Beyond cardioversion, ablation and pharmacotherapies: Risk factors, lifestyle change and behavioral counseling strategies in the prevention and treatment of atrial fibrillation

Intersection of sepsis, atrial fibrillation, and severe obesity: a population-based analysis in the United States

BACKGROUND

Atrial fibrillation (AF) is an indicator of poor prognosis in patients with sepsis and can increase the risk of stroke and mortality. Data on the impact of severe obesity on the outcomes of sepsis complicated by AF remains poorly understood.

METHODS

National Inpatient Sample (2018) and ICD-10 CM codes were used to identify the principal sepsis admissions with AF. We assessed comorbidities and outcomes of sepsis in people without obesity (BMI < 30) vs. non-severe obesity (BMI 30-35) and severe obesity (BMI > 35) cohorts. We also did a subgroup analysis to further stratify obesity based on metabolic health and analyzed the findings. The primary outcomes were the prevalence and adjusted odds of AF, AF-associated stroke, and all-cause mortality in sepsis by obesity status. Multivariable regression analyses were adjusted for patient- and hospital-level characteristics and comorbidities.

RESULTS

Our main analysis showed that of the 1,345,595 sepsis admissions, the severe obesity cohort was the youngest (median age 59 vs. non-severe 64 and people without obesity 68 years). Patients with obesity, who were often female, were more likely to have hypertension, diabetes, congestive heart failure, chronic pulmonary disease, and chronic kidney disease. The crude prevalence of AF was highest in non-severe obesity (19.9%). The adjusted odds of AF in non-severe obesity (OR 1.21; 95% CI:1.16-1.27) and severe obesity patients with sepsis (OR 1.49; 95% CI:1.43-1.55) were significantly higher than in people without obesity (p < 0.001). Paradoxically, the rates of AF-associated stroke (1%, 1.5%, and 1.7%) and in-hospital mortality (3.3%, 4.9%, and 7.1%) were lowest in the severe obesity cohort vs. the non-severe and people without obesity cohorts, respectively. On multivariable regression analyses, the all-cause mortality revealed lower odds in sepsis-AF patients with severe obesity (OR 0.78; 95% CI:0.67-0.91) or non-severe obesity (OR 0.63; 95% CI:0.54-0.74) vs. people without obesity. There was no significant difference in stroke risk.

CONCLUSIONS

A higher prevalence of cardiovascular comorbidities can be linked to a higher risk of AF in people with obesity and sepsis. Paradoxically, lower rates of stroke and all-cause mortality secondary to AF in people with obesity and sepsis warrant further investigation.

Nurse-led care after ablation of atrial fibrillation: a randomized controlled trial

AIMS

The added value of advanced practitioner nurse (APN) care after ablation of atrial fibrillation (AF) is unknown. The present study investigates the impact of APN-led care on AF recurrence, patient knowledge, lifestyle, and patient satisfaction.

METHODS AND RESULTS

Sixty-five patients undergoing AF ablation were prospectively randomized to usual care (N = 33) or intervention (N = 32) group. In addition to usual care, the intervention consisted of an educational session, three consultations spread over 6 months and telephone accessibility coordinated by the APN. Primary outcome was the AF recurrence rate at 6-month follow-up. Secondary outcomes were lifestyle factors (alcohol intake, exercise, BMI, smoking), patient satisfaction and AF knowledge measured at 1 and 6 months between groups and within each group. Study demographics at 1 month were similar, except AF knowledge was higher in the intervention group (8.6 vs. 7, P = 0.001). At 6 months, AF recurrence was significantly lower in the intervention group (13.5 vs. 39.4%, P = 0.014). Between groups, patient satisfaction and AF knowledge were significantly higher in the intervention group, respectively, 9.4 vs. 8.7 (P < 0.001) and 8.6 vs. 7.0 out of 10 (P < 0.001). Within the intervention group, alcohol intake decreased from 3.9 to 2.6 units per week (P = 0.031) and physical activity increased from 224.4 ± 210.7 to 283.8 ± 169.3 (P = 0.048). No changes occurred within the usual care group. Assignment to the intervention group was the only protective factor for AF recurrence [Exp(B) 0.299, P = 0.04] in multivariable-adjusted analysis.

CONCLUSION

Adding APN-led care after ablation of AF improves short-term clinical outcome, patient satisfaction and physical activity and decreases alcohol intake.

The Synergistic Relationship Between Atrial Fibrillation and Diabetes Mellitus: Implications for Cardiovascular and Metabolic Health

Type 2 diabetes mellitus (T2DM) and atrial fibrillation (AF) are widespread chronic conditions that profoundly impact public health. While the intricate mechanisms linking these two diseases remain incompletely understood, this review sets out to comprehensively analyze the current evidence about their pathophysiology, epidemiology, diagnosis, prognosis, and treatment. We reveal that T2DM can influence the electrical and structural properties of the atria through multiple pathways, including oxidative stress, inflammation, fibrosis, connexin remodeling, glycemic variability, and autonomic dysfunction. Moreover, it significantly influences AF's clinical course, elevating the risk of heart failure, stroke, and cardiovascular mortality. Our review also explores treatment options for individuals with T2DM and AF, encompassing antidiabetic and antiarrhythmic drugs and non-pharmacological interventions, such as cardioversion catheter ablation and direct current cardioversion. This review depicts an insight into the clinical interplay between T2DM and AF. It deepens our comprehension of the fundamental mechanisms, potential therapeutic interventions, and their implications for patient care. This comprehensive resource benefits researchers seeking to deepen their knowledge in this domain. Ultimately, our findings pave the way for more effective strategies in managing AF within the context of T2DM.

Obesity and atrial fibrillation: Prevalence, pathogenesis, and prognosis

The prevalence of atrial fibrillation (AF) and obesity are rising significantly. There is a shared association between these conditions with obesity predisposing individuals to a number of shared risk factors. In addition, obesity in itself has been shown to cause changes to the structure, function and hemodynamics of the heart. There is evidence to show that weight-loss has significant impact on AF symptoms, burden and more recently the potential to reverse the type of AF. Through risk factor management and in the case of morbid obesity, bariatric surgery, there is an improved prognosis for patients with AF and obesity. In this paper we provide a review of the current data on obesity and AF prevalence, pathogenesis and prognosis.

Clinical decision support to Optimize Care of patients with Atrial Fibrillation or flutter in the Emergency department: protocol of a stepped-wedge cluster randomized pragmatic trial (O'CAFÉ trial)

BACKGROUND

Management of adults with atrial fibrillation (AF) or atrial flutter in the emergency department (ED) includes rate reduction, cardioversion, and stroke prevention. Different approaches to these components of care may lead to variation in frequency of hospitalization and stroke prevention actions, with significant implications for patient experience, cost of care, and risk of complications. Standardization using evidence-based recommendations could reduce variation in management, preventable hospitalizations, and stroke risk.

METHODS

We describe the rationale for our ED-based AF treatment recommendations. We also describe the development of an electronic clinical decision support system (CDSS) to deliver these recommendations to emergency physicians at the point of care. We implemented the CDSS at three pilot sites to assess feasibility and solicit user feedback. We will evaluate the impact of the CDSS on hospitalization and stroke prevention actions using a stepped-wedge cluster randomized pragmatic clinical trial across 13 community EDs in Northern California.

DISCUSSION

We hypothesize that the CDSS intervention will reduce hospitalization of adults with isolated AF or atrial flutter presenting to the ED and increase anticoagulation prescription in eligible patients at the time of ED discharge and within 30 days. If our hypotheses are confirmed, the treatment protocol and CDSS could be recommended to other EDs to improve management of adults with AF or atrial flutter.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05009225 .  Registered on 17 August 2021.

Physical Activity Changes and the Risk of Incident Atrial Fibrillation in Patients With Type 2 Diabetes Mellitus: A Nationwide Longitudinal Follow-up Cohort Study of 1.8 Million Subjects

OBJECTIVE

We investigated the association between alterations in regular physical activity (PA) and the risk of developing AF in patients with type 2 diabetes mellitus (T2DM) and the optimal PA range based on energy expenditure.

RESEARCH DESIGN AND METHODS

In a nationwide database, subjects who underwent health examinations twice at a 2-year interval between 2009 and 2012 were studied. After 1,815,330 patients with T2DM who did not have a history of AF were identified, they were followed until 2018. Regular PA alterations over time were used to divide individuals into four groups: persistent nonexercisers (n = 1,181,837), new exercisers (n = 242,968), exercise dropouts (n = 225,124), and exercise maintainers (n = 165,401).

RESULTS

During a mean follow-up period of 5.6 ± 1.3 years, 46,589 cases (2.6%) of new-onset AF occurred. Compared with the persistent nonexerciser group, both the exercise dropout group (adjusted hazard ratio [HR] 0.96, 95% CI 0.94-0.99) and new exerciser group (HR 0.95, 95% CI 0.93-0.98) had lower risks of incident AF. The exercise maintainer group showed the lowest risk (HR 0.91, 95% CI 0.89-0.94). When we stratified patients with T2DM according to energy expenditure, undergoing regular PA with ≥1,500 MET-min/week in new exercisers and ≥1,000 MET-min/week in exercise maintainers was associated with lower risks of incident AF than nonexercisers.

