisco, CA, USA
| | - Katrin Borof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20248 Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Carla Reinbold
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20248 Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Anna Suling
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Bruno Reissmann
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20248 Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Hamburg/Kiel/Lübeck, Germany
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20248 Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Hamburg/Kiel/Lübeck, Germany
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20248 Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Hamburg/Kiel/Lübeck, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Karl Wegscheider
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Larissa Fabritz
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20248 Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Hamburg/Kiel/Lübeck, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Wolfson Drive, Birmingham, UK
| | - Patrick T Ellinor
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20248 Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Hamburg/Kiel/Lübeck, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Wolfson Drive, Birmingham, UK
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Nakano Y. Genome and atrial fibrillation. J Arrhythm 2023; 39:303-309. [PMID: 37324776 PMCID: PMC10264727 DOI: 10.1002/joa3.12847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/11/2023] [Accepted: 03/27/2023] [Indexed: 06/17/2023] Open
Abstract
Atrial fibrillation (AF), the most common type of arrhythmia, can cause several adverse effects, such as stroke, heart failure, and cognitive dysfunction, also in addition to reducing quality of life and increasing mortality. Evidence suggests that AF is caused by a combination of genetic and clinical predispositions. In line with this, genetic studies on AF have progressed significantly through linkage studies, genome-wide association studies, use of polygenic risk scores, and studies on rare coding variations, gradually elucidating the relationship between genes and the pathogenesis and prognosis of AF. This article will review current trends in genetic analysis concerning AF.
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Affiliation(s)
- Yukiko Nakano
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health SciencesHiroshimaJapan
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Jin Z, Hwang I, Lim B, Kwon OS, Park JW, Yu HT, Kim TH, Joung B, Lee MH, Pak HN. Ablation and antiarrhythmic drug effects on PITX2+/− deficient atrial fibrillation: A computational modeling study. Front Cardiovasc Med 2022; 9:942998. [PMID: 35928934 PMCID: PMC9343754 DOI: 10.3389/fcvm.2022.942998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/23/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionAtrial fibrillation (AF) is a heritable disease, and the paired-like homeodomain transcription factor 2 (PITX2) gene is highly associated with AF. We explored the differences in the circumferential pulmonary vein isolation (CPVI), which is the cornerstone procedure for AF catheter ablation, additional high dominant frequency (DF) site ablation, and antiarrhythmic drug (AAD) effects according to the patient genotype (wild-type and PITX2+/− deficient) using computational modeling.MethodsWe included 25 patients with AF (68% men, 59.8 ± 9.8 years of age, 32% paroxysmal AF) who underwent AF catheter ablation to develop a realistic computational AF model. The ion currents for baseline AF and the amiodarone, dronedarone, and flecainide AADs according to the patient genotype (wild type and PITX2+/− deficient) were defined by relevant publications. We tested the virtual CPVI (V-CPVI) with and without DF ablation (±DFA) and three virtual AADs (V-AADs, amiodarone, dronedarone, and flecainide) and evaluated the AF defragmentation rates (AF termination or changes to regular atrial tachycardia (AT), DF, and maximal slope of the action potential duration restitution curves (Smax), which indicates the vulnerability of wave-breaks.ResultsAt the baseline AF, mean DF (p = 0.003), and Smax (p < 0.001) were significantly lower in PITX2+/− deficient patients than wild-type patients. In the overall AF episodes, V-CPVI (±DFA) resulted in a higher AF defragmentation relative to V-AADs (65 vs. 42%, p < 0.001) without changing the DF or Smax. Although a PITX2+/− deficiency did not affect the AF defragmentation rate after the V-CPVI (±DFA), V-AADs had a higher AF defragmentation rate (p = 0.014), lower DF (p < 0.001), and lower Smax (p = 0.001) in PITX2+/− deficient AF than in wild-type patients. In the clinical setting, the PITX2+/− genetic risk score did not affect the AF ablation rhythm outcome (Log-rank p = 0.273).ConclusionConsistent with previous clinical studies, the V-CPVI had effective anti-AF effects regardless of the PITX2 genotype, whereas V-AADs exhibited more significant defragmentation or wave-dynamic change in the PITX2+/− deficient patients.
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Lee JH, Hwang I, Yu HT, Kim TH, Uhm JS, Joung B, Lee MH, Pak HN. Lower pulmonary vein-to-left atrium volume ratio predicts poor rhythm outcome after atrial fibrillation catheter ablation. Front Cardiovasc Med 2022; 9:934168. [PMID: 35911561 PMCID: PMC9334901 DOI: 10.3389/fcvm.2022.934168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022] Open
Abstract
Although left atrial (LA) dimension (LAD) is one of the predictors of atrial fibrillation (AF) recurrence after catheter ablation, repetitive recurrences occur in patients without enlarged LAD. We explored the predictive value of pulmonary vein (PV) to LA volume percent ratio (PV/LA%vol) for rhythm outcomes after AF catheter ablation (AFCA). We included 2913 patients (73.5% male, 60.0 [52.0–67.0] years old, 60.6% paroxysmal AF) who underwent AFCA. We evaluated the association between PV/LA%vol and AF recurrence after AFCA and compared the predictive value for AF recurrences according to the LA size with LAD. We additionally investigated the association between PV/LA%vol and PITX2 gene using a genome-wide association study. LAD affected 1-year recurrence only in the highest tertile group (T3, p = 0.046), but PV/LA%vol determined 1-year recurrence in all LAD groups (T1, p = 0.044; T2, p = 0.021; and T3, p = 0.045). During 20.0 (8.0–45.0) months of follow-up, AF recurrence rate was significantly higher in patients with lower PV/LA%vol (Log-rank p = 0.004, HR 0.91 [0.84–1.00], p = 0.044). In the T1 and T2 LAD groups, predicting AF recurrences was better with PV/LA%vol than with LAD (AUC 0.63 vs. 0.51, p < 0.001 at T1; AUC 0.61 vs. 0.50, p = 0.007 at T2). We replicated PITX2-related rs12646447, which was independently associated with PV/LA%vol (β = 0.15 [0–0.30], p = 0.047). In conclusion, smaller PV volumes after LA volume adjustments have genetic background of PITX2 gene and predictive value for poorer rhythm outcomes after AFCA, especially in patients without LA enlargement.
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Affiliation(s)
- Jae-Hyuk Lee
- Department of Cardiology, Myongji Hospital, Hanyang University Medical Center, Gyeonggi-do, South Korea
| | - Inseok Hwang
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Hee Tae Yu
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Tae-Hoon Kim
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Jae-Sun Uhm
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Boyoung Joung
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Moon-Hyoung Lee
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
| | - Hui-Nam Pak
- Department of Internal Medicine, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea
- *Correspondence: Hui-Nam Pak,
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Pensa AV, Baman JR, Puckelwartz MJ, Wilcox JE. Genetically Based Atrial Fibrillation: Current Considerations for Diagnosis and Management. J Cardiovasc Electrophysiol 2022; 33:1944-1953. [PMID: 35262243 DOI: 10.1111/jce.15446] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation (AF) is the most common atrial arrhythmia and is subcategorized into numerous clinical phenotypes. Given its heterogeneity, investigations into the genetic mechanisms underlying AF have been pursued in recent decades, with predominant analyses focusing on early onset or lone AF. Linkage analyses, genome wide association studies (GWAS), and single gene analyses have led to the identification of rare and common genetic variants associated with AF risk. Significant overlap with genetic variants implicated in dilated cardiomyopathy syndromes, including truncating variants of the sarcomere protein titin, have been identified through these analyses, in addition to other genes associated with cardiac structure and function. Despite this, widespread utilization of genetic testing in AF remains hindered by the unclear impact of genetic risk identification on clinical outcomes and the high prevalence of variants of unknown significance (VUS). However, genetic testing is a reasonable option for patients with early onset AF and in those with significant family history of arrhythmia. While many knowledge gaps remain, emerging data support genotyping to inform selection of AF therapeutics. In this review we highlight the current understanding of the complex genetic basis of AF and explore the overlap of AF with inherited cardiomyopathy syndromes. We propose a set of criteria for clinical genetic testing in AF patients and outline future steps for the integration of genetics into AF care. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Anthony V Pensa
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jayson R Baman
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Megan J Puckelwartz
- Department of Pharmacology, Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jane E Wilcox
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL
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Hwang I, Kwon OS, Hong M, Yang SY, Park JW, Yu HT, Kim TH, Uhm JS, Joung B, Lee MH, Pak HN. Association of ZFHX3 Genetic Polymorphisms and Extra-Pulmonary Vein Triggers in Patients With Atrial Fibrillation Who Underwent Catheter Ablation. Front Physiol 2022; 12:807545. [PMID: 35069262 PMCID: PMC8766666 DOI: 10.3389/fphys.2021.807545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/09/2021] [Indexed: 01/11/2023] Open
Abstract
Background: The ZFHX3 gene (16q22) is the second most highly associated gene with atrial fibrillation (AF) and is related to inflammation and fibrosis. We hypothesized that ZFHX3 is associated with extra-pulmonary vein (PV) triggers, left atrial (LA) structural remodeling, and poor rhythm outcomes of AF catheter ablation (AFCA). Methods: We included 1,782 patients who underwent a de novo AFCA (73.5% male, 59.4 ± 10.8 years old, 65.9% paroxysmal AF) and genome-wide association study and divided them into discovery (n = 891) and replication cohorts (n = 891). All included patients underwent isoproterenol provocation tests and LA voltage mapping. We analyzed the ZFHX3, extra-PV trigger-related factors, and rhythm outcomes. Result: Among 14 single-nucleotide polymorphisms (SNPs) of ZFHX3, rs13336412, rs61208973, rs2106259, rs12927436, and rs1858801 were associated with extra-PV triggers. In the overall patient group, extra-PV triggers were independently associated with the ZFHX3 polygenic risk score (PRS) (OR 1.65 [1.22-2.22], p = 0.001, model 1) and a low LA voltage (OR 0.74 [0.56-0.97], p = 0.029, model 2). During 49.9 ± 40.3 months of follow-up, clinical recurrence of AF was significantly higher in patients with extra-PV triggers (Log-rank p < 0.001, HR 1.89 [1.49-2.39], p < 0.001, model 1), large LA dimensions (Log-rank p < 0.001, HR 1.03 [1.01-1.05], p = 0.002, model 2), and low LA voltages (Log-rank p < 0.001, HR 0.73 [0.61-0.86], p < 0.001, model 2) but not the ZFHX3 PRS (Log-rank p = 0.819). Conclusion: The extra-PV triggers had significant associations with both ZFHX3 genetic polymorphisms and acquired LA remodeling. Although extra-PV triggers were an independent predictor of AF recurrence after AFCA, the studied AF risk SNPs intronic in ZFHX3 were not associated with AF recurrence.
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Zigova M, Petrejèíková E, Blašèáková M, Kmec J, Bernasovská J, Boroòová I, Kmec M. Genetic targets in the management of atrial fibrillation in patients with cardiomyopathy. JOURNAL OF THE PRACTICE OF CARDIOVASCULAR SCIENCES 2022. [DOI: 10.4103/jpcs.jpcs_65_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Kwon OS, Hwang I, Pak HN. Computational modeling of atrial fibrillation. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2021. [DOI: 10.1186/s42444-021-00051-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractWith the aging society, the prevalence of atrial fibrillation (AF) continues to increase. Nevertheless, there are still limitations in antiarrhythmic drugs (AAD) or catheter interventions for AF. If it is possible to predict the outcome of AF management according to various AADs or ablation lesion sets through computational modeling, it will be of great clinical help. AF computational modeling has been utilized for in-silico arrhythmia research and enabled high-density entire chamber mapping, reproducible condition control, virtual intervention, not possible clinically or experimentally, in-depth mechanistic research. With the recent development of computer science and technology, more sophisticated and faster computational modeling has become available for clinical application. In particular, it can be applied to determine the extra-PV target of persistent AF catheter ablation or to select the AAD with the best effect. AF computational modeling combined with artificial intelligence is expected to contribute to precision medicine for more diverse uses in the future. Therefore, in this review, we will deal with the history, development, and various applications of computation modeling.
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Koniari I, Artopoulou E, Velissaris D, Ainslie M, Mplani V, Karavasili G, Kounis N, Tsigkas G. Biomarkers in the clinical management of patients with atrial fibrillation and heart failure. J Geriatr Cardiol 2021; 18:908-951. [PMID: 34908928 PMCID: PMC8648548 DOI: 10.11909/j.issn.1671-5411.2021.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Atrial fibrillation (AF) and heart failure (HF) are two cardiovascular diseases with an increasing prevalence worldwide. These conditions share common pathophysiologiesand frequently co-exit. In fact, the occurrence of either condition can 'cause' the development of the other, creating a new patient group that demands different management strategies to that if they occur in isolation. Regardless of the temproral association of the two conditions, their presence is linked with adverse cardiovascular outcomes, increased rate of hospitalizations, and increased economic burden on healthcare systems. The use of low-cost, easily accessible and applicable biomarkers may hasten the correct diagnosis and the effective treatment of AF and HF. Both AF and HF effect multiple physiological pathways and thus a great number of biomarkers can be measured that potentially give the clinician important diagnostic and prognostic information. These will then guide patient centred therapeutic management. The current biomarkers that offer potential for guiding therapy, focus on the physiological pathways of miRNA, myocardial stretch and injury, oxidative stress, inflammation, fibrosis, coagulation and renal impairment. Each of these has different utility in current clinincal practice.
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Affiliation(s)
- Ioanna Koniari
- Manchester Heart Institute, Manchester University Foundation Trust, Manchester, United Kingdom
| | - Eleni Artopoulou
- Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | | | - Mark Ainslie
- Manchester Heart Institute, Manchester University Foundation Trust, Manchester, United Kingdom
- Division of Cardiovascular Sciences, University of Manchester
| | - Virginia Mplani
- Department of Cardiology, University Hospital of Patras, Patras, Greece
| | - Georgia Karavasili
- Manchester Heart Institute, Manchester University Foundation Trust, Manchester, United Kingdom
| | - Nicholas Kounis
- Department of Cardiology, University Hospital of Patras, Patras, Greece
| | - Grigorios Tsigkas
- Department of Cardiology, University Hospital of Patras, Patras, Greece
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12
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A Higher Polygenic Risk Score Is Associated with a Higher Recurrence Rate of Atrial Fibrillation in Direct Current Cardioversion-Treated Patients. Medicina (B Aires) 2021; 57:medicina57111263. [PMID: 34833481 PMCID: PMC8624440 DOI: 10.3390/medicina57111263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/08/2021] [Accepted: 11/16/2021] [Indexed: 11/23/2022] Open
Abstract
Background and Objectives: Recurrence of atrial fibrillation (AF) within six months after sinus rhythm restoration with direct current cardioversion (DCC) is a significant treatment challenge. Currently, the factors influencing outcome are mostly unknown. Studies have found a link between genetics and the risk of AF and efficacy of rhythm control. The aim of this study was to examine the association between eight single-nucleotide variants (SNVs) and the risk of AF development and recurrence after DCC. Materials and Methods: Regarding the occurrence of AF, 259 AF cases and 108 controls were studied. Genotypes for the eight SNVs located in the genes CAV1, MYH7, SOX5, KCNN3, ZFHX3, KCNJ5 and PITX2 were determined using high-resolution melting analysis and confirmed with Sanger sequencing. Six months after DCC, a telephone interview was conducted to determine whether AF had recurred. A polygenic risk score (PRS) was calculated as the unweighted sum of risk alleles. Multivariate regression analyses were performed to assess SNV and PRS association with AF occurrence and recurrence after DCC. Results: The risk allele of rs2200733 (PITX2) was significantly associated with the development of AF (p = 0.012, OR = 2.31, 95% CI = 1.206–4.423). AF recurred in 60% of patients and the allele generally associated with a decreased risk of AF of rs11047543 (SOX5) was associated with a greater risk of AF recurrence (p = 0.014, OR = 0.223, 95% CI = 0.067–0.738). A PRS of greater than 7 was significantly associated (p = 0.008) with a higher likelihood of developing AF after DCC (OR = 4.174, 95% CI = 1.454–11.980). Conclusions: A higher PRS is associated with increased odds of AF recurrence after treatment with DCC. PITX2 (rs2200733) is significantly associated with an increased risk of AF. The protective allele of rs11047543 (SOX5) is associated with a greater risk of AF recurrence. Further studies are needed to predict the success of rhythm control and guide patient selection towards the most efficacious treatment.
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Bai J, Lu Y, Zhu Y, Wang H, Yin D, Zhang H, Franco D, Zhao J. Understanding PITX2-Dependent Atrial Fibrillation Mechanisms through Computational Models. Int J Mol Sci 2021; 22:7681. [PMID: 34299303 PMCID: PMC8307824 DOI: 10.3390/ijms22147681] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 01/11/2023] Open
Abstract
Atrial fibrillation (AF) is a common arrhythmia. Better prevention and treatment of AF are needed to reduce AF-associated morbidity and mortality. Several major mechanisms cause AF in patients, including genetic predispositions to AF development. Genome-wide association studies have identified a number of genetic variants in association with AF populations, with the strongest hits clustering on chromosome 4q25, close to the gene for the homeobox transcription PITX2. Because of the inherent complexity of the human heart, experimental and basic research is insufficient for understanding the functional impacts of PITX2 variants on AF. Linking PITX2 properties to ion channels, cells, tissues, atriums and the whole heart, computational models provide a supplementary tool for achieving a quantitative understanding of the functional role of PITX2 in remodelling atrial structure and function to predispose to AF. It is hoped that computational approaches incorporating all we know about PITX2-related structural and electrical remodelling would provide better understanding into its proarrhythmic effects leading to development of improved anti-AF therapies. In the present review, we discuss advances in atrial modelling and focus on the mechanistic links between PITX2 and AF. Challenges in applying models for improving patient health are described, as well as a summary of future perspectives.
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Affiliation(s)
- Jieyun Bai
- College of Information Science and Technology, Jinan University, Guangzhou 510632, China; (Y.L.); (Y.Z.)
- Auckland Bioengineering Institute, University of Auckland, Auckland 1010, New Zealand
| | - Yaosheng Lu
- College of Information Science and Technology, Jinan University, Guangzhou 510632, China; (Y.L.); (Y.Z.)
| | - Yijie Zhu
- College of Information Science and Technology, Jinan University, Guangzhou 510632, China; (Y.L.); (Y.Z.)
| | - Huijin Wang
- College of Information Science and Technology, Jinan University, Guangzhou 510632, China; (Y.L.); (Y.Z.)
| | - Dechun Yin
- Department of Cardiology, First Affiliated Hospital of Harbin Medical University, Harbin 150000, China;
| | - Henggui Zhang
- Biological Physics Group, School of Physics & Astronomy, The University of Manchester, Manchester M13 9PL, UK;
| | - Diego Franco
- Department of Experimental Biology, University of Jaen, 23071 Jaen, Spain;
| | - Jichao Zhao
- Auckland Bioengineering Institute, University of Auckland, Auckland 1010, New Zealand
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Hwang I, Jin Z, Park JW, Kwon OS, Lim B, Hong M, Kim M, Yu HT, Kim TH, Uhm JS, Joung B, Lee MH, Pak HN. Computational Modeling for Antiarrhythmic Drugs for Atrial Fibrillation According to Genotype. Front Physiol 2021; 12:650449. [PMID: 34054570 PMCID: PMC8155488 DOI: 10.3389/fphys.2021.650449] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/22/2021] [Indexed: 01/11/2023] Open
Abstract
Background: The efficacy of antiarrhythmic drugs (AAD) can vary in patients with atrial fibrillation (AF), and the PITX2 gene affects the responsiveness of AADs. We explored the virtual AAD (V-AAD) responses between wild-type and PITX2 +/--deficient AF conditions by realistic in silico AF modeling. Methods: We tested the V-AADs in AF modeling integrated with patients' 3D-computed tomography and 3D-electroanatomical mapping, acquired in 25 patients (68% male, 59.8 ± 9.8 years old, 32.0% paroxysmal type). The ion currents for the PITX2 +/- deficiency and each AAD (amiodarone, sotalol, dronedarone, flecainide, and propafenone) were defined based on previous publications. Results: We compared the wild-type and PITX2 +/- deficiency in terms of the action potential duration (APD90), conduction velocity (CV), maximal slope of restitution (Smax), and wave-dynamic parameters, such as the dominant frequency (DF), phase singularities (PS), and AF termination rates according to the V-AADs. The PITX2 +/--deficient model exhibited a shorter APD90 (p < 0.001), a lower Smax (p < 0.001), mean DF (p = 0.012), PS number (p < 0.001), and a longer AF cycle length (AFCL, p = 0.011). Five V-AADs changed the electrophysiology in a dose-dependent manner. AAD-induced AFCL lengthening (p < 0.001) and reductions in the CV (p = 0.033), peak DF (p < 0.001), and PS number (p < 0.001) were more significant in PITX2 +/--deficient than wild-type AF. PITX2 +/--deficient AF was easier to terminate with class IC AADs than the wild-type AF (p = 0.018). Conclusions: The computational modeling-guided AAD test was feasible for evaluating the efficacy of multiple AADs in patients with AF. AF wave-dynamic and electrophysiological characteristics are different among the PITX2-deficient and the wild-type genotype models.
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Kany S, Reissmann B, Metzner A, Kirchhof P, Darbar D, Schnabel RB. Genetics of atrial fibrillation-practical applications for clinical management: if not now, when and how? Cardiovasc Res 2021; 117:1718-1731. [PMID: 33982075 PMCID: PMC8208749 DOI: 10.1093/cvr/cvab153] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Indexed: 12/12/2022] Open
Abstract
The prevalence and economic burden of atrial fibrillation (AF) are predicted to more than double over the next few decades. In addition to anticoagulation and treatment of concomitant cardiovascular conditions, early and standardized rhythm control therapy reduces cardiovascular outcomes as compared with a rate control approach, favouring the restoration, and maintenance of sinus rhythm safely. Current therapies for rhythm control of AF include antiarrhythmic drugs (AADs) and catheter ablation (CA). However, response in an individual patient is highly variable with some remaining free of AF for long periods on antiarrhythmic therapy, while others require repeat AF ablation within weeks. The limited success of rhythm control therapy for AF is in part related to incomplete understanding of the pathophysiological mechanisms and our inability to predict responses in individual patients. Thus, a major knowledge gap is predicting which patients with AF are likely to respond to rhythm control approach. Over the last decade, tremendous progress has been made in defining the genetic architecture of AF with the identification of rare mutations in cardiac ion channels, signalling molecules, and myocardial structural proteins associated with familial (early-onset) AF. Conversely, genome-wide association studies have identified common variants at over 100 genetic loci and the development of polygenic risk scores has identified high-risk individuals. Although retrospective studies suggest that response to AADs and CA is modulated in part by common genetic variation, the development of a comprehensive clinical and genetic risk score may enable the translation of genetic data to the bedside care of AF patients. Given the economic impact of the AF epidemic, even small changes in therapeutic efficacy may lead to substantial improvements for patients and health care systems.
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Affiliation(s)
- Shinwan Kany
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Martinistraße 52, 20251 Hamburg, Hamburg, Germany
| | - Bruno Reissmann
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Martinistraße 52, 20251 Hamburg, Hamburg, Germany.,The Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston Birmingham B15 2TT, UK
| | - Dawood Darbar
- Division of Cardiology, Departments of Medicine, University of Illinois at Chicago and Jesse Brown Veterans Administration, 840 South Wood Street, Suite 928 M/C 715, Chicago, IL 60612, USA
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg Eppendorf, Martinistraße 52, 20251 Hamburg, Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Martinistraße 52, 20251 Hamburg, Hamburg, Germany
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16
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Abstract
PURPOSE OF REVIEW Atrial fibrillation is the most common sustained cardiac arrhythmia. In addition to traditional risk factors, it is increasingly recognized that a genetic component underlies atrial fibrillation development. This review aims to provide an overview of the genetic cause of atrial fibrillation and clinical applications, with a focus on recent developments. RECENT FINDINGS Genome-wide association studies have now identified around 140 genetic loci associated with atrial fibrillation. Studies into the effects of several loci and their tentative gene targets have identified novel pathways associated with atrial fibrillation development. However, further validations of causality are still needed for many implicated genes. Genetic variants at identified loci also help predict individual atrial fibrillation risk and response to different therapies. SUMMARY Continued advances in the field of genetics and molecular biology have led to significant insight into the genetic underpinnings of atrial fibrillation. Potential clinical applications of these studies include the identification of new therapeutic targets and development of genetic risk scores to optimize management of this common cardiac arrhythmia.
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Affiliation(s)
- Jitae A. Kim
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mihail G. Chelu
- Department of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Na Li
- Department of Medicine (Section of Cardiovascular Research), Baylor College of Medicine, Houston, TX
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX
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Nattel S, Aguilar M. Do Atrial Fibrillation-Promoting Gene Variants Act by Enhancing Atrial Remodeling? JACC Clin Electrophysiol 2021; 6:1522-1524. [PMID: 33213812 DOI: 10.1016/j.jacep.2020.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/01/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Stanley Nattel
- Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, Montréal, Québec, Canada; Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Duisburg, Germany; Institut Hospitalo Universitaire de rythmologie et de modélisation cardiaque and Fondation Bordeaux Université, Bordeaux, France.
| | - Martin Aguilar
- Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, Montréal, Québec, Canada
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Bai J, Zhu Y, Lo A, Gao M, Lu Y, Zhao J, Zhang H. In Silico Assessment of Class I Antiarrhythmic Drug Effects on Pitx2-Induced Atrial Fibrillation: Insights from Populations of Electrophysiological Models of Human Atrial Cells and Tissues. Int J Mol Sci 2021; 22:1265. [PMID: 33514068 PMCID: PMC7866025 DOI: 10.3390/ijms22031265] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 02/07/2023] Open
Abstract
Electrical remodelling as a result of homeodomain transcription factor 2 (Pitx2)-dependent gene regulation was linked to atrial fibrillation (AF) and AF patients with single nucleotide polymorphisms at chromosome 4q25 responded favorably to class I antiarrhythmic drugs (AADs). The possible reasons behind this remain elusive. The purpose of this study was to assess the efficacy of the AADs disopyramide, quinidine, and propafenone on human atrial arrhythmias mediated by Pitx2-induced remodelling, from a single cell to the tissue level, using drug binding models with multi-channel pharmacology. Experimentally calibrated populations of human atrial action po-tential (AP) models in both sinus rhythm (SR) and Pitx2-induced AF conditions were constructed by using two distinct models to represent morphological subtypes of AP. Multi-channel pharmaco-logical effects of disopyramide, quinidine, and propafenone on ionic currents were considered. Simulated results showed that Pitx2-induced remodelling increased maximum upstroke velocity (dVdtmax), and decreased AP duration (APD), conduction velocity (CV), and wavelength (WL). At the concentrations tested in this study, these AADs decreased dVdtmax and CV and prolonged APD in the setting of Pitx2-induced AF. Our findings of alterations in WL indicated that disopyramide may be more effective against Pitx2-induced AF than propafenone and quinidine by prolonging WL.
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Affiliation(s)
- Jieyun Bai
- Department of Electronic Engineering, College of Information Science and Technology, Jinan University, Guangzhou 510632, China;
| | - Yijie Zhu
- Department of Electronic Engineering, College of Information Science and Technology, Jinan University, Guangzhou 510632, China;
| | - Andy Lo
- Auckland Bioengineering Institute, University of Auckland, Auckland 1010, New Zealand; (A.L.); (J.Z.)
| | - Meng Gao
- Department of Computer Science and Technology, College of Electrical Engineering and Information, Northeast Agricultural University, Harbin 150030, China
| | - Yaosheng Lu
- Department of Electronic Engineering, College of Information Science and Technology, Jinan University, Guangzhou 510632, China;
| | - Jichao Zhao
- Auckland Bioengineering Institute, University of Auckland, Auckland 1010, New Zealand; (A.L.); (J.Z.)
| | - Henggui Zhang
- Biological Physics Group, School of Physics and Astronomy, The University of Manchester, Manchester M13 9PL, UK;
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19
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Iroegbu CD, Chen W, Wu X, Cheng L, Zhang H, Wu M, Zhao Y, Liu LM, Yang J. Evaluating the cost-effectiveness of catheter ablation of atrial fibrillation. Cardiovasc Diagn Ther 2020; 10:1200-1215. [PMID: 33224744 DOI: 10.21037/cdt-20-574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The pursuit of a clearer understanding of the pathogenesis of atrial fibrillation (AFib) and the development of new technology has resulted in a surge of interest in the surgical ablation for AFib. Here, we report our 8-year experience in the surgical treatment and management of AFib alongside, evaluating the cost-effectiveness in southern Mainland China over a 1-year follow-up. Methods Data of 3,068 patients from March 2011 through June 2019 was retrospectively extracted from The Provincial National Cardiac Database of Xiangya Second Hospital. The activities considered (and costs calculated) were outpatient consultations, hospital admissions, and drug treatment. Quality of life (QoL) questionnaires were also carried out to assess whether concomitant AFib correction procedures increase risk in patients, or improve patient's QoL. Results A total of 3,068 patients completed the questionnaires at a minimum of one time-point during the follow-up. The total cost was combined to obtain incremental costs per quality-adjusted life-years (QALYs). The total costs of the AFib catheter ablation group were remarkably higher compared to surgery as usual group. The incremental cost-effectiveness ratio was $76,513,227 (¥542,287,667) per QALY, with an acceptability line graph for cost at 43%. Conclusions AFib is an extraordinarily costly and worrisome public health problem. Precision medicine is vital as it provides a platform for the clinical translation of targeted interventions that are designed to help treat and prevent AFib. Thus, to improve the QoL expectancy outcome(s), both therapeutic and surgical interventions should be aimed at addressing the underlying heart disease rather than restoring sinus rhythm.
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Affiliation(s)
- Chukwuemeka Daniel Iroegbu
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Wangping Chen
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xun Wu
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Luo Cheng
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Hao Zhang
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Ming Wu
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Yuan Zhao
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Li Ming Liu
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
| | - Jinfu Yang
- Department of Cardiovascular Surgery, Second Xiangya Hospital, Central South University, Changsha, China
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Wong CK, Tse HF. New methodological approaches to atrial fibrillation drug discovery. Expert Opin Drug Discov 2020; 16:319-329. [PMID: 33016154 DOI: 10.1080/17460441.2021.1826432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice and rhythm control using pharmacological agents is required in selected patients. Nonetheless, current medication is only modestly efficacious and associated with significant cardiovascular and systemic side effects. More efficacious and safe drugs are required to restore and maintain sinus rhythm in patients with AF. AREAS COVERED In this review, several potential drug targets are discussed including trans-membrane ion channels, intracellular calcium signaling, gap junction signaling, atrial inflammation and fibrosis, and the autonomic nervous system. New tools and methodologies for AF drug development are also reviewed including gene therapy, genome-guided therapy, stem cell technologies, tissue engineering, and optogenetics. EXPERT OPINION In recent decades, there has been an increased understanding of the underlying pathogenesis of AF. As a result, there is a gradual paradigm shift from focusing only on trans-membrane ion channel inhibition to developing therapeutic agents that target other underlying arrhythmogenic mechanisms. Gene therapy and genome-guided therapy are emerging as novel treatments for AF with some success in proof-of-concept studies. Recent advances in stem cell technology, tissue engineering, and optogenetics may allow more effective in-vitro drug screening than conventional methodologies.
