Bariatric surgery reduces incidence of atrial fibrillation: a propensity score–matched analysis

Impact of Bariatric Surgery on the Prevalence and Outcomes of Atrial Fibrillation in Obese Patients

Obesity has been identified as a significant factor contributing to the development of numerous cardiovascular conditions and as a result, the cardiovascular community has prioritized efforts to address obesity and reduce its associated risks. However, despite these efforts, the prevalence of obesity continues to rise steadily, and is projected to double in the upcoming years. Atrial fibrillation is among the most prevalent and extensively researched cardiovascular comorbidities associated with obesity. Several mechanisms have been postulated, including scar tissue formation and fat deposition, which ultimately leads to atrial remodeling and subsequent arrhythmogenesis. Numerous strategies have been implemented to prevent and manage obesity, encompassing lifestyle adjustments, dietary modifications, pharmacological treatments, and surgical interventions. Bariatric surgery has garnered significant recognition over the years due to its promising outcomes, including a decrease in the overall prevalence of atrial fibrillation and other cardiovascular comorbidities in general in obese patients. This study focuses on the current trends regarding the impact of bariatric surgery on obese patients with atrial fibrillation.

Obesity and atrial fibrillation: a narrative review from arrhythmogenic mechanisms to clinical significance

The prevalence of obesity and atrial fibrillation (AF), which are inextricably linked, is rapidly increasing worldwide. Obesity rates are higher among patients with AF than healthy individuals. Some epidemiological data indicated that obese patients were more likely to develop AF, but others reported no significant correlation. Obesity-related hypertension, diabetes, and obstructive sleep apnea are all associated with AF. Additionally, increased epicardial fat, systemic inflammation, and oxidative stress caused by obesity can induce atrial enlargement, inflammatory activation, local myocardial fibrosis, and electrical conduction abnormalities, all of which led to AF and promoted its persistence. Weight loss reduced the risk and reversed natural progression of AF, which may be due to its anti-fibrosis and inflammation effect. However, fluctuations in weight offset the benefits of weight loss. Therefore, the importance of steady weight loss urges clinicians to incorporate weight management interventions in the treatment of patients with AF. In this review, we discuss the epidemiology of obesity and AF, summarize the mechanisms by which obesity triggers AF, and explain how weight loss improves the prognosis of AF.

Effect of Prolonged and Substantial Weight Loss on Incident Atrial Fibrillation: A Systematic Review and Meta-Analysis

Background. Overweight and obesity are associated with atrial fibrillation (AF), and bariatric surgery (BS), able to induce sustained and prolonged weight loss, might represent the ideal treatment in the prevention of AF. Previous studies could not definitely establish a role for weight loss and BS in preventing incident AF so far. During the last few years, several studies on the effect of bariatric surgery on cardiovascular diseases have been published, and we performed a systematic review and meta-analysis to evaluate the role of weight loss through BS in the prevention of incident AF in obesity. Methods. This meta-analysis followed the PRISMA guideline. Eligible studies were controlled trials evaluating the appearance of atrial fibrillation in patients undergoing weight loss through BS as compared with patients receiving medical treatment. Quality of studies was assessed according to the Newcastle-Ottawa Quality Assessment Scale, and risk-of-bias was evaluated employing the Egger's test. All analyses were run by a random-effects model according to Hartung and Knapp and sensitivity analyses were performed. Heterogeneity was assessed through Q and I² statistics for each comparison, and potential publication bias was formally investigated. Results. Ten studies were included in the meta-analysis, and the overall result was statistically significant [OR = 0.665 (0.475-0.929), p = 0.017], with significant heterogeneity (Q = 48.98, p < 0.001; I² = 81.6%), but with no publication bias. In sensitivity analyses, the amount of weight loss, percentage of patients with diabetes and value of the Newcastle-Ottawa Quality Assessment Scale, were all associated with significance of effect. Since age was different in one study, a sensitivity analysis was performed by excluding this study; OR was similar [OR = 0.608 (0.454-0.814), p < 0.001]; heterogeneity was reduced but still significant (Q = 35.74, p < 0.001, I² = 77.6%) and again no publication bias was detected. Conclusions. Bariatric surgery as compared to medical treatment is associated with reduced appearance of incident AF.