CONCLUSIONS

In patients with T2DM, starting and maintaining regular PA were both associated with lower risk of incident AF. Optimal PA ranges based on energy expenditure, which were associated with lower risks of incident AF, can be defined.

An Exercise and Physical Activity Program in Patients With Atrial Fibrillation: The ACTIVE-AF Randomized Controlled Trial

BACKGROUND

There are limited data on the effect of exercise interventions on atrial fibrillation (AF) recurrence and symptoms.

OBJECTIVES

The aim of this study was to determine the efficacy of an exercise and physical activity intervention on AF burden and symptoms among patients with symptomatic AF.

METHODS

This prospective, randomized controlled trial included 120 patients with paroxysmal or persistent, symptomatic AF, randomized 1:1 to receive an exercise intervention, combining home and supervised aerobic exercise over 6 months, or to receive usual care. The coprimary outcomes were: 1) AF recurrence, off antiarrhythmic medications and without catheter ablation; and 2) symptom severity assessed by using a validated questionnaire.

RESULTS

By 12 months, freedom from AF was achieved in 24 (40%) of 60 patients in the exercise group and 12 (20%) of 60 patients in the control group (HR: 0.50: 95% CI: 0.33 to 0.78). At 6 months, AF symptom severity was lower in the exercise group compared with the control group (mean difference -2.3; 95% CI: -4.3 to -0.2; P = 0.033). This difference persisted at 12 months (-2.3; 95% CI: -4.5 to -0.1; P = 0.041). Total symptom burden was lower at 6 months in the exercise group but not at 12 months. Peak oxygen consumption was increased in the exercise group at both 6 and 12 months. There were no between-group differences in cardiac structure or function, body mass index, or blood pressure.

CONCLUSIONS

Participation in an exercise-based intervention over 6 months reduced arrhythmia recurrence and improved symptom severity among patients with AF. (A Lifestyle-based, PhysiCal AcTIVity IntErvention for Patients With Symptomatic Atrial Fibrillation [the ACTIVE-AF Study]; ACTRN12615000734561).

Imaging-based body fat depots and new-onset atrial fibrillation in general population: a prospective cohort study

BACKGROUND

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

METHODS

In the prospective population-based Rotterdam Study, body composition was assessed using dual-energy X-ray absorptiometry (DXA) and liver and epicardial fat using computed tomography (CT). A body composition score was constructed by adding tertile scores of each fat depot. Principal component analysis was conducted to identify potential body fat distribution patterns. Cox proportional hazards regression was used to calculate hazard ratios and 95% confidence intervals (HR; 95% CI) per 1-standard deviation increase in corresponding fat depots to enable comparisons.

RESULTS

Over a median follow-up of 9.6 and 8.6 years, 395 (11.4%) and 172 (8.0%) AF cases were ascertained in the DXA and the CT analyses, respectively. After adjustments for cardiovascular risk factors, absolute fat mass (HR; 95% CI 1.33; 1.05-1.68), gynoid fat mass (HR; 95% CI 1.36; 1.12-1.65), epicardial fat mass (HR; 95% CI 1.27; 1.09-1.48), and android-to-gynoid fat ratio (HR; 95% CI 0.81; 0.70-0.94) were independently associated with new-onset AF. After further adjustment for lean mass, associations between fat mass (HR; 95% CI 1.17; 1.04-1.32), gynoid fat mass (HR; 95% CI 1.21; 1.08-1.37), and android-to-gynoid fat ratio (HR; 95% CI 0.84; 0.72-0.97) remained statistically significant. Larger body fat score was associated with a higher AF risk (HR; 95% CI 1.10; 1.02-1.20). Borderline significant association was found between a subcutaneous fat predominant pattern with AF onset (HR; 95% CI 1.21; 0.98-1.49).

CONCLUSIONS

Various body fat depots were associated with new-onset AF. Total fat mass and gynoid fat mass were independently associated with AF after adjustment for body size. The inverse association between android-to-gynoid fat ratio with AF presents a novel finding. A significant dose-response relationship between body fat accumulation and AF was observed. Our results underscore the predominant role of subcutaneous fat on AF development among a middle-aged and elderly population. Associations betw2een body fat depots, fat distribution and new-onset atrial fibrillation.

ABBREVIATIONS

AF, atrial fibrillation.

The complex interplay between diabetes mellitus and atrial fibrillation

INTRODUCTION

: A growing body of evidence suggests that diabetes mellitus (DM) is associated with an increased risk of new-onset atrial fibrillation (AF) and contributes to suboptimal arrhythmia control and poor prognosis in patients with AF. The high prevalence of AF among patients with DM is primarily attributed to common risk factors, shared pathophysiological mechanisms, and associated atrial remodeling and autonomic dysfunction.

AREAS COVERED

: This comprehensive review covers the current data on the role of DM in the development and prognosis of AF. In addition, we review the impact of anti-DM medications on AF prevention and the role of anticoagulation in patients with coexisting DM and AF.

EXPERT OPINION

: DM is independently associated with new-onset AF, and the coexistence of these two conditions contributes to poor outcomes, from reduced quality of life to increased risks of thromboembolic events, heart failure, and mortality. Despite this strong link, the current evidence is insufficient to recommend routine screening for AF in patients with DM. Although some observations exist on preventing AF with anti-DM medications, randomized controlled trials are warranted to explore the proposed benefits of novel anti-DM medicines in reducing the risk of incident AF.

PAGln, an Atrial Fibrillation-Linked Gut Microbial Metabolite, Acts as a Promoter of Atrial Myocyte Injury

Phenylacetylglutamine (PAGln), a gut microbiota (GM)-derived metabolite, is associated with cardiovascular disease. Studies have shown that disordered GM participated in the progression of atrial fibrillation (AF), but the relationship between PAGln and AF is unclear. This study investigated the characteristics of PAGln in AF patients and its impact on atrial myocytes. Based on our previous metagenomic data, the relative abundance of porA, a critical bacterial enzyme for PAGln synthesis, exhibited an increased tendency in AF. In an independent cohort consisting of 42 controls without AF and 92 AF patients, plasma PAGln levels were higher in AF patients than in controls (p < 0.001) by immunoassay. Notably, PAGln exerted a predictive potential of AF with an AUC of 0.774 (p < 0.001), and a predictive model constructed based on the PAGln and Taiwan AF score further improved the predictive potential. Furthermore, a positive correlation was determined between PAGln and LA diameter. Subsequently, the effect of PAGln intervention was examined on HL-1 cells in vitro, revealing that PAGln increased apoptosis, reactive oxygen species (ROS) production, CaMKII and RyR2 activation and decreased cell viability. In conclusion, increased PAGln was associated with AF, and PAGln might contribute to the AF pathogenesis by promoting oxidative stress and apoptosis in atrial myocytes.

Association of physical activity with the incidence of atrial fibrillation in persons > 65 years old: the Atherosclerosis Risk in Communities (ARIC) study

AIMS

To evaluate the association of physical activity (PA) with atrial fibrillation (AF) incidence in an elderly population.

METHODS

We studied 5166 participants of the Atherosclerosis Risk in Communities cohort examined in 2011-2013 free of AF. Self-reported PA was evaluated with a validated questionnaire. Weekly minutes of leisure-time moderate to vigorous physical activity (MVPA) were calculated and categorized using the 2018 Physical Activity Guidelines for Americans (no activity [0 min/week], low [> 0- < 150 min/week], adequate [150- < 300 min/week], high [≥ 300 min/week]). Incident AF through 2019 was ascertained from hospital discharges and death certificates. Cox models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for AF by levels of physical activity adjusting for potential confounders.

RESULTS

The mean (SD) age for the sample was 75 (5) years (59% female, 22% Black). During a mean (SD) follow-up time of 6.3 (2.0) years, 703 AF events were identified. The association of MVPA with AF incidence showed a U-shaped relationship. Compared to those not engaging in MVPA, individuals with low MVPA had a 23% lower hazard of AF (HR = 0.77; 95% CI 0.61, 0.96), while those with adequate MVPA had a 14% lower hazard (HR 0.86; 95% CI 0.69, 1.06). High levels of MVPA were not associated with AF risk (HR 0.97; 95% CI 0.78, 1.20).

CONCLUSION

This study suggests that being involved in low to moderate levels of MVPA is associated with lower AF risk, with no evidence of increased risk of AF in those with higher levels of MVPA.

Effect of a 1-Year Controlled Lifestyle Intervention on Body Weight and Other Risk Markers (the Healthy Lifestyle Community Programme, Cohort 2)

INTRODUCTION

The prevalence of obesity is high and increasing worldwide. Obesity is generally associated with an increased risk of chronic disease and mortality. The objective of the study was to test the effect of a lifestyle intervention on body weight and other chronic disease risk markers.

