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Mahadevan A, Garikipati S, Vanani S, Sundaram DM, Thompson-Edwards A, Reyaz N, Babu K, Rajarajan S, Dhavapalani D, Anand DP, Vasavada A, Desai R. Meta-analysis of Renin Angiotensin Aldosterone Modulators Mitigating Atrial Fibrillation Risk in Hypertensive Patients. Am J Med Sci 2024:S0002-9629(24)01351-X. [PMID: 38997068 DOI: 10.1016/j.amjms.2024.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 05/14/2024] [Accepted: 07/08/2024] [Indexed: 07/14/2024]
Abstract
INTRODUCTION Hypertension is associated with left ventricular hypertrophy/enlargement/fibrosis and atrial ectopic rhythm, leading to an increased risk of Atrial Fibrillation (AF). We aimed to stratify the effect of Angiotensin Converting Enzyme Inhibitors (ACEi) and Angiotensin Receptor Blