Effect of Cigarette Smoking on the Risk of Atrial Fibrillation Recurrence after Pulmonary Vein Isolation

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

The impact of lifestyle factors on atrial fibrillation

Atrial fibrillation (AF), with its significant associated morbidity and mortality contributes to significant healthcare utilisation and expenditure. Given its progressively rising incidence, strategies to limit AF development and progression are urgently needed. Lifestyle modification is a potentially potent but underutilised weapon against the AF epidemic. The purpose of this article is to review the role of lifestyle factors as risk factors for AF, outline potential mechanisms of pathogenesis and examine the available evidence for lifestyle intervention in primary and secondary AF prevention. It will also highlight the need for investment by physicians, researchers, health services and governments in order to facilitate delivery of the comprehensive, multidisciplinary AF care that is required to manage this complex and multifactorial disease.

Clinical impact of smoking on atrial fibrillation recurrence after pulmonary vein isolation

BACKGROUND

The clinical impact of smoking on atrial fibrillation (AF) recurrences after pulmonary vein isolation (PVI) have contradictory results in previous studies, performed on Asian populations.

METHODS AND AIM

Smoking habit and other cardiovascular risk-factors were assessed in patients who underwent their first radiofrequency PVI for symptomatic AF. The study aims to assess the clinical impact of smoking on AF recurrences after PVI in a contemporary European cohort of patients.

RESULTS

The study included 186 consecutive patients (135 males [72.6%]) with a mean age of 63.4 ± 9.7 years. Current smokers resulted 29 (15.7%). No statistically significant baseline differences were detected between current smokers and non-current smokers. After a follow-up of 418 ± 246 days, AF recurrence was higher in currently smoking patients vs. non-currently smoker patients, the latter intended as a combination between previous smokers and never smokers (34.5% vs. 14% p = 0.01). A previous smoking habit was not associated with increased risk of AF recurrence when compared with patients who never smoked (13.2% vs. 14.6%, p = 0.23), while a current smoking habit impacted on AF recurrence in comparison with previous smokers (p = 0.01) and never smokers (p = 0.04). The increased incidence of AF recurrence in current smokers was consistent also considering only paroxysmal AF (31.4% vs 9.6%, p = 0.012) or persistent AF (50% vs 31.2%, p = 0.03). Smoking (HR =2.96 95% CI 1.32-6.64) and persistent AF (HR =2.64 95% CI 1.22-5.7) resulted independent predictors of AF recurrence.

CONCLUSION

Cigarette smoking is associated with an increased risk of AF recurrences after PVI, both in paroxysmal and in persistent AF.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

Risk factors modification in atrial fibrillation: a brief review

INTRODUCTION

Atrial fibrillation (AF) is a supraventricular arrhythmia characterized by fibrillatory waves in the atria with an irregular ventricular rhythm. It is the most common arrhythmia treated in clinical practice. AF is associated with approximately five-fold increase in risk of cerebrovascular accident (stroke) and two-fold increase in cognitive dysfunction and all-cause mortality.

AREAS COVERED

Multiple risk factors have been identified for development of AF including age, hypertension, diabetes, and obesity. Primary and secondary prevention strategies aimed at reducing the incidence of AF can have a dramatic clinical and economic impact. Multiple studies have shown that lifestyle interventions can reduce predisposing factors, reverse the pathophysiology behind AF, and decrease disease burden. In this brief review we aim at exploring the current state of knowledge regarding risk factor modifications that decrease incidence and prevalence of AF.

EXPERT OPINION

This is an evolving field of research and further studies to elucidate the magnitude of effect of these interventions as well as the pathophysiological mechanisms driving these effects are underway.

Lifestyle changes in atrial fibrillation management and intervention

Atrial fibrillation (AF) is one of the most common arrhythmias in adults, and its continued rise in the United States is complicated by the increased incidence and prevalence of several AF risk factors, such as obesity, physical inactivity, hypertension, obstructive sleep apnea, diabetes mellitus, coronary artery disease, and alcohol, tobacco, or caffeine use. Lifestyle and risk factor modification has been proposed as an additional pillar of AF therapy, added to rhythm control, rate control, and anticoagulation, to reduce AF burden and risk. Although emerging evidence largely supports the integration of lifestyle and risk factor management in clinical practice, randomized clinical trials investigating the long-term sustainability and reproducibility of these benefits remain sparse. The purpose of this review is to discuss potentially reversible risk factors on AF, share evidence for the impact on AF by modification of these risk factors, and then provide an overview of the effects of reversing or managing these risk factors on the success of various AF management strategies, such as antithrombotic, rate control, and rhythm control therapies.