METHODS

A non-randomized controlled trial was conducted, including mostly middle-aged and elderly participants recruited from the general population in rural northwest Germany (intervention: n = 114; control: n = 87). The intervention consisted of a 1-year lifestyle programme, focussing on four key areas: a largely plant-based diet (strongest emphasis), physical activity, stress management, and community support. Parameters were assessed at baseline, 10 weeks, 6 months, and 1 year. The control group received no intervention.

RESULTS

Compared to the control, in the intervention group, significantly lower 1-year trajectories were observed for body weight, body mass index (BMI), waist circumference (WC), total cholesterol, calculated LDL cholesterol, non-HDL cholesterol, remnant cholesterol (REM-C), glucose, HbA1c, and resting heart rate (RHR). However, between-group differences at 1 year were small for glucose, HbA1c, and cholesterol (apart from REM-C). No significant between-group differences were found for 1-year trajectories of measured LDL cholesterol, HDL cholesterol, triglycerides, insulin, blood pressure, and pulse pressure.

CONCLUSION

The intervention successfully reduced body weight, BMI, WC, REM-C, and RHR. However, at 1 year, effectiveness of the intervention regarding other risk markers was either very modest or could not be shown.

Prevention and Treatment of Atrial Fibrillation via Risk Factor Modification

Atrial fibrillation (AF) is the most common clinically significant arrhythmia, and it increases stroke risk. A preventive approach to AF is needed because virtually all treatments such as cardioversion, antiarrhythmic drugs, ablation, and anticoagulation are associated with high cost and carry significant risk. A systematic review was performed to identify effective lifestyle-based strategies for reducing primary and secondary AF. A PubMed search was performed using articles up to March 1, 2021. Search terms included atrial fibrillation, atrial flutter, exercise, diet, metabolic syndrome, type 2 diabetes mellitus, obesity, hypertension, stress, tobacco smoking, alcohol, Mediterranean diet, sodium, and omega-3 fatty acids. Additional articles were identified from the bibliographies of retrieved articles. The control of hypertension, ideally with a renin-angiotensin-aldosterone system inhibitor, is effective for preventing primary AF and recurrence. Obstructive sleep apnea is a common cause of AF, and treating it effectively reduces AF episodes. Alcohol increases the risk of AF in a dose-dependent manner, and abstinence reduces risk of recurrence. Sedentary behavior and chronic high-intensity endurance exercise are both risk factors for AF; however, moderate physical activity is associated with lower risk of AF. Recently, sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 agonists have been associated with reduced risk of AF. Among overweight/obese patients, weight loss of ≥10% is associated with reduced AF risk. Lifestyle changes and risk factor modification are highly effective for preventing AF.

The Influential Factors of Adherence to Physical Activity and Exercise among Community-Dwelling Stroke Survivors: A Path Analysis

AIMS AND OBJECTIVES

To investigate the status of physical activity and exercise (PAE) adherence and identify its influential factors among community-dwelling stroke survivors.

BACKGROUND

Regular PAE after stroke is essential for recovery and secondary prevention, while adherence to PAE and its influential factors are rarely studied.

DESIGN

A cross-sectional descriptive study.

METHODS

In total, 208 stroke survivors (70.25 ± 9.08 years) were randomly selected from three communities. The influential factors of PAE adherence and associations between these variables were explored using multiple linear regression and path analyses. This study adhered to the EQUATOR checklist, STROBE.

RESULTS

The mean adherence rate was moderate (62.00%), and stroke survivors tended to be more adherent to PAE than monitoring and seeking advice (70.30%>53.50%>48.30%). The regression results revealed that seven factors were significantly associated with PAE adherence, including knowledge, attitude, self-efficacy, social support, self-care ability, community rehabilitation experience and times since stroke. Furthermore, the path analysis showed that knowledge had a significant indirect positive influence on adherence with self-efficacy as a mediator, while attitude and social support impacted both directly and indirectly with self-efficacy as the mediator. Moreover, self-efficacy had the most substantial direct effect on community-dwelling stroke survivors' PAE adherence. These four variables accounted for a total of 67.00% of the variance in PAE adherence among community-dwelling stroke survivors.

CONCLUSIONS

The PAE adherence of community stroke survivors needs to be improved. Healthcare professionals should develop more effective interventions to promote PAE adherence through enhancing self-efficacy among this population.

RELEVANCE TO CLINICAL PRACTICE

Adherence to the recommended regimen is the most challenging dimension of stroke physical activity and exercise. This study contributes to exploring status and influential factors of PAE adherence, and self-efficacy was found to be a significant determinant. The results could be used to inspire future community-based intervention programs for stroke survivors.