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Affiliation(s)
- Chun-Ka Wong
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, SAR China
| | - Hung-Fat Tse
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, SAR China
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21
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Wong GR, Nalliah CJ, Lee G, Voskoboinik A, Prabhu S, Parameswaran R, Sugumar H, Anderson RD, Ling LH, McLellan A, Johnson R, Sanders P, Kistler PM, Fatkin D, Kalman JM. Genetic Susceptibility to Atrial Fibrillation Is Associated With Atrial Electrical Remodeling and Adverse Post-Ablation Outcome. JACC Clin Electrophysiol 2020; 6:1509-1521. [PMID: 33213811 DOI: 10.1016/j.jacep.2020.05.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES This study sought to assess the atrial electrophysiological properties and post-ablation outcomes in patients with atrial fibrillation (AF) with and without the rs2200733 single nucleotide variant. BACKGROUND The phenotype associated with chromosome 4q25 of the AF-susceptibility locus remains unknown. METHODS In this study, 102 consecutive patients (ages 61 ± 9 years, 64% male) with paroxysmal or persistent AF were prospectively recruited prior to ablation. Patients were genotyped for rs2200733 and high-density left atrial (LA) electroanatomic maps were created using a multipolar catheter during distal coronary sinus (CS) pacing at 600 ms. Voltage, conduction velocity (CV), CV heterogeneity, and fractionated signals of 6 LA segments were determined. Arrhythmia recurrence was assessed by continuous device (51%) and Holter monitoring. RESULTS Overall, 41 patients (40%) were single nucleotide variant carriers (38 heterozygous, 3 homozygous). A mean of 2,239 ± 852 points per patient were collected. Carriers had relatively increased CV heterogeneity (45.7 ± 7.5% vs. 35.9 ± 2.3%; p < 0.001), complex signals (9.4 ± 2.9% vs 6.0 ± 1.2%; p = 0.008), regional LA slowing, or conduction block (31.7 ± 8.2% vs. 17.9 ± 1.9%; p = 0.013) particularly in the posterior and lateral walls. There were no differences in CV, voltage, atrial refractoriness, or sinus node function. At follow-up (median: 27 months; range 19 to 31 months), carriers had lower arrhythmia-free survival (51% vs. 80%; p = 0.003). On multivariable analysis, carrier status was independently associated with CV heterogeneity (p = 0.001), complex signals (p = 0.002), and arrhythmia recurrence (p = 0.019). CONCLUSIONS These data provide the first evidence that the rs2200733-tagged haplotype alters LA electrical remodeling and is a determinant of long-term outcome following AF ablation. The molecular mechanisms underpinning these changes warrant further investigation.
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Affiliation(s)
- Geoffrey R Wong
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Chrishan J Nalliah
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Aleksandr Voskoboinik
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Heart Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Sandeep Prabhu
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Heart Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Ramanathan Parameswaran
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Hariharan Sugumar
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Heart Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Robert D Anderson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Liang-Han Ling
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Heart Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Alex McLellan
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Renee Johnson
- Molecular Cardiology Division, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Peter M Kistler
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Heart Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Diane Fatkin
- Molecular Cardiology Division, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; Cardiology Department, St. Vincent's Hospital, Darlinghurst, New South Wales, Australia; Faculty of Medicine, University of New South Wales Sydney, Kensington, New South Wales, Australia.
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.
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Huang X, Li Y, Zhang J, Wang X, Li Z, Li G. The molecular genetic basis of atrial fibrillation. Hum Genet 2020; 139:1485-1498. [PMID: 32617797 DOI: 10.1007/s00439-020-02203-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/26/2020] [Indexed: 12/15/2022]
Abstract
As the most common cardiac arrhythmia, atrial fibrillation (AF) is a major risk factor for stroke, heart failure, and premature death with considerable associated costs. However, no available treatment options have optimal benefit-harm profiles currently, reflecting an incomplete understanding of the biological mechanisms underlying this complex arrhythmia. Recently, molecular epidemiological studies, especially genome-wide association studies, have emphasized the substantial genetic component of AF etiology. A comprehensive mapping of the genetic underpinnings for AF can expand our knowledge of AF mechanism and further facilitate the process of locating novel therapeutics for AF. Here we provide a state-of-the-art review of the molecular genetics of AF incorporating evidence from linkage analysis and candidate gene, as well as genome-wide association studies of common variations and rare copy number variations; potential epigenetic modifications (e.g., DNA methylation, histone modification, and non-coding RNAs) are also involved. We also outline the challenges in mechanism investigation and potential future directions in this article.
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Affiliation(s)
- Xin Huang
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, 466 Newport Middle Road, Haizhu District, Guangzhou, 510317, Guangdong, China
| | - Yuhui Li
- Department of Cardiology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Junguo Zhang
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, 466 Newport Middle Road, Haizhu District, Guangzhou, 510317, Guangdong, China
| | - Xiaojie Wang
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, 466 Newport Middle Road, Haizhu District, Guangzhou, 510317, Guangdong, China
| | - Ziyi Li
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, 466 Newport Middle Road, Haizhu District, Guangzhou, 510317, Guangdong, China
| | - Guowei Li
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, 466 Newport Middle Road, Haizhu District, Guangzhou, 510317, Guangdong, China. .,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University Hamilton, 1280 Main St West, Hamilton, ON, L8S 4L8, Canada.
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Abstract
Susceptibility to atrial fibrillation (AF) is determined by well-recognized risk factors such as diabetes mellitus or hypertension, emerging risk factors such as sleep apnea or inflammation, and increasingly well-defined genetic variants. As discussed in detail in a companion article in this series, studies in families and in large populations have identified multiple genetic loci, specific genes, and specific variants increasing susceptibility to AF. Since it is becoming increasingly inexpensive to obtain genotype data and indeed whole genome sequence data, the question then becomes to define whether using emerging new genetics knowledge can improve care for patients both before and after development of AF. Examples of improvements in care could include identifying patients at increased risk for AF (and thus deploying increased surveillance or even low-risk preventive therapies should these be available), identifying patient subsets in whom specific therapies are likely to be effective or ineffective or in whom the driving biology could motivate the development of new mechanism-based therapies or identifying an underlying susceptibility to comorbid cardiovascular disease. While current guidelines for the care of patients with AF do not recommend routine genetic testing, this rapidly increasing knowledge base suggests that testing may now or soon have a place in the management of select patients. The opportunity is to generate, validate, and deploy clinical predictors (including family history) of AF risk, to assess the utility of incorporating genomic variants into those predictors, and to identify and validate interventions such as wearable or implantable device-based monitoring ultimately to intervene in patients with AF before they present with catastrophic complications like heart failure or stroke.
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Affiliation(s)
- M. Benjamin Shoemaker
- Department of Medicine (Cardiovascular Medicine), Vanderbilt University Medical Center, Nashville, TN
| | - Rajan L. Shah
- Department of Medicine (Cardiovascular Medicine), Stanford University Medical Center, Palo Alto, CA
| | - Dan M. Roden
- Departments of Medicine (Cardiovascular Medicine and Clinical Pharmacology), Pharmacology, and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Marco V. Perez
- Stanford Center for Inherited Cardiovascular Diseases, Stanford University, Palo Alto, CA
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Correa A, Haider SW, Aronow WS. Precision medicine in cardiac electrophysiology: where we are and where we need to go. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2020. [DOI: 10.1080/23808993.2020.1754127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Ashish Correa
- Department of Cardiology, Mount Sinai Morningside (formerly Mount St. Luke’s), Icahn School of Medicine, New York, NY, USA
| | - Syed Waqas Haider
- Department of Cardiology, Mount Sinai Morningside (formerly Mount St. Luke’s), Icahn School of Medicine, New York, NY, USA
| | - Wilbert S. Aronow
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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25
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Herraiz-Martínez A, Llach A, Tarifa C, Gandía J, Jiménez-Sabado V, Lozano-Velasco E, Serra SA, Vallmitjana A, Vázquez Ruiz de Castroviejo E, Benítez R, Aranega A, Muñoz-Guijosa C, Franco D, Cinca J, Hove-Madsen L. The 4q25 variant rs13143308T links risk of atrial fibrillation to defective calcium homoeostasis. Cardiovasc Res 2020; 115:578-589. [PMID: 30219899 PMCID: PMC6383060 DOI: 10.1093/cvr/cvy215] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 05/15/2018] [Accepted: 09/13/2018] [Indexed: 11/13/2022] Open
Abstract
AIMS Single nucleotide polymorphisms on chromosome 4q25 have been associated with risk of atrial fibrillation (AF) but the exiguous knowledge of the mechanistic links between these risk variants and underlying electrophysiological alterations hampers their clinical utility. Here, we tested the hypothesis that 4q25 risk variants cause alterations in the intracellular calcium homoeostasis that predispose to spontaneous electrical activity. METHODS AND RESULTS Western blotting, confocal calcium imaging, and patch-clamp techniques were used to identify mechanisms linking the 4q25 risk variants rs2200733T and rs13143308T to defects in the calcium homoeostasis in human atrial myocytes. Our findings revealed that the rs13143308T variant was more frequent in patients with AF and that myocytes from carriers of this variant had a significantly higher density of calcium sparks (14.1 ± 4.5 vs. 3.1 ± 1.3 events/min, P = 0.02), frequency of transient inward currents (ITI) (1.33 ± 0.24 vs. 0.26 ± 0.09 events/min, P < 0.001) and incidence of spontaneous membrane depolarizations (1.22 ± 0.26 vs. 0.56 ± 0.17 events/min, P = 0.001) than myocytes from patients with the normal rs13143308G variant. These alterations were linked to higher sarcoplasmic reticulum calcium loading (10.2 ± 1.4 vs. 7.3 ± 0.5 amol/pF, P = 0.01), SERCA2 expression (1.37 ± 0.13 fold, P = 0.03), and RyR2 phosphorylation at ser2808 (0.67 ± 0.08 vs. 0.47 ± 0.03, P = 0.01) but not at ser2814 (0.28 ± 0.14 vs. 0.31 ± 0.14, P = 0.61) in patients carrying the rs13143308T risk variant. Furthermore, the presence of a risk variant or AF independently increased the ITI frequency and the increase in the ITI frequency observed in carriers of the risk variants was exacerbated in those with AF. By contrast, the presence of a risk variant did not affect the amplitude or properties of the L-type calcium current in patients with or without AF. CONCLUSIONS Here, we identify the 4q25 variant rs13143308T as a genetic risk marker for AF, specifically associated with excessive calcium release and spontaneous electrical activity linked to increased SERCA2 expression and RyR2 phosphorylation.