The Effects of Bariatric Surgery on Cardiovascular Outcomes and Cardiovascular Mortality: A Systematic Review and Meta-Analysis

Obesity is a major public health problem that is associated with serious comorbidities and premature mortality. Cardiovascular disease (CVD) is the major cause of morbidity and mortality associated with obesity. Lifestyle modifications, pharmacological therapy, and weight reduction surgery are the major interventions to date available for obesity management. Bariatric surgery has been increasingly utilized as a therapeutic option for obesity. In this meta-analysis, we aim to assess the effects of bariatric surgery on CVD outcomes and cardiovascular mortality. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. PubMed, Embase, Cochrane Library, Google Scholar, and Web of Science were searched until 03/01/2022. Our search included three types of bariatric surgery: Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy, and gastric banding (GB). All were searched in conjunction with "coronary artery disease," "ischemic heart disease," "myocardial infarction," "cerebrovascular accident," "stroke," "atrial fibrillation," "heart failure," "arrhythmias," and "mortality." We included 49 studies meeting the study criteria. Bariatric surgery showed a beneficial effect on coronary artery disease (CAD) (hazard ratio (HR) of 0.68 {95% confidence interval (CI): 0.52-0.91}, p = 0.008), myocardial infarction (MI) (HR of 0.53 {95% CI: 0.44-0.64}, p < 0.01) heart failure (HF) (HR of 0.45 {95% CI: 0.37-0.55}, p < 0.01), cerebrovascular accident (CVA) (HR of 0.68 {95% CI: 0.59-0.78}, p < 0.01), and cardiovascular mortality (HR of 0.48 {95% CI: 0.40-0.57}, p < 0.01). The effect on atrial fibrillation (AF) did not reach statistical significance: HR of 0.81 (95% CI: 0.65-1.01), p = 0.07. Our study, that is, an updated meta-analysis, including the three types of procedure, confirms beneficial effects on the major CVD outcomes, including coronary artery disease, myocardial infarction, cerebrovascular accident, and heart failure, and on CVD mortality. This study provides updated insights into the long-term CV effects of bariatric surgery, an increasingly common intervention for obesity.

Relationship among Self-Efficacy Expectations, Locus of Control, and Attributions in Bariatric Patients

Background: Bariatric surgery is the most effective method for achieving accelerated weight loss. However, in the short- and medium-term, between 20% and 40% of patients regain a significant percentage of the weight lost. Cognitive and attitudinal psychological variables contribute to explaining weight regain. The aim of this study was to analyze differences in self-efficacy, locus of control, and attributions among bariatric patients, in accordance with weight maintenance or weight regain. Methods: Participants were classified according to weight regain (≥15% weight regain) and weight maintenance (<15% weight regain). A receiver operating characteristic (ROC) curve analysis was employed to assess the diagnostic value of the locus of control for weight loss and to establish a cutoff point to differentiate those who maintained weight loss from those who regained more than 15% of the weight lost. Results: Those who maintained weight loss showed a statistically higher locus of control ratio than those who regained weight. The locus of control ratio was associated with a lower risk of weight regain (odds ratio 0.760, p = 0.018). Using the area under the ROC curve (AUC), the locus of control significantly identified those who maintained weight (AUC = 0.761; p = 0.001). The maximum combination of sensitivity and specificity was shown at the cutoff point of 39. Qualitative results show a difference in the type of attributions and expectations according to current weight maintenance or weight regain status. Conclusion: Participants’ self-efficacy expectations, locus of control, and attributions change in accordance with the outcome achieved in terms of weight regain or weight maintenance.

Bariatric Surgery Improves Heart Geometry and Plasticity

BACKGROUND

Obesity is commonly associated with increased sympathetic tone, changes in heart geometry, and mortality. The aforementioned translates into a higher and potentially modifiable mortality risk for this specific population.

OBJECTIVES

The aim of the study was to analyze the extent of changes in the heart ventricular structure following rapid weight loss after bariatric surgery.

SETTING

Academic, university-affiliated hospital.

METHODS

We retrospectively reviewed all the patients that underwent bariatric surgery at our institution between 2010 and 2015. Data analyzed included demographics, BMI, and associated medical problems. Preoperative and postoperative echography readings were compared looking at the heart geometry, cardiac volumes, and wall thickness.

RESULTS

Fifty-one patients who had bariatric surgery and had echocardiography before and after the surgery were identified. There were 33 females (64.7%). The mean age was 63.4 ± 12.0 years with an average BMI of 40.3 ± 6.3. The mean follow-up was 1.2 years after the procedure. At 1 year follow-up 25 patients (49%, p = 0.01) showed normal left ventricular geometry. The left ventricular mass (229 ± 82.1 vs 193.2 ± 42.5, p<0.01) and the left ventricular end diastolic volume (129.4 ± 53 vs 96.4 ± 36.5, p = 0.01) showed a significant modification following the procedure. There was a significant improvement in the interventricular septal thickness (p = 0.01) and relative wall thickness (p < 0.01) following surgery.

CONCLUSION

The patients with obesity present a significant cardiac remodeling from concentric remodeling to normal geometry after bariatric surgery. The decrease in BMI has a direct effect on improvement of the left ventricular structure. Further studies must be carried out to define the damage of obesity to diastolic function.

Management of atrial fibrillation: two decades of progress - a scientific statement from the European Cardiac Arrhythmia Society

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. The aim of this review was to evaluate the progress made in the management of AF over the two last decades.

RESULTS

Clinical classification of AF is usually based on the presence of symptoms, the duration of AF episodes and their possible recurrence over time, although incidental diagnosis is not uncommon. The majority of patients with AF have associated cardiovascular diseases and more recently the recognition of modifiable risk factors both cardiovascular and non-cardiovascular which should be considered in its management. Among AF-related complications, stroke and transient ischaemic accidents (TIAs) carry considerable morbidity and mortality risk. The use of implantable devices such as pacemakers and defibrillators, wearable garments and subcutaneous cardiac monitors with recording capabilities has enabled to access the burden of "subclinical AF". The recent introduction of non-vitamin K antagonists has led to improve the prevention of stroke and peripheral embolism. Agents capable of reversing non-vitamin K antagonists have also become available in case of clinically relevant major bleeding. Transcatheter closure of left atrial appendage represents an option for patients unable to take oral anticoagulation. When treating patients with AF, clinicians need to select the most suitable strategy, i.e. control of heart rate and/or restoration and maintenance of sinus rhythm. The studies comparing these two strategies have not shown differences in terms of mortality. If an AF episode is poorly tolerated from a haemodynamic standpoint, electrical cardioversion is indicated. Otherwise, restoration of sinus rhythm can be obtained using intravenous pharmacological cardioversion and oral class I or class III antiarrhythmic is used to prevent recurrences. During the last two decades after its introduction in daily practice, catheter ablation has gained considerable escalation in popularity. Progress has also been made in AF associated with heart failure with reduced or preserved ejection fraction.

CONCLUSIONS

Significant progress has been made within the past 2 decades both in the pharmacological and non-pharmacological managements of this cardiac arrhythmia.

Adherence is an optimal factor for maximizing the effective and safe use of oral anticoagulants in patients with atrial fibrillation

Few studies assessed the association between major adverse cardiovascular events and adherence to warfarin and direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF). Therefore, we aimed to evaluate the effects of adherence to oral anticoagulants (OACs) in patients with AF using claims data (July 2014–April 2019). Using the initial 3-month medication possession rate (MPR), patients were categorized into adherent (MPR ≥ 0.8) or non-adherent (MPR < 0.8) groups. Propensity score matching of non-adherent group to adherent group was conducted for warfarin (1:1) and DOAC (1:3), respectively. Incidence of ischemic stroke, myocardial infarction (MI), intracranial hemorrhage, and all-cause death was assessed in the matched cohort (67,147 patients). The hazard ratio (HR) for adherence to OAC was estimated using the Cox proportional hazard model with adjusting covariate including age and sex. The risk for ischemic stroke, MI, and all-cause death was lower in the DOAC adherent group than in the DOAC non-adherent group (HR: 0.78; 95% confidence intervals: 0.73–0.84; 0.75, 0.60–0.94; 0.54, 0.51–0.57, respectively). Adherence to OAC was not associated with the risk of intracranial hemorrhage (1.01, 0.85–1.20). Commitment programs to improve adherence in patients with AF could maximize drug effectiveness and safety.

OUP accepted manuscript

Aims

Obesity is a global health problem, associated with significant morbidity and mortality, often due to cardiovascular (CV) diseases. While bariatric surgery is increasingly performed in patients with obesity and reduces CV risk factors, its effect on CV disease is not established. We conducted a systematic review and meta-analysis to evaluate the effect of bariatric surgery on CV outcomes, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

Methods and results

PubMed and Embase were searched for literature until August 2021 which compared bariatric surgery patients to non-surgical controls. Outcomes of interest were all-cause and CV mortality, atrial fibrillation (AF), heart failure (HF), myocardial infarction, and stroke. We included 39 studies, all prospective or retrospective cohort studies, but randomized outcome trials were not available. Bariatric surgery was associated with a beneficial effect on all-cause mortality [pooled hazard ratio (HR) of 0.55; 95% confidence interval (CI) 0.49–0.62, P < 0.001 vs. controls], and CV mortality (HR 0.59, 95% CI 0.47–0.73, P < 0.001). In addition, bariatric surgery was also associated with a reduced incidence of HF (HR 0.50, 95% CI 0.38–0.66, P < 0.001), myocardial infarction (HR 0.58, 95% CI 0.43–0.76, P < 0.001), and stroke (HR 0.64, 95% CI 0.53–0.77, P < 0.001), while its association with AF was not statistically significant (HR 0.82, 95% CI 0.64–1.06, P = 0.12).

Conclusion

The present systematic review and meta-analysis suggests that bariatric surgery is associated with reduced all-cause and CV mortality, and lowered incidence of several CV diseases in patients with obesity. Bariatric surgery should therefore be considered in these patients.

The Influence of Surgical Weight Reduction on Left Atrial Strain

Background

Obesity increases and surgical weight reduction decreases the risk of atrial fibrillation (AF) and heart failure (HF). We hypothesized that surgically induced weight loss may favorably affect left atrial (LA) mechanical function measured by longitudinal strain, which has recently emerged as an independent imaging biomarker of increased AF and HF risk.

Methods

We retrospectively evaluated echocardiograms performed before and 12.2 ± 2.2 months after bariatric surgery in 65 patients with severe obesity (mean age 39 [36; 47] years, 72% of females) with no known cardiac disease or arrhythmia. The LA mechanical function was measured by the longitudinal strain using the semi-automatic speckle tracking method.

Results

After surgery, body mass index decreased from 43.72 ± 4.34 to 30.04 ± 4.33 kg/m². We observed a significant improvement in all components of the LA strain. LA reservoir strain (LASR) and LA conduit strain (LASCD) significantly increased (35.7% vs 38.95%, p = 0.0005 and − 19.6% vs − 24.4%, p < 0.0001) and LA contraction strain (LASCT) significantly decreased (− 16% vs − 14%, p = 0.0075). There was a significant correlation between an increase in LASR and LASCD and the improvement in parameters of left ventricular diastolic and longitudinal systolic function (increase in E’ and MAPSE). Another significant correlation was identified between the decrease in LASCT and an improvement in LA function (decrease in A’).

Conclusions

The left atrial mechanical function improves after bariatric surgery. It is partially explained by the beneficial effect of weight reduction on the left ventricular diastolic and longitudinal systolic function. This effect may contribute to decreased risk of AF and HF after bariatric surgery.

Graphical abstract

Association of Bariatric Surgery With Vascular Outcomes

IMPORTANCE

Bariatric surgical weight loss is associated with reduced cardiovascular mortality; however, the mechanisms underlying this association are incompletely understood.

OBJECTIVES

To identify variables associated with vascular remodeling after bariatric surgery and to examine how sex, race, and metabolic status are associated with microvascular and macrovascular outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This population-based longitudinal cohort included 307 individuals who underwent bariatric surgery. Participants were enrolled in the bariatric weight loss program at Boston Medical Center, a large, multi-ethnic urban hospital, with presurgical and postsurgical assessments. Data were collected from December 11, 2001 to August 27, 2019. Data were analyzed in September 2019.

EXPOSURE

Bariatric surgery.

MAIN OUTCOMES AND MEASURES

Flow-mediated dilation (FMD) and reactive hyperemia (RH) (as measures of macrovascular and microvascular function, respectively) and clinical variables were measured preoperatively at baseline and at least once postoperatively within 12 months of the bariatric intervention.

RESULTS

A total of 307 participants with obesity (mean [SD] age, 42 [12] years; 246 [80%] women; 199 [65%] White; mean [SD] body mass index, 46 [8]) were enrolled in this study. Bariatric surgery was associated with significant weight loss and improved macrovascular and microvascular function across subgroups of sex, race, and traditional metabolic syndrome (mean [SD] pre- vs postsurgery weight: 126 [25] kg vs 104 [25] kg; P < .001; mean [SD] pre- vs postsurgery FMD: 9.1% [5.3] vs 10.2% [5.1]; P < .001; mean [SD] pre- vs postsurgery RH: 764% [400] vs 923% [412]; P < .001). Factors associated with change in vascular phenotype correlated most strongly with adiposity markers and several metabolic variables depending on vascular territory (eg, association of weight change with change in RH: estimate, -3.2; 95% CI, -4.7 to -1.8; association of hemoglobin A1c with change in FMD: estimate, -0.5; 95% CI, -0.95 to -0.05). While changes in macrovascular function among individuals with metabolically healthy obesity were not observed, the addition of biomarker assessment using high-sensitivity C-reactive protein plasma levels greater than 2 mg/dL identified participants with seemingly metabolically healthy obesity who had low-grade inflammation and achieved microvascular benefit from weight loss surgery.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that bariatric intervention is associated with weight loss and favorable remodeling of the vasculature among a wide range of individuals with cardiovascular risk. Moreover, differences in arterial responses to weight loss surgery by metabolic status were identified, underscoring heterogeneity in physiological responses to adiposity change and potential activation of distinct pathological pathways in clinical subgroups. As such, individuals with metabolically healthy obesity represent a mixed population that may benefit from more refined phenotypic classification.

Risk of Atrial Fibrillation and Stroke After Bariatric Surgery in Patients With Morbid Obesity With or Without Obstructive Sleep Apnea

[Figure: see text].

Metabolic surgery: A clinical update

Metabolic and bariatric surgery has grown beyond 'experimental' weight-loss surgery. As techniques have advanced over the last few decades, so has the growing body of research and evidence, proving that both weight-loss and metabolic health improvement are induced. Metabolic surgery has become the more appropriate term for weight-loss surgery because of the altered gastrointestinal anatomy and subsequent beneficial metabolic effects. Although the tool of metabolic surgery has been well refined, a large portion of the global population does not have adequate access to it. This clinical update aims to (a) inform healthcare providers from all disciplines about the myriad of benefits of metabolic surgery and (b) equip them with the necessary knowledge to bridge the gap between patients in need of metabolic treatment and the therapies in metabolic surgery available to them.

New Onset Cardiac Arrhythmias after Metabolic and Bariatric Surgery

BACKGROUND

Metabolic and bariatric surgery (MBS) has been shown to improve medical problems; however, there are known arrhythmias that can occur after MBS (i.e., sick sinus syndrome [SSS] and sinus bradyarrhythmias). While the literature in this area contains case reports, there is a lack of published data on a state or national level. We used a large state administrative database to evaluate the occurrence of cardiac arrhythmias after MBS.