Harmful Impact of Tobacco Smoking and Alcohol Consumption on the Atrial Myocardium

Tobacco smoking and alcohol consumption are widespread exposures that are legal and socially accepted in many societies. Both have been widely recognized as important risk factors for diseases in all vital organ systems including cardiovascular diseases, and with clinical manifestations that are associated with atrial dysfunction, so-called atrial cardiomyopathy, especially atrial fibrillation and stroke. The pathogenesis of atrial cardiomyopathy, atrial fibrillation, and stroke in context with smoking and alcohol consumption is complex and multifactorial, involving pathophysiological mechanisms, environmental, and societal aspects. This narrative review summarizes the current literature regarding alterations in the atrial myocardium that is associated with smoking and alcohol.

Lifestyle Modification and Atrial Fibrillation: Critical Care for Successful Ablation

Management of atrial fibrillation (AF) requires a comprehensive approach due to the limited success of medical or procedural approaches in isolation. Multiple modifiable risk factors contribute to the development and progression of the underlying substrate, with a heightened risk of progression evident with inadequate risk factor management. With increased mortality, stroke, heart failure and healthcare utilisation linked to AF, international guidelines now strongly support risk factor modification as a critical pillar of AF care due to evidence demonstrating the efficacy of this approach. Effective lifestyle management is key to arrest and reverse the progression of AF, in addition to increasing the likelihood of freedom from arrhythmia following catheter ablation.

Social Risk Factors and Atrial Fibrillation

Modifiable risk factor management is becoming one of the 3 treatment pillars in atrial fibrillation management along with anticoagulation as well as conventional rate and rhythm control strategies. Preventive therapies, such as reducing blood pressure and treating obstructive sleep apnea, are paramount in the strategy of preventing atrial fibrillation. Identification of new modifiable risk factors and triggers also could help in the global strategy to reduce atrial fibrillation. This article covers alcohol intake, tobacco smoking, caffeine, chocolate, cannabis use, and air pollution as social risk factors related to lifestyle habits that potentially could contribute to atrial fibrillation development.

CHA2DS2-VASc and SAMe-TT2R2 scores as predictors of recurrence for nonvalvular atrial fibrillation patients on vitamin K antagonists after radiofrequency catheter ablation

AIMS

Atrial fibrillation is the most common sustained arrhythmia in the general population, and circumferential pulmonary vein isolation has emerged as a cornerstone in the treatment of drug-resistant atrial fibrillation. However, there is a paucity of data regarding the CHA2DS2-VASc and SAMe-TT2R2 scores as predictors of outcomes among patients with nonvalvular atrial fibrillation on vitamin K antagonists after radiofrequency catheter ablation (RFCA).

METHODS

The current prospective observational study enrolled 304 consecutive patients with atrial fibrillation who underwent RFCA. Warfarin was maintained for at least 3 months after RFCA. The 1-year atrial fibrillation recurrence rate was documented.

RESULTS

Persistent atrial fibrillation (P = 0.003), heart failure (P < 0.001), an enlarged left atrium (P = 0.003), current smoking (P < 0.001), the CHA2DS2-VASc score (P = 0.001), and the SAMe-TT2R2 score (P < 0.001) were univariate associated with recurrent atrial fibrillation. Cutoff analysis showed that a CHA2DS2-VASc score at least 3 (areas under the curve = 0.612; 95% confidence interval 0.537-0.687) and a SAMe-TT2R2 score at least 5 (areas under the curve = 0.642, 95% confidence interval 0.575-0.708) had the highest predictive value for atrial fibrillation recurrence. Patients with a CHA2DS2-VASc score at least 3 (P < 0.001) and a SAMe-TT2R2 score at least 5 (P = 0.001) had a higher probability of experiencing atrial fibrillation recurrence after RFCA compared with patients with a CHA2DS2-VASc score less than 3 and a SAMe-TT2R2 score less than 5.

CONCLUSION

CHA2DS2-VASc and SAMe-TT2R2 scores were associated with 1-year recurrence of atrial fibrillation in patients on vitamin K antagonists after RFCA. For CHA2DS2-VASc and SAMe-TT2R2 scores, a cutoff value of at least 3 and at least 5 had the highest predictive value for atrial fibrillation recurrence, respectively.

