Inflammation and atrial fibrillation: cause or para-phenomenon?

The prognostic value of P-wave dispersion and left atrial functions assessed with three-dimensional echocardiography in patients with cirrhosis

BACKGROUND

Cirrhotic cardiomyopathy (CCM) is a well-known entity. The aim of this study was to compare left atrial three-dimensional (3D) volume and P-wave dispersion (PWd) in patients with cirrhosis and a healthy population. The secondary purpose was to assess the left phasic volumes and reservoir functions with 3D echocardiography for the prediction of an increased risk of poor outcomes in patients with cirrhosis.

METHODS

The study included 50 patients with cirrhosis and 43 healthy control subjects without atrial fibrillation. All patients were assessed with two-dimensional (2D), 3D, and tissue Doppler transthoracic echocardiography. The PWd was calculated using a 12-lead surface electrocardiogram (ECG). Cirrhotic patients were followed up for 2.5 years for the evaluation of poor outcomes and the development of atrial fibrillation.

RESULTS

Patients with cirrhosis were observed to have significantly higher left atrial phasic volumes such as minimal left atrial volume (3D-LAVmin, P = 0.004) and indexed LAVmin (3D-LAVImin, P = 0.0001), and significantly decreased left atrial reservoir functions such as left atrial emptying volume (3D-LAEV, P = 0,001), left atrial ejection fraction (3D-LAEF, P = 0,001) on 3D echocardiography. PWd was determined to be significantly longer in the cirrhotic group compared with the control group (P = 0.003). In the 2.5-year follow-up period, poor outcomes occurred in 34 patients (22 patients died, six patients had liver transplantation, six patients developed atrial fibrillation/AHRE episodes). In Cox regression analysis, the MELD score (HR, 1.16 (1.06-1.26), P = 0.001) and 3D-LAVImin (HR, 0.95 (0.86-1.00), P = 0.040) were significantly associated with all-cause mortality. Cirrhotic patients with LAVImin of >15 ml/m2 were seen to have poor survival (long rank P = 0.033).

CONCLUSION

The results of this study showed that patients with cirrhosis had higher left atrial volume, longer PWd and worse diastolic functions compared with the control group. Higher disease severity scores were associated with left atrial function and volume. In addition, left atrial volume measured with 3DE was a strong predictor of future adverse events, and minimal left atrial volumes had a higher prognostic value than any other left atrial function indices.

Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA

Hemodynamic instability (HDI) during liver transplantation (LT) can be difficult to manage and increases postoperative morbidity and mortality. In addition to surgical causes of HDI, patient- and graft-related factors are also important. Nitric oxide-mediated vasodilatation is a common denominator associated with end-stage liver disease related to HDI. Despite intense investigation, optimal management strategies remain elusive. In this consensus article, experts from the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of HDI during LT. Special attention has been paid to unique LT-associated conditions including the causes and management of vasoplegic syndrome, cardiomyopathies, LT-related arrhythmias, right and left ventricular dysfunction, and the specifics of medical and fluid management in end-stage liver disease as well as problems specifically related to portal circulation. When possible, management recommendations are made.

Predictive markers of atrial fibrillation in patients after acute ST-elevated myocardial infarction (the results of observational program “FAKEL”)

Aim. To assess probability of atrial fibrillation (AF) in patients after ST-elevated myocardial infarction (STEMI) with undergone primary percutaneous coronary intervention (PCI).

Material and methods. Prospective study in the period from December 2015 to November 2017 was carried out with consecutive inclusion of 107 patients at outpatient follow-up stage after STEMI who have undergone primary PCI. The mean age of patients was 69,5+7,8 years (40 (37,4%) women). Follow-up period was 18 months and included three visits (V): V1 — when included in the study, V2 — after 12 months, and V3 — after 18 months. The endpoints of the study were cases of first diagnosed AF, cardioembolic stroke and death. At all visits predictive markers (Willebrand factor, Cystatin C, N-terminal prohormone of brain natriuretic peptide (NT-proBNP), galectin-3) in the blood plasma were determined.

Results. After 18 months of follow-up period in 19 (17,8%) patients were diagnosed AF, 5 of them (4,7%) had cardioembolic stroke, and 3 patients died. Median time of AF development from the onset of STEMI was 308 days. Cox multivariate analysis showed that the risk factors for first diagnosed AF were NT-proBNP — relative risk (RR): 1,05; 95% confidence interval (CI): 0,99-1,10 (p=0,038), cystatin C — RR: 1,44; 95% CI: 0,98-2,12 (p=0,043), galectin-3 — RR: 1,20; 95% CI: 1,03-1,40 (p=0,022).

Conclusion. There was a highly significant relationship between NT-proBNP of ≥400,0 pg/mL, cystatin С of ≥1,45 ng/mL and galectin-3 of ≥25 mg/mL in patients after STEMI who underwent primary PCI. These markers might serve as predictors of first diagnosed AF. Identification of these biomarkers may have potential therapeutic benefit in improving the prognosis of patients after STEMI who have undergone primary PCI and reduce mortality from cardioembolic stroke.

Plasma markers of myocardial inflammation at isolated atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is one of the widest spread forms of arrhythmia, which is associated with the increased mortality and thromboembolic complications. To date, the involvement of renin-angiotensin-aldosterone system and immunomediators of inflammation into the mechanisms of development and maintenance of isolated AF is not clear. Specificity of their changes with respect to the latent myocarditis at AF is not proved.

METHODS

In 96 patients with persistent isolated atrial fibrillation (IsAF), scheduled for radiofrequency ablation and endomyocardial biopsy (EMB), and in 20 healthy volunteers (HVT), levels of plasma tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, IL-6, IL-8, IL-10, fatty acid-binding protein (FABP), neopterin, C-reactive protein (CRP) were determined by ELISA, level of aldosterone and the renin activity were determined by radioimmunoassay. Results were compared between the study and HVT groups and related to the EMB data.