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Affiliation(s)
- Adela Herraiz-Martínez
- Biomedical Research Institute Barcelona CSIC-IIBB Antiguo Hospital de la Santa Creu i Sant Pau, Pabellon 11, St Antoni Ma Claret 167, Barcelona, Spain.,IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Anna Llach
- IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Carmen Tarifa
- Biomedical Research Institute Barcelona CSIC-IIBB Antiguo Hospital de la Santa Creu i Sant Pau, Pabellon 11, St Antoni Ma Claret 167, Barcelona, Spain.,IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jorge Gandía
- Biomedical Research Institute Barcelona CSIC-IIBB Antiguo Hospital de la Santa Creu i Sant Pau, Pabellon 11, St Antoni Ma Claret 167, Barcelona, Spain
| | | | | | - Selma A Serra
- Biomedical Research Institute Barcelona CSIC-IIBB Antiguo Hospital de la Santa Creu i Sant Pau, Pabellon 11, St Antoni Ma Claret 167, Barcelona, Spain.,IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alexander Vallmitjana
- Department of Automatic Control, Universitat Politècnica de Catalunya, Barcelona, Spain
| | | | - Raúl Benítez
- Department of Automatic Control, Universitat Politècnica de Catalunya, Barcelona, Spain
| | - Amelia Aranega
- Department of Experimental Biology, University of Jaén, Spain
| | | | - Diego Franco
- Department of Experimental Biology, University of Jaén, Spain
| | - Juan Cinca
- IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,CIBERCV, Spain
| | - Leif Hove-Madsen
- Biomedical Research Institute Barcelona CSIC-IIBB Antiguo Hospital de la Santa Creu i Sant Pau, Pabellon 11, St Antoni Ma Claret 167, Barcelona, Spain.,IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,CIBERCV, Spain
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26
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Liang W, Al Qarawi W, Davis DR. Disease Modelling and Precision Medicine Using Canadian Cardiomyocytes. Can J Cardiol 2020; 36:467-469. [PMID: 32146064 DOI: 10.1016/j.cjca.2019.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 10/25/2022] Open
Affiliation(s)
- Wenbin Liang
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada; Department of Cellular and Molecular Medicine, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Wael Al Qarawi
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Darryl R Davis
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada; Department of Cellular and Molecular Medicine, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada.
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27
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Ragab AAY, Sitorus GDS, Brundel BBJJM, de Groot NMS. The Genetic Puzzle of Familial Atrial Fibrillation. Front Cardiovasc Med 2020; 7:14. [PMID: 32118049 PMCID: PMC7033574 DOI: 10.3389/fcvm.2020.00014] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/28/2020] [Indexed: 12/17/2022] Open
Abstract
Atrial fibrillation (AF) is the most common clinical tachyarrhythmia. In Europe, AF is expected to reach a prevalence of 18 million by 2060. This estimate will increase hospitalization for AF to 4 million and 120 million outpatient visits. Besides being an independent risk factor for mortality, AF is also associated with an increased risk of morbidities. Although there are many well-defined risk factors for developing AF, no identifiable risk factors or cardiac pathology is seen in up to 30% of the cases. The heritability of AF has been investigated in depth since the first report of familial atrial fibrillation (FAF) in 1936. Despite the limited value of animal models, the advances in molecular genetics enabled identification of many common and rare variants related to FAF. The importance of AF heritability originates from the high prevalence of lone AF and the lack of clear understanding of the underlying pathophysiology. A better understanding of FAF will facilitate early identification of people at high risk of developing FAF and subsequent development of more effective management options. In this review, we reviewed FAF epidemiological studies, identified common and rare variants, and discussed their clinical implications and contributions to developing new personalized therapeutic strategies.
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Affiliation(s)
- Ahmed A Y Ragab
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Gustaf D S Sitorus
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Bianca B J J M Brundel
- Department of Physiology, Institute for Cardiovascular Research, VU Medical Center, Amsterdam, Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands
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28
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Bai J, Lo A, Gladding PA, Stiles MK, Fedorov VV, Zhao J. In silico investigation of the mechanisms underlying atrial fibrillation due to impaired Pitx2. PLoS Comput Biol 2020; 16:e1007678. [PMID: 32097431 PMCID: PMC7059955 DOI: 10.1371/journal.pcbi.1007678] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 03/06/2020] [Accepted: 01/22/2020] [Indexed: 01/04/2023] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is a major cause of stroke and morbidity. Recent genome-wide association studies have shown that paired-like homeodomain transcription factor 2 (Pitx2) to be strongly associated with AF. However, the mechanisms underlying Pitx2 modulated arrhythmogenesis and variable effectiveness of antiarrhythmic drugs (AADs) in patients in the presence or absence of impaired Pitx2 expression remain unclear. We have developed multi-scale computer models, ranging from a single cell to tissue level, to mimic control and Pitx2-knockout atria by incorporating recent experimental data on Pitx2-induced electrical and structural remodeling in humans, as well as the effects of AADs. The key findings of this study are twofold. We have demonstrated that shortened action potential duration, slow conduction and triggered activity occur due to electrical and structural remodelling under Pitx2 deficiency conditions. Notably, the elevated function of calcium transport ATPase increases sarcoplasmic reticulum Ca2+ concentration, thereby enhancing susceptibility to triggered activity. Furthermore, heterogeneity is further elevated due to Pitx2 deficiency: 1) Electrical heterogeneity between left and right atria increases; and 2) Increased fibrosis and decreased cell-cell coupling due to structural remodelling slow electrical propagation and provide obstacles to attract re-entry, facilitating the initiation of re-entrant circuits. Secondly, our study suggests that flecainide has antiarrhythmic effects on AF due to impaired Pitx2 by preventing spontaneous calcium release and increasing wavelength. Furthermore, our study suggests that Na+ channel effects alone are insufficient to explain the efficacy of flecainide. Our study may provide the mechanisms underlying Pitx2-induced AF and possible explanation behind the AAD effects of flecainide in patients with Pitx2 deficiency.
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Affiliation(s)
- Jieyun Bai
- Department of Electronic Engineering, College of Information Science and Technology, Jinan University, Guangzhou, China
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Andy Lo
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Patrick A. Gladding
- Department of Cardiology, Waitemata District Health Board, Auckland, New Zealand
| | - Martin K. Stiles
- Waikato Clinical School, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Vadim V. Fedorov
- Department of Physiology & Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States of America
| | - Jichao Zhao
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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29
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Schneider-Warme F, Ravens U. Ménage à trois: single-nucleotide polymorphisms, calcium and atrial fibrillation. Cardiovasc Res 2019; 115:479-481. [PMID: 30428015 DOI: 10.1093/cvr/cvy283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Franziska Schneider-Warme
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg - Bad Krozingen, Medical Center - University of Freiburg, Elsässerstr. 2Q, Freiburg Germany.,Faculty of Medicine, University of Freiburg, Hugstetter Str 55, Freiburg, Germany
| | - Ursula Ravens
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg - Bad Krozingen, Medical Center - University of Freiburg, Elsässerstr. 2Q, Freiburg Germany.,Faculty of Medicine, University of Freiburg, Hugstetter Str 55, Freiburg, Germany
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30
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Roden DM, Van Driest SL, Wells QS, Mosley JD, Denny JC, Peterson JF. Opportunities and Challenges in Cardiovascular Pharmacogenomics: From Discovery to Implementation. Circ Res 2019; 122:1176-1190. [PMID: 29700066 DOI: 10.1161/circresaha.117.310965] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This review will provide an overview of the principles of pharmacogenomics from basic discovery to implementation, encompassing application of tools of contemporary genome science to the field (including areas of apparent divergence from disease-based genomics), a summary of lessons learned from the extensively studied drugs clopidogrel and warfarin, the current status of implementing pharmacogenetic testing in practice, the role of genomics and related tools in the drug development process, and a summary of future opportunities and challenges.
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Affiliation(s)
- Dan M Roden
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.) .,Department of Pharmacology (D.M.R., Q.S.W.).,Department of Biomedical Informatics (D.M.R., J.C.D., J.F.P.)
| | - Sara L Van Driest
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.).,Department of Pediatrics (S.L.V.D.), Vanderbilt University Medical Center, Nashville, TN
| | - Quinn S Wells
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.).,Department of Pharmacology (D.M.R., Q.S.W.)
| | - Jonathan D Mosley
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.)
| | - Joshua C Denny
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.).,Department of Biomedical Informatics (D.M.R., J.C.D., J.F.P.)
| | - Josh F Peterson
- From the Department of Medicine (D.M.R., S.L.V.D., Q.S.W., J.D.M., J.C.D., J.F.P.).,Department of Biomedical Informatics (D.M.R., J.C.D., J.F.P.)
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31
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Kalstø SM, Siland JE, Rienstra M, Christophersen IE. Atrial Fibrillation Genetics Update: Toward Clinical Implementation. Front Cardiovasc Med 2019; 6:127. [PMID: 31552271 PMCID: PMC6743416 DOI: 10.3389/fcvm.2019.00127] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/12/2019] [Indexed: 12/16/2022] Open
Abstract
Atrial fibrillation (AF) is the most common heart rhythm disorder worldwide and may have serious cardiovascular health consequences. AF is associated with increased risk of stroke, dementia, heart failure, and death. There are several known robust, clinical risk predictors for AF, such as male sex, increasing age, and hypertension; however, during the last couple of decades, a substantive genetic component has also been established. Over the last 10 years, the discovery of novel AF-related genetic variants has accelerated, increasing our understanding of mechanisms behind AF. Current studies are focusing on mapping the polygenic structure of AF, improving risk prediction, therapeutic development, and patient-specific management. Nevertheless, it is still difficult for clinicians to interpret the role of genetics in AF prediction and management. Here, we provide an overview of relevant topics within the genetics of AF and attempt to provide some guidance on how to interpret genetic advances and their implementation into clinical decision-making.
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Affiliation(s)
- Silje Madeleine Kalstø
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Rud, Norway
| | - Joylene Elisabeth Siland
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Ingrid E Christophersen
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Rud, Norway.,The Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
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32
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Cruz D, Pinto R, Freitas-Silva M, Nunes JP, Medeiros R. GWAS contribution to atrial fibrillation and atrial fibrillation-related stroke: pathophysiological implications. Pharmacogenomics 2019; 20:765-780. [PMID: 31368859 DOI: 10.2217/pgs-2019-0054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Atrial fibrillation (AF) and stroke are included in a group of complex traits that have been approached regarding of their study by susceptibility genetic determinants. Since 2007, several genome-wide association studies (GWAS) aiming to identify genetic variants modulating AF risk have been conducted. Thus, 11 GWAS have identified 26 SNPs (p < 5 × 10-2), of which 19 reached genome-wide significance (p < 5 × 10-8). From those variants, seven were also associated with cardioembolic stroke and three reached genome-wide significance in stroke GWAS. These associations may shed a light on putative shared etiologic mechanisms between AF and cardioembolic stroke. Additionally, some of these identified variants have been incorporated in genetic risk scores in order to elucidate new approaches of stroke prediction, prevention and treatment.