METHODS

We studied the years 2016 to 2018 using the Texas Inpatient Public Use Data File. Inclusion criteria were patients who had a pacemaker installed and were ≥ 18 years. Quantitative variables were described using mean and standard deviation. Categorical variables were described using frequency and proportion. The student's t-test and chi-squared test were used to assess the differences across pacemaker installation.

RESULTS

There were a total of 79,807 (10.2%) who had a history of MBS and 31,072 (4%) patients who underwent pacemaker insertion, respectively. After excluding all patients < 18 years, the prevalence of pacemakers installed in patients with prior bariatric surgery was 0.8% (n = 257/30,823) or about 8 in every 1000 patients. Of note, bariatric patients who had a pacemaker placed were younger than non-bariatric patients (P < 0.001). The most common reason for pacemaker placement was SSS (51.5%), followed by atrioventricular block (13.1%), and then bradycardia at 8.5%. The most common arrhythmia overall was bradycardia.

CONCLUSIONS

Eight out of every 1000 patients with a pacemaker installed in the study period had a history of MBS. The most common arrhythmia was bradycardia and the most common reason for pacemaker placement was sick sinus syndrome. These results do not indicate causality but may demonstrate an association between MBS and arrhythmias. Bariatric patients undergo pacemaker placement at a younger age. The relationship between bariatric surgery and cardiac arrhythmias warrants further study.

High variability in bodyweight is associated with an increased risk of atrial fibrillation in patients with type 2 diabetes mellitus: a nationwide cohort study

Background

Bodyweight variability is a risk factor for atrial fibrillation (AF). We aimed to examine the relationship between bodyweight variability and the risk of AF in patients with type 2 diabetes mellitus (DM), and whether this relationship was affected by baseline body mass index (BMI), weight change, or advanced diabetic stage.

Methods

A nationwide population-based cohort of 670,797 patients with type 2 DM from the Korean National Health Insurance Service database without a history of AF and with ≥ 3 measurements of bodyweight over a 5-year period were followed up for AF development. Intra-individual bodyweight variability was calculated using variability independent of mean, and high bodyweight variability was defined as the quintile with the highest variability with the lower four quintiles as reference.

Results

During a median of 7.0 years of follow-up, 22,019 patients (3.3%) newly developed AF. After multivariate adjustment, those in the highest quintile of bodyweight variability showed a higher risk of incident AF (HR 1.16, 95% CI 1.12–1.20) compared to those in the lower 4 quintiles with reference bodyweight variability, irrespective of baseline BMI group and direction of overall weight change. This association was greater in magnitude in subjects with lower BMI, those on insulin, and those with a DM duration of greater than 5 years. In sensitivity analyses, high bodyweight variability was consistently associated with AF development using other indices of variability and adjusting for glycemic variability.

Conclusions

High variability in bodyweight was associated with AF development, independently of traditional cardiovascular risk factors and baseline BMI. This association was stronger in underweight patients and with advanced diabetic stage. Weight fluctuation may interfere with the beneficial effects of weight loss and should be avoided when possible in weight control regimens for DM patients.

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

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

Cardiometabolic-Based Chronic Disease, Addressing Knowledge and Clinical Practice Gaps: JACC State-of-the-Art Review

In the second part of this JACC State-of-the-Art Review, an early and sustainable preventive care plan is described for cardiometabolic-based chronic disease. This plan can improve cardiometabolic health by targeting early mechanistic events to decrease the risk for certain cardiovascular diseases (e.g., coronary heart disease, heart failure, and atrial fibrillation). Included are various prevention modalities, intensive lifestyle interventions, pharmacotherapy and cardiovascular outcome trial evidence, and bariatric/metabolic procedures. A tactical approach of implementing published clinical practice guidelines/algorithms for early behavioral, adiposity, and dysglycemia targeting is emphasized, as well as relevant educational and research implications.