Clinical, electrophysiological and imaging predictors of atrial fibrillation ablation outcome

INTRODUCTION

Significant technological advances for catheter ablation of atrial fibrillation (AF) have occurred over the last decade, with a consequent increase in numbers of patients referred for AF ablation worldwide. Despite this, long-term success rates, particularly in those with persistent AF, remain modest. The patient population presenting for AF ablation are heterogeneous with regard to age, type of AF and presence of associated cardiovascular disease. Improved understanding of factors predicting response to AF ablation may therefore help to improve patient selection for ablation procedures. Areas covered: This review outlines the clinical, electrophysiological and imaging predictors of response to radiofrequency ablation for AF in contemporary practice. Recently developed scoring systems incorporating these parameters are examined, as are factors identified thus far which may predict the outcome of cryoballoon ablation. Expert commentary: Traditional clinical factors associated with ablation outcomes serve as surrogates rather than direct measures of the underlying arrhythmia substrate. An improved understanding of this substrate could improve the prediction of response to radiofrequency ablation. Continued development of methods for characterising the arrhythmia substrate, including atrial cardiac magnetic resonance imaging and invasive voltage mapping, may inform patient risk assessment and help guide selection for catheter ablation on an increasingly individualistic basis.

Relationship between smoking and adverse outcomes in patients with atrial fibrillation: A meta-analysis and systematic review

BACKGROUND

Several studies have investigated the impact of smoking on the prognosis of atrial fibrillation (AF), but the results remain controversial. We therefore aimed to estimate the association between smoking and adverse outcomes in patients with AF.

METHODS

We systematically searched the Cochrane Library, PubMed, and Elsevier databases through May 2016 for studies regarding the association between smoking and adverse outcomes in AF patients. Risk ratios [RRs] and 95% confidence intervals [CIs] were abstracted and then pooled using a random-effects model.

RESULTS

A total of 8 cohort studies with 87,373 participants were included in this meta-analysis. Among patients with AF, smoking was associated with increased risks of all-cause death (RR=1.82, 95% CI: 1.33-2.49, P=0.0002) and cardiovascular death (RR=1.54, 95% CI: 1.31-1.81, P<0.00001) but not stroke/thromboembolism (RR=1.19, 95% CI 0.97-1.46; P=0.10). In addition, smoking was associated with an increased risk of major bleeding (RR=1.93, 95% CI 1.08-3.47, P=0.03), even after adjustment for the antithrombotic treatment.

CONCLUSIONS

The published literature demonstrates that smoking is not associated with the risk of stroke/thromboembolism but increases the risks of all-cause death and cardiovascular death in AF patients, as well as the risk of major bleeding in AF patients using anticoagulants.

Association of smoking with the risk of incident atrial fibrillation: A meta-analysis of prospective studies

BACKGROUND

Several studies have investigated the role of smoking in incident atrial fibrillation (AF) but have reported contradictory results. Identifying the quantitative association between smoking and AF risk is important for AF management and prevention; therefore, we aimed to estimate the association of smoking with incident AF.

METHODS

We systematically retrieved relevant studies reporting on the association between smoking and AF using the Cochrane Library, PubMed, and Embase databases. The data were extracted from applicable articles, and we used a random effects model to pool the effect estimates.

RESULTS

Sixteen prospective studies with an overall number of 286,217 participants and 11,878 AF cases met the inclusion criteria. A higher prevalence of AF was confirmed among smokers (risk ratio [RR]=1.23, 95% confidence interval [CI] 1.08-1.39; P=0.001). These results were stable in the sensitivity analysis. The pooled RRs showed consistent positive associations in most subgroups. Specifically, 8 articles compared both current smokers (RR=1.39, 95% CI 1.11-1.75) and former smokers (RR=1.16, 95% CI: 1.00-1.36) with never smokers. Four articles compared ever smokers (pooled RR=1.21, 95% CI 0.93-1.57) with never smokers, and 7 articles compared current smokers (pooled RR=1.21, 95% CI 1.03-1.42) with non-current smokers. Additionally, we estimated that 6.7% of the total risk of AF in men and 1.4% of the risk in women were attributable to smoking worldwide.

CONCLUSIONS

Based on the published literature, smoking is associated with a modest increased risk of incident AF. Smoking cessation seemed to reduce but not entirely eliminate the excess risk of AF.