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Affiliation(s)
- Diana Cruz
- Molecular Oncology & Viral Pathology Group-Research Center, Portuguese Institute of Oncology, Edifício Laboratórios. 4° piso, Rua Dr António Bernardino de Almeida, 4200-4072 Porto, Portugal.,FMUP, Faculty of Medicine, Porto University, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Ricardo Pinto
- Molecular Oncology & Viral Pathology Group-Research Center, Portuguese Institute of Oncology, Edifício Laboratórios. 4° piso, Rua Dr António Bernardino de Almeida, 4200-4072 Porto, Portugal
| | - Margarida Freitas-Silva
- FMUP, Faculty of Medicine, Porto University, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal.,Department of Medicine, Centro Hospitalar São João, Porto, Portugal
| | - José Pedro Nunes
- FMUP, Faculty of Medicine, Porto University, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal.,Department of Medicine, Centro Hospitalar São João, Porto, Portugal
| | - Rui Medeiros
- Molecular Oncology & Viral Pathology Group-Research Center, Portuguese Institute of Oncology, Edifício Laboratórios. 4° piso, Rua Dr António Bernardino de Almeida, 4200-4072 Porto, Portugal.,FMUP, Faculty of Medicine, Porto University, Alameda Prof Hernâni Monteiro, 4200-319 Porto, Portugal.,Research Department, Portuguese League Against Cancer (NRNorte), Estrada Interior da Circunvalação, 6657, 4200-172 Porto, Portugal.,CEBIMED, Faculty of Health Sciences, Fernando Pessoa University, Praça 9 de Abril, 349, 4249-004 Porto, Portugal
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MicroRNAs: Emerging biomarkers for atrial fibrillation. J Cardiol 2019; 74:475-482. [PMID: 31324570 DOI: 10.1016/j.jjcc.2019.05.018] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 05/20/2019] [Accepted: 05/20/2019] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) causes severe cardiac dysrhythmia among patients with cardiovascular diseases. AF increases the risk of stroke and heart failure and is a growing public health concern. AF is also associated with various disease conditions such as hypertension, coronary artery disease, aging, and diabetes mellitus. The mechanism underlying AF is not completely understood due to its complexity. However, experimental and clinical data have revealed that the prevalence of this disease is associated with atrial arrhythmogenic remodeling. Currently, there are no biomarkers that are available for the early diagnosis of AF. Several studies have proposed microRNAs (miRNAs) as useful biomarkers for the diagnosis of AF due to their stability and easy availability both in atrial tissue and circulating blood. miRNAs play an important role in the development of the heart. The dysregulation of miRNA expression is associated with cardiac remodeling. Genetic factors strongly contribute to the pathogenesis of AF. Recently, single nucleotide polymorphisms (SNPs) in various genes and miRNAs have been reported to be associated with AF. The aim of this review was to discuss the correlation between SNPs in miRNAs and AF, including those miRNAs that are commonly reported as potential biomarkers for AF.
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34
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Podzolkov VI, Tarzimanova AI. Antiarrhythmic therapy in the treatment of atrial fibrillation: yesterday, today, tomorrow. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2019. [DOI: 10.15829/1728-8800-2019-3-81-87] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Atrial fibrillation (AF) is the most common heart rhythm disorder encountered in clinical practice. Each year, the number of patients with AF significantly increases. It is associated with an increase of life expectancy and frequency of cardiovascular pathologies. Treatment of AF remains one of the most difficult tasks of modern cardiology. Currently, only a few antiarrhythmic drugs are available for use in Russia. More and more new attempts are being made to create a universal antiarrhythmic drug with a high level of anti-relapsing efficacy and adverse effects. The accumulated information suggests that the tactics of management of patients with arrhythmias will be intended to improving the new surgical and interventional treatment methods with use of anticoagulants and antiarrhythmic drugs. The multidisciplinary team of specialists on AF treatment should include an expert (cardiologist) in antiarrhythmic drug therapy, an interventional electrophysiologist, and a cardiac surgeon — master the technology of interventional or surgical ablation. Effective interaction of specialists of various levels will improve the results of rhythm control and prevention of complications in patients with AF.
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35
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Yamashita K, Ranjan R. Imaging for Risk Stratification in Atrial Fibrillation with Heart Failure. Cardiol Clin 2019; 37:147-156. [PMID: 30926016 PMCID: PMC6446587 DOI: 10.1016/j.ccl.2019.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac rhythm disorder and is associated with heart failure (HF). Cardiac imaging modalities play an important role in risk assessment and managing AF. This article reviews the use of cardiac imaging for risk assessment and to optimize treatment strategy in patients with AF and HF. First, the clinical role of echocardiography, computed tomography, and cardiac magnetic resonance for risk stratification is provided. Second, the value of imaging in catheter ablation is reviewed, including preoperative assessment, optimizing patient selection for ablation, use during the ablation procedure, and postoperative scar assessment.
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Affiliation(s)
- Kennosuke Yamashita
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, 30 N 1900 E, Room 4A100, Salt Lake City, Utah 84132, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, 95 South 2000 East, Salt Lake City, UT 84112, USA
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, 30 N 1900 E, Room 4A100, Salt Lake City, Utah 84132, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, 95 South 2000 East, Salt Lake City, UT 84112, USA; Department of Biomedical Engineering, University of Utah, 36 S. Wasatch Drive, Rm. 3100, Salt Lake City, UT 84112, USA.
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36
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Podzolkov VI, Tarzimanova AI. Personalized Medicine in the Treatment of Atrial Fibrillation: Myth or Reality? RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2019. [DOI: 10.20996/1819-6446-2019-15-1-90-94] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Due to the spectacular progress made in human genomic studies, molecular biology and genetics have become an essential part of modern medicine making it possible to early detect the risk factors and select the personalized treatment. The genetic studies have been widely used in the diagnosis and treatment of arrhythmias. Significant advances in the study of electrophysiological and genetic mechanisms of life-threatening arrhythmias have been achieved through studies of familial conditions with high risk of sudden cardiac death. However, the area of special interest for a practitioner is the identification of mutations associated with atrial fibrillation (AF). The novel methods enable us to study histological, structural, cellular and molecular causes of this arrhythmia. The two main directions of molecular genetic studies of AF are the identification of genetic mutations causing familial atrial fibrillation and the study of different genes polymorphism predisposing to arrhythmia in general population. Gene polymorphism screening helps both identify AF risk factors and predict its evolution from paroxysmal to chronic type. Emerging genetic studies provided explanation for the variable efficacy of antiarrhythmic drugs. It can be assumed that the clinical use of genetic methods will allow accurate and personalized selection of antiarrhythmics. Currently, therapeutic drug monitoring is widely recommended for a number of medications including cytostatics, aminoglycosides, anticonvulsants, and, by some researchers, antiarrhythmic and anticoagulant drugs. Medicine from the very beginning was intended to be personalized, but until recently it was a little more than a myth. The discovery of the human genome makes it possible to choose the most effective treatment with minimal adverse drug reactions for a particular patient.
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Affiliation(s)
- V. I. Podzolkov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. I. Tarzimanova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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Choe WS, Kang JH, Choi EK, Shin SY, Lubitz SA, Ellinor PT, Oh S, Lim HE. A Genetic Risk Score for Atrial Fibrillation Predicts the Response to Catheter Ablation. Korean Circ J 2018; 49:338-349. [PMID: 30808078 PMCID: PMC6428949 DOI: 10.4070/kcj.2018.0161] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 07/30/2018] [Accepted: 11/28/2018] [Indexed: 11/29/2022] Open
Abstract
Background and Objectives The association of susceptibility loci for atrial fibrillation (AF) with AF recurrence after ablation has been reported, although with controversial results. In this prospective cohort analysis, we aimed to investigate whether a genetic risk score (GRS) can predict the rhythm outcomes after catheter ablation of AF. Methods We determined the association between 20 AF-susceptible single nucleotide polymorphisms (SNPs) and AF recurrence after catheter ablation in 746 patients (74% males; age, 59±11 years; 56% paroxysmal AF). A GRS was calculated by summing the unweighted numbers of risk alleles of selected SNPs. A Cox proportional hazard model was used to identify the association between the GRS and risk of AF recurrence after catheter ablation. Results AF recurrences after catheter ablation occurred in 168 (22.5%) subjects with a median follow-up of 23 months. The GRS was calculated using 5 SNPs (rs1448818, rs2200733, rs6843082, rs6838973 at chromosome 4q25 [PITX2] and rs2106261 at chromosome 16q22 [ZFHX3]), which showed modest associations with AF recurrence. The GRS was significantly associated with AF recurrence (hazard ratio [HR] per each score, 1.13; 95% confidence interval [CI], 1.03–1.24). Patients with intermediate (GRS 4–6) and high risks (GRS 7–10) showed HRs of 2.00 (95% CI, 0.99–4.04) and 2.66 (95% CI, 1.32–5.37), respectively, compared to patients with low risk (GRS 0–3). Conclusions Our novel GRS using 5 AF-susceptible SNPs was strongly associated with AF recurrence after catheter ablation in Korean population, beyond clinical risk factors. Further efforts are warranted to construct a generalizable, robust genetic prediction model which can guide the optimal treatment strategies.
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Affiliation(s)
- Won Seok Choe
- Division of Cardiology, Department of Internal Medicine, Sejong Hospital, Bucheon, Korea
| | - Jun Hyuk Kang
- Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Eue Keun Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Seung Yong Shin
- Division of Cardiology, Heart Research Institute, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Steven A Lubitz
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA.,Program in Medical and Population Genetics, The Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Patrick T Ellinor
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA.,Program in Medical and Population Genetics, The Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Seil Oh
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hong Euy Lim
- Division of Cardiology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea.
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Hu Z, Zou D. Genotype-phenotype associations in atrial fibrillation: meta-analysis. J Interv Card Electrophysiol 2018; 54:283-288. [PMID: 30448967 DOI: 10.1007/s10840-018-0484-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 10/30/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Genome-wide association studies have identified several single-nucleotide polymorphisms (SNPs) associated with atrial fibrillation (AF). The relationship between SNPs and the incidence of stroke, heart failure, and the recurrence rate of AF after cardioversion has been reported. This meta-analysis focuses on the genotype-phenotype associations in AF. METHODS We searched PubMed/Medline and Embase for literature providing the phenotypic parameters and genotypes of RS10033464, RS13376333, RS2106261, RS2200733, and RS7193343. We selected literature published in English and reviewed the full text of included studies to perform a meta-analysis. RESULTS Fifteen papers, and 7034 patients with AF, were included. The mean risk gene frequency of the investigated variants was between 12 and 43%. The mean age of patients was between 50 and 70 and 70-80% of them were male. The stroke and heart failure frequencies in AF patients with RS2200733 were 10 and 7%, respectively. There was no significant difference in left ventricular ejection fraction and left ventricular end-diastolic diameter for all risk genotypes. For the AF recurrence after cardioversion treatment with direct current electric conversion, catheter ablation therapy, and anti-arrhythmic drugs. The early AF recurrence rate was 46% in RS10033464 and RS13376333 patients, and the late AF recurrence rate was 53% in RS2200733 patients. CONCLUSIONS Pooled analysis showed a significantly high prevalence of stroke (10%) in RS2200733 AF patients. AF patients with the studied SNPs had preserved left ventricular systolic function (i.e., ejection fraction greater than 50%). AF patients with RS10033464 presented larger left atrium diameter (44 mm (95% CI 42.02-45.98)) than those with other SNPs. The late AF recurrence rate was highest in RS2200733 patients (53% (95% CI 0.43-0.64)). This study aids our understanding of the existing genetic findings and the function-altering "strongest" SNPs.