The Role of Cardiovascular and Metabolic Comorbidities in the Link between Atrial Fibrillation and Cognitive Impairment: An Appraisal of Current Scientific Evidence

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice with implications on long-term outcomes. Metabolic disorders including diabetes mellitus and obesity are independent predictors of atrial fibrillation and present therapeutic targets to reduce both the incidence and duration burden of atrial fibrillation. The presence of pericardial fat in direct contact with cardiac structures, as well the subsequent release of proinflammatory cytokines, may play an important role in this connection. Atrial fibrillation is an independent predictor of cognitive impairment and dementia. While clinical stroke is a major contributor, other factors such as cerebral hypoperfusion and microbleeds play important roles. New evidence suggests that atrial fibrillation and cognitive impairment may be downstream events of atrial cardiomyopathy, which may be caused by several factors including metabolic syndrome, obesity, and obstructive sleep apnea. The mechanisms linking these comorbidities to cognitive impairment are not yet fully elucidated. A clearer understanding of the association of AF with dementia and cognitive impairment is imperative. Future studies should focus on the predictors of cognitive impairment among those with AF and aim to understand the potential mechanisms underlying these associations. This would inform strategies for the management of AF aiming to prevent continued cognitive impairment.

Effects of Bariatric Surgery on Cardiovascular Disease: A Concise Update of Recent Advances

Patients with obesity often have multiple cardiovascular comorbidities as obesity is an established risk factor for various cardiovascular diseases (CVDs)—e. g., heart failure (HF), coronary artery disease (CAD), hypertension, dysrhythmia, and venous thromboembolism. In the United States, obesity is the nationwide public health issue of the day with the prevalence exceeding 30%. It has become a substantial health and financial burden to the society and national healthcare system; the direct cost accounted for 150 billion US dollars in 2014. Lifestyle interventions have been shown to be successful in the short term, however their long-term results are still equivocal likely due to modest weight reduction and high recurrence rates. For instance, the mean weight reduction in a randomized controlled trial of patients with type 2 diabetes mellitus (DM) and either overweight or obesity was 6.0% in the intensive lifestyle modification arm and 3.5% in the control arm. On the contrary, bariatric surgery is known to be the most effective in achieving substantial and long-term weight loss and can prevent the development of CVD risk factors such as DM, hypertension, and dyslipidemia. Bariatric surgery induces prompt weight loss within a few months which lasts for at least 12–18 months, with mean weight loss of ~35% (~70% loss of excess weight), lowering the risk of all-cause mortality, myocardial infarction, and stroke. Furthermore, recent studies demonstrated that bariatric surgery contributed to the reduction of acute care use for HF, CAD, and hypertension. On the other hand, it was reported that bariatric surgery may worsen the control of certain types of CVD (e.g., dysrhythmia), especially in the early postoperative period. Additionally, the notion that being overweight or obese could contribute to higher survival rate in certain populations (e.g., patients with HF)—also known as “obesity paradox”—has been repetitively documented in the past, while most recent investigations suggested that the observed paradox may be attributable to confounding factors including pre-existing comorbidities. Considering the aforementioned advances in the field, this paper reviews a series of recent studies with regard to the short-term and long-term effects of bariatric surgery on various types of CVDs.

Epicardial Adipose Tissue and Cardiovascular Disease

PURPOSE OF REVIEW

Epicardial adipose tissue has been associated with the development/progression of cardiovascular disease. We appraise the strength of the association between epicardial adipose tissue and development/progression of cardiovascular diseases like coronary artery disease, atrial fibrillation, and heart failure with preserved ejection fraction.

RECENT FINDINGS

Cross-sectional clinical and translational correlative studies have established an association between epicardial adipose tissue and progression of coronary artery disease. Recent studies question this association and underline the need for longitudinal studies. Epicardial adipose tissue also plays a definite role in the pathobiology of atrial fibrillation and its recurrence after ablation. In contrast to an early paradigm, epicardial adipose tissue does not appear to play a key role in the pathogenesis of heart failure with preserved ejection fraction in obese patients. The association of epicardial adipose tissue with atrial fibrillation is robust. In contrast, the association of epicardial adipose tissue with coronary artery disease and heart failure with preserved ejection fraction is tenuous. Additional research, including longitudinal studies, is needed to confirm or refute these proposed associations.