RESULTS

Endomyocardial biopsy revealed lymphocytic myocarditis in 29%, immunohistochemical signs of viruses' persistence in the myocardium-in 43.8% of patient. We formed 4 subgroups: «myocarditis», «fibrosis», «virus positive», «virus negative». In the group «myocarditis», level of IL-6 was significantly higher than in group «fibrosis» (P < .01). ROC analysis showed its sensitivity 75%, specificity 75% (AUC = 0.759, Cutoff Value > 1.6 pg/mL, P < .01). In the group «virus positive», level of neopterin was significantly higher than in group «virus negative» (P < .01), with sensitivity 51%, specificity 84% (AUC = 0.675, Cutoff Value > 13.2 nmol/L, P < .01).

CONCLUSION

Levels of plasma IL-6 and neopterin may serve as a marker of latent viral myocarditis in IsAF.

Arrhythmia risk in liver cirrhosis

Interactions between the functioning of the heart and the liver have been described, with heart diseases affecting the liver, liver diseases affecting the heart, and conditions that simultaneously affect both. The heart is one of the most adversely affected organs in patients with liver cirrhosis. For example, arrhythmias and electrocardiographic changes are observed in patients with liver cirrhosis. The risk for arrhythmia is influenced by factors such as cirrhotic cardiomyopathy, cardiac ion channel remodeling, electrolyte imbalances, impaired autonomic function, hepatorenal syndrome, metabolic abnormalities, advanced age, inflammatory syndrome, stressful events, impaired drug metabolism and comorbidities. Close monitoring of cirrhotic patients is needed for arrhythmias, particularly when QT interval-prolonging drugs are given, or if electrolyte imbalances or hepatorenal syndrome appear. Arrhythmia risk may persist after liver transplantation due to possible QT interval prolongation, persistence of the parasympathetic impairment, post-transplant reperfusion and chronic immunosuppression, as well as consideration of the fact that the transplant itself is a stressful event for the cardiovascular system. The aims of the present article were to provide a review of the most important data regarding the epidemiology, pathophysiology, and biomarkers of arrhythmia risk in patients with liver cirrhosis, to elucidate the association with long-term outcome, and to propose future research directions.

Relation of hs-CRP and BNP levels with the atrial spontaneous echo contrast and thrombi in permanent atrial fibrillation patients with different etiologies

Background

Thromboembolic risk in permanent atrial fibrillation (AF) is strongly associated with the underlying etiology, and inflammatory parameters may contribute. The present study aimed to investigate the relationship of hs-CRP and BNP levels with left and right atrial appendage (LAA and RAA) function, presence of spontaneous echo contrast (SEC) and thrombus.

Material/Methods

Eighty-four permanent AF patients with different etiologies (20 mitral stenosis, 44 hypertension and 20 hyperthyroidism) and 23 patients with sinus rhythm were included. LAA and RAA flow velocities were measured by pulsed-wave Doppler and wall motion velocities with tissue Doppler imaging (TDI) in transesophageal echocardiography.

Results

Hs-CRP and BNP levels significantly differed among the 3 AF groups: levels were highest in mitral stenosis patients (8.6±5.3 mg/L and 98.0±125.7 pg/mL, respectively), the lowest hs-CRP was in hyperthyroidism patients (4.3±3.8 mg/L), and the lowest BNP was in hypertensive patients (64.8±44.3 pg/mL). There were also significant differences between the AF group and controls regarding hs-CRP and BNP levels. In the correlation analysis, BNP level was not significantly correlated with LAA and RAA functions, whereas hs-CRP level was significantly correlated with some LAA and RAA functions. On the other hand, hs-CRP level was significantly related to the presence of mild-moderate SEC and thrombi, mainly in mitral stenosis patients. Moreover, hs-CRP was the most important determinant of RAA thrombus formation, followed by RAA ejection fraction. In contrast, no positive or negative correlation was found between BNP levels and RAA and LAA thrombi.

Conclusions

Higher hs-CRP levels in AF patients may be a predictor for the presence of SEC and thrombi in the atria.

A multimarker approach to assess the influence of inflammation on the incidence of atrial fibrillation in women

AIMS

To assess the joint influence of inflammatory biomarkers on the risk of incident atrial fibrillation (AF) in women.

METHODS AND RESULTS

We performed a prospective cohort study among women participating in the Women's Health Study. All women were free of AF at study entry and provided a baseline blood sample assayed for high-sensitivity C-reactive protein, soluble intercellular adhesion molecule-1, and fibrinogen. To evaluate the joint effect of these three biomarkers, an inflammation score was created that ranged from 0 to 3 and reflected the number of biomarkers in the highest tertile per individual. During a median follow-up of 14.4 years, 747 of 24,734 women (3.0%) experienced a first AF event. Assessed individually, all three biomarkers were associated with incident AF, even after adjustment for traditional risk factors. When combined into an inflammation score, a strong and independent relationship between inflammation and incident AF emerged. Across increasing inflammation score categories, there were 1.66, 2.22, 2.73, and 3.25 AF events per 1000 person-years of follow-up. The corresponding hazard ratios (95% confidence intervals) across inflammation score categories were 1.0, 1.22 (1.00-1.49), 1.32 (1.06-1.65), and 1.59 (1.22-2.06) (P for linear trend 0.0006) after multivariable adjustment.

CONCLUSION

In this large-scale prospective study among women without a history of cardiovascular disease, markers of systemic inflammation were significantly related to AF even after controlling for traditional risk factors.