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Affiliation(s)
- Zhen Hu
- Department of Cardiology, ShengJing Hospital of China Medical University, Shenyang, China
| | - Deling Zou
- Department of Cardiology, ShengJing Hospital of China Medical University, Shenyang, China.
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Cheniti G, Vlachos K, Pambrun T, Hooks D, Frontera A, Takigawa M, Bourier F, Kitamura T, Lam A, Martin C, Dumas-Pommier C, Puyo S, Pillois X, Duchateau J, Klotz N, Denis A, Derval N, Jais P, Cochet H, Hocini M, Haissaguerre M, Sacher F. Atrial Fibrillation Mechanisms and Implications for Catheter Ablation. Front Physiol 2018; 9:1458. [PMID: 30459630 PMCID: PMC6232922 DOI: 10.3389/fphys.2018.01458] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/26/2018] [Indexed: 01/14/2023] Open
Abstract
AF is a heterogeneous rhythm disorder that is related to a wide spectrum of etiologies and has broad clinical presentations. Mechanisms underlying AF are complex and remain incompletely understood despite extensive research. They associate interactions between triggers, substrate and modulators including ionic and anatomic remodeling, genetic predisposition and neuro-humoral contributors. The pulmonary veins play a key role in the pathogenesis of AF and their isolation is associated to high rates of AF freedom in patients with paroxysmal AF. However, ablation of persistent AF remains less effective, mainly limited by the difficulty to identify the sources sustaining AF. Many theories were advanced to explain the perpetuation of this form of AF, ranging from a single localized focal and reentrant source to diffuse bi-atrial multiple wavelets. Translating these mechanisms to the clinical practice remains challenging and limited by the spatio-temporal resolution of the mapping techniques. AF is driven by focal or reentrant activities that are initially clustered in a relatively limited atrial surface then disseminate everywhere in both atria. Evidence for structural remodeling, mainly represented by atrial fibrosis suggests that reentrant activities using anatomical substrate are the key mechanism sustaining AF. These reentries can be endocardial, epicardial, and intramural which makes them less accessible for mapping and for ablation. Subsequently, early interventions before irreversible remodeling are of major importance. Circumferential pulmonary vein isolation remains the cornerstone of the treatment of AF, regardless of the AF form and of the AF duration. No ablation strategy consistently demonstrated superiority to pulmonary vein isolation in preventing long term recurrences of atrial arrhythmias. Further research that allows accurate identification of the mechanisms underlying AF and efficient ablation should improve the results of PsAF ablation.
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Affiliation(s)
- Ghassen Cheniti
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France.,Cardiology Department, Hopital Sahloul, Universite de Sousse, Sousse, Tunisia
| | - Konstantinos Vlachos
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Thomas Pambrun
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Darren Hooks
- Cardiology Department, Wellington Hospital, Wellington, New Zealand
| | - Antonio Frontera
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Masateru Takigawa
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Felix Bourier
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Takeshi Kitamura
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Anna Lam
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Claire Martin
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | | | - Stephane Puyo
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Xavier Pillois
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France
| | - Josselin Duchateau
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Nicolas Klotz
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Arnaud Denis
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Nicolas Derval
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Pierre Jais
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Hubert Cochet
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France.,Department of Cardiovascular Imaging, Hopital Haut Leveque, Bordeaux, France
| | - Meleze Hocini
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Michel Haissaguerre
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Frederic Sacher
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
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40
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Atrial Structural Remodeling Gene Variants in Patients with Atrial Fibrillation. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4862480. [PMID: 30276209 PMCID: PMC6151856 DOI: 10.1155/2018/4862480] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/30/2018] [Accepted: 07/17/2018] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is a common arrhythmia for which the genetic studies mainly focused on the genes involved in electrical remodeling, rather than left atrial muscle remodeling. To identify rare variants involved in atrial myopathy using mutational screening, a high-throughput next-generation sequencing (NGS) workflow was developed based on a custom AmpliSeq™ panel of 55 genes potentially involved in atrial myopathy. This workflow was applied to a cohort of 94 patients with AF, 76 with atrial dilatation and 18 without. Bioinformatic analyses used NextGENe® software and in silico tools for variant interpretation. The AmpliSeq custom-made panel efficiently explored 96.58% of the targeted sequences. Based on in silico analysis, 11 potentially pathogenic missense variants were identified that were not previously associated with AF. These variants were located in genes involved in atrial tissue structural remodeling. Three patients were also carriers of potential variants in prevalent arrhythmia-causing genes, usually associated with AF. Most of the variants were found in patients with atrial dilatation (n=9, 82%). This NGS approach was a sensitive and specific method that identified 11 potentially pathogenic variants, which are likely to play roles in the predisposition to left atrial myopathy. Functional studies are needed to confirm their pathogenicity.
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Chalazan B, Dickerman D, Sridhar A, Farrell M, Gayle K, Samuels DC, Shoemaker B, Darbar D. Relation of Body Mass Index to Symptom Burden in Patients withAtrial Fibrillation. Am J Cardiol 2018; 122:235-241. [PMID: 29914646 PMCID: PMC6028292 DOI: 10.1016/j.amjcard.2018.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 03/24/2018] [Accepted: 04/02/2018] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with significant morbidity and increased mortality. As body mass index (BMI) is increasingly recognized as an important risk factor for the development of AF, we tested the hypothesis that BMI modulates symptomatic AF burden. Cross-sectional data collected from 1,382 patients in the Vanderbilt AF Registry were analyzed. AF severity was assessed using the Toronto atrial fibrillation severity scale (AFSS). BMI was categorized according to World Health Organization guidelines and patients were grouped according to their present AF treatment regimen: no treatment (n = 185), rate control therapy with atrioventricular nodal blocking agents (n = 351), rhythm control with antiarrhythmic drugs (n = 636), and previous AF ablation (n = 210). Patients with BMI >35 kg/m2 had higher AFSS scores than those with BMI <30 kg/m2 in the rate control (43.57 vs 38.21: p = 0.0057), rhythm control (46.61 vs 41.08: p = 1.6 × 10-4), and ablation (44.01 vs 39.02: p = 0.047) groups. Inunivariate linear models, BMI was associated with an increase in the AFSS score in the rate control (0.27, 95% confidence interval [CI] 0.05 to 0.5, p = 0.02), rhythm control (0.38, 95% CI 0.21 to 0.56, p = 2.49 × 10-5), and ablation (0.38, 95% CI 0.03 to 0.73, p = 0.03) groups. The association remained significant in the rhythm control groups after adjusting for age, gender, race, and comorbidities (0.29, 95% CI 0.11 to 0.49, p = 0.002). In conclusion, increasing BMI was directly associated with patient reported measures of AF symptom severity, burden, and quality of life. This was most significant in patients treated with rhythm-control strategies.
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Affiliation(s)
- Brandon Chalazan
- Department of Medicine, University of Illinois at Chicago, Jesse Brown VA Medical Center, Chicago, Illinois
| | - Deanna Dickerman
- Departments of Medicine and Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee
| | - Arvind Sridhar
- Department of Medicine, University of Illinois at Chicago, Jesse Brown VA Medical Center, Chicago, Illinois
| | - Maureen Farrell
- Departments of Medicine and Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee
| | - Katherine Gayle
- Departments of Medicine and Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee
| | - David C Samuels
- Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee
| | - Benjamin Shoemaker
- Departments of Medicine and Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee
| | - Dawood Darbar
- Department of Medicine, University of Illinois at Chicago, Jesse Brown VA Medical Center, Chicago, Illinois; Departments of Medicine and Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee.
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42
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Calvo D, Filgueiras-Rama D, Jalife J. Mechanisms and Drug Development in Atrial Fibrillation. Pharmacol Rev 2018; 70:505-525. [PMID: 29921647 PMCID: PMC6010660 DOI: 10.1124/pr.117.014183] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation is a highly prevalent cardiac arrhythmia and the most important cause of embolic stroke. Although genetic studies have identified an increasing assembly of AF-related genes, the impact of these genetic discoveries is yet to be realized. In addition, despite more than a century of research and speculation, the molecular and cellular mechanisms underlying AF have not been established, and therapy for AF, particularly persistent AF, remains suboptimal. Current antiarrhythmic drugs are associated with a significant rate of adverse events, particularly proarrhythmia, which may explain why many highly symptomatic AF patients are not receiving any rhythm control therapy. This review focuses on recent advances in AF research, including its epidemiology, genetics, and pathophysiological mechanisms. We then discuss the status of antiarrhythmic drug therapy for AF today, reviewing molecular mechanisms, and the possible clinical use of some of the new atrial-selective antifibrillatory agents, as well as drugs that target atrial remodeling, inflammation and fibrosis, which are being tested as upstream therapies to prevent AF perpetuation. Altogether, the objective is to highlight the magnitude and endemic dimension of AF, which requires a significant effort to develop new and effective antiarrhythmic drugs, but also improve AF prevention and treatment of risk factors that are associated with AF complications.
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Affiliation(s)
- David Calvo
- Department of Cardiology, Arrhythmia Unit, Hospital Universitario Central de Asturias and Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain (D.C.); Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (D.F.-R., J.J.); Department of Cardiology, Arrhythmia Unit, Hospital Clínico Universitario San Carlos, Madrid, Spain (D.F.-R.); Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (D.F.-R., J.J.); and Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (J.J.)
| | - David Filgueiras-Rama
- Department of Cardiology, Arrhythmia Unit, Hospital Universitario Central de Asturias and Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain (D.C.); Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (D.F.-R., J.J.); Department of Cardiology, Arrhythmia Unit, Hospital Clínico Universitario San Carlos, Madrid, Spain (D.F.-R.); Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (D.F.-R., J.J.); and Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (J.J.)
| | - José Jalife
- Department of Cardiology, Arrhythmia Unit, Hospital Universitario Central de Asturias and Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain (D.C.); Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (D.F.-R., J.J.); Department of Cardiology, Arrhythmia Unit, Hospital Clínico Universitario San Carlos, Madrid, Spain (D.F.-R.); Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (D.F.-R., J.J.); and Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (J.J.)
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Abstract
Considerable interindividual variability in response to cardiovascular pharmacotherapy exists with drug responses varying from being efficacious to inadequate to induce severe adverse events. Fueled by advancements and multidisciplinary collaboration across disciplines such as genetics, bioinformatics, and basic research, the vision of personalized medicine, rather than a one-size-fits-all approach, may be within reach. Pharmacogenetics offers the potential to optimize the benefit-risk profile of drugs by tailoring diagnostic and treatment strategies according to the individual patient. To date, a multitude of studies has tried to delineate the effects of gene-drug interactions for drugs commonly used to treat cardiovascular-related disease. The focus of this review is on how genetic variability may modify drug responsiveness and patient outcomes following therapy with commonly used cardiovascular drugs including clopidogrel, warfarin, statins, and β-blockers. Also included are examples of how genetic studies can be used to guide drug discovery and examples of how genetic information may be deployed in clinical decision making.
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Affiliation(s)
- Peter E Weeke
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.
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44
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McCauley M, Darbar D. Germline versus somatic mutations in genetic atrial fibrillation. Heart Rhythm 2017; 14:1539-1540. [PMID: 28734984 PMCID: PMC5705188 DOI: 10.1016/j.hrthm.2017.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Mark McCauley
- Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois
| | - Dawood Darbar
- Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois.
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45
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Bapat A, Anderson CD, Ellinor PT, Lubitz SA. Genomic basis of atrial fibrillation. Heart 2017; 104:201-206. [PMID: 28893835 DOI: 10.1136/heartjnl-2016-311027] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/03/2017] [Accepted: 08/11/2017] [Indexed: 01/24/2023] Open
Abstract
Atrial fibrillation (AF) is a prevalent arrhythmia associated with substantial morbidity, mortality and costs. Available management strategies generally have limited efficacy and are associated with potential adverse effects. In part, the limited efficacy of approaches to managing AF reflect an incomplete understanding of the biological mechanisms underlying the arrhythmia, and only a partial understanding of how best to individualise management. Over the last several decades, a greater understanding of genome biology has led to recognition of a widespread genetic susceptibility to AF. Through genome-wide association studies, at least 30 genetic loci have been identified in association with AF, most of which implicate mechanisms not previously appreciated to be involved in the development of AF. We now recognise that AF is a polygenic condition, yet a great deal of work lies ahead to better understand the precise mechanisms by which genomic variation causes AF. Understanding the genetic basis of AF could provide a better understanding of AF mechanisms and cardiovascular biology, inform the management of patients through risk-guided approaches and facilitate the development of novel therapeutics.
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Affiliation(s)
- Aneesh Bapat
- Cardiology Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christopher D Anderson
- Department of Neurology, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA.,Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Patrick T Ellinor
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, Massachusetts, USA
| | - Steven A Lubitz
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, Massachusetts, USA
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46
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Heijman J, Ghezelbash S, Dobrev D. Investigational antiarrhythmic agents: promising drugs in early clinical development. Expert Opin Investig Drugs 2017; 26:897-907. [PMID: 28691539 PMCID: PMC6324729 DOI: 10.1080/13543784.2017.1353601] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Although there have been important technological advances for the treatment of cardiac arrhythmias (e.g., catheter ablation technology), antiarrhythmic drugs (AADs) remain the cornerstone therapy for the majority of patients with arrhythmias. Most of the currently available AADs were coincidental findings and did not result from a systematic development process based on known arrhythmogenic mechanisms and specific targets. During the last 20 years, our understanding of cardiac electrophysiology and fundamental arrhythmia mechanisms has increased significantly, resulting in the identification of new potential targets for mechanism-based antiarrhythmic therapy. Areas covered: Here, we review the state-of-the-art in arrhythmogenic mechanisms and AAD therapy. Thereafter, we focus on a number of antiarrhythmic targets that have received significant attention recently: atrial-specific K+-channels, the late Na+-current, the cardiac ryanodine-receptor channel type-2, and the small-conductance Ca2+-activated K+-channel. We highlight for each of these targets available antiarrhythmic agents and the evidence for their antiarrhythmic effect in animal models and early clinical development. Expert opinion: Targeting AADs to specific subgroups of well-phenotyped patients is likely necessary to detect improved outcomes that may be obscured in the population at large. In addition, specific combinations of selective AADs may have synergistic effects and may enable a mechanism-based tailored antiarrhythmic therapy.
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Affiliation(s)
- Jordi Heijman
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Shokoufeh Ghezelbash
- Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Essen, Germany
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Essen, Germany
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47
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Syeda F, Kirchhof P, Fabritz L. PITX2-dependent gene regulation in atrial fibrillation and rhythm control. J Physiol 2017; 595:4019-4026. [PMID: 28217939 PMCID: PMC5471504 DOI: 10.1113/jp273123] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 01/17/2017] [Indexed: 01/15/2023] Open
Abstract
Atrial fibrillation (AF) is a common arrhythmia. Better prevention and treatment of AF are needed to reduce AF-associated morbidity and mortality. There are several major mechanisms that cause AF in patients, including a genetic predisposition to develop AF. Genome-wide association studies have identified genetic variants associated with AF populations, with the strongest hits clustering on chromosome 4q25, close to the gene for the homeobox transcription factor PITX2. The effect of these common gene variants on cardiac PITX2 mRNA is currently under study. PITX2 protein regulates right-left differentiation of the embryonic heart, thorax and aorta. PITX2 is expressed in the adult left atrium, but much less so in other heart chambers. Pitx2 deficiency results in electrical and structural remodelling, and impaired repair of the heart in murine models, all of which may influence AF through divergent mechanisms. PITX2 levels and single nucleotide polymorphisms on chromosome 4q25 may also be a predictor of the effectiveness of anti-arrhythmic drug therapy.
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Affiliation(s)
- Fahima Syeda
- Institute of Cardiovascular SciencesUniversity of BirminghamBirminghamUK
| | - Paulus Kirchhof
- Institute of Cardiovascular SciencesUniversity of BirminghamBirminghamUK
- Department of CardiologyUHB NHS TrustBirminghamUK
- Department of CardiologySWBTBirminghamUK
| | - Larissa Fabritz
- Institute of Cardiovascular SciencesUniversity of BirminghamBirminghamUK
- Department of CardiologyUHB NHS TrustBirminghamUK
- Department of Cardiovascular Medicine, Division of RhythmologyUniversity Hospital MünsterMünsterGermany
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Zakeri R, Van Wagoner DR, Calkins H, Wong T, Ross HM, Heist EK, Meyer TE, Kowey PR, Mentz RJ, Cleland JG, Pitt B, Zannad F, Linde C. The burden of proof: The current state of atrial fibrillation prevention and treatment trials. Heart Rhythm 2017; 14:763-782. [PMID: 28161513 PMCID: PMC5403606 DOI: 10.1016/j.hrthm.2017.01.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is an age-related arrhythmia of enormous socioeconomic significance. In recent years, our understanding of the basic mechanisms that initiate and perpetuate AF has evolved rapidly, catheter ablation of AF has progressed from concept to reality, and recent studies suggest lifestyle modification may help prevent AF recurrence. Emerging developments in genetics, imaging, and informatics also present new opportunities for personalized care. However, considerable challenges remain. These include a paucity of studies examining AF prevention, modest efficacy of existing antiarrhythmic therapies, diverse ablation technologies and practice, and limited evidence to guide management of high-risk patients with multiple comorbidities. Studies examining the long-term effects of AF catheter ablation on morbidity and mortality outcomes are not yet completed. In many ways, further progress in the field is heavily contingent on the feasibility, capacity, and efficiency of clinical trials to incorporate the rapidly evolving knowledge base and to provide substantive evidence for novel AF therapeutic strategies. This review outlines the current state of AF prevention and treatment trials, including the foreseeable challenges, as discussed by a unique forum of clinical trialists, scientists, and regulatory representatives in a session endorsed by the Heart Rhythm Society at the 12th Global CardioVascular Clinical Trialists Forum in Washington, DC, December 3-5, 2015.
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Affiliation(s)
- Rosita Zakeri
- Royal Brompton & Harefield NHS Trust, London, United Kingdom.
| | | | | | - Tom Wong
- Royal Brompton & Harefield NHS Trust, London, United Kingdom
| | | | - E Kevin Heist
- Massachusetts General Hospital, Boston, Massachusetts
| | | | - Peter R Kowey
- Lankenau Heart Institute and Jefferson Medical College, Wynnewood, Pennsylvania
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina
| | - John G Cleland
- Royal Brompton & Harefield NHS Trust, London, United Kingdom
| | | | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, France
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Lee JY, Kim TH, Yang PS, Lim HE, Choi EK, Shim J, Shin E, Uhm JS, Kim JS, Joung B, Oh S, Lee MH, Kim YH, Pak HN. Korean atrial fibrillation network genome-wide association study for early-onset atrial fibrillation identifies novel susceptibility loci. Eur Heart J 2017; 38:2586-2594. [DOI: 10.1093/eurheartj/ehx213] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 04/06/2017] [Indexed: 11/14/2022] Open
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Roberts JD, Soliman EZ, Alonso A, Vittinghoff E, Chen LY, Loehr L, Marcus GM. Electrocardiographic intervals associated with incident atrial fibrillation: Dissecting the QT interval. Heart Rhythm 2017; 14:654-660. [PMID: 28189824 DOI: 10.1016/j.hrthm.2017.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Prolongation of the QT interval has been associated with an increased risk of developing atrial fibrillation (AF), but the responsible mechanism remains unknown. OBJECTIVES The aims of this study were to subdivide the QT interval into its components and identify the resultant electrocardiographic interval(s) responsible for the association with AF. METHODS Predefined QT-interval components were assessed for association with incident AF in the Atherosclerosis Risk in Communities study using Cox proportional hazards models. Hazard ratios (HRs) were calculated per 1-SD increase in each component. Among QT-interval components exhibiting significant associations, additional analyses evaluating long extremes, defined as greater than the 95th percentile, were performed. RESULTS Of the 14,625 individuals, 1505 (10.3%) were diagnosed with incident AF during a mean follow-up period of 17.6 years. After multivariable adjustment, QT-interval components involved in repolarization, but not depolarization, exhibited significant associations with incident AF, including a longer ST segment (HR 1.27; 95% confidence interval [CI] 1.14-1.41; P < .001) and a prolonged T-wave onset to T-wave peak (T-onset to T-peak) (HR 1.13; 95% CI 1.07-1.20; P < .001). Marked prolongation of the ST segment (HR 1.31; 95% CI 1.04-1.64; P = .022) and T-onset to T-peak (HR 1.36; 95% CI 1.09-1.69; P = .006) was also associated with an increased risk of incident AF. CONCLUSION The association between a prolonged QT interval and incident AF is primarily explained by components involved in ventricular repolarization: prolongation of the ST segment and T-onset to T-peak. These observations suggest that prolongation of phases 2 and 3 of the cardiac action potential drives the association between the QT interval and AF risk.
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Affiliation(s)
- Jason D Roberts
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada.
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Lin Y Chen
- Cardiovascular Division, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Laura Loehr
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Gregory M Marcus
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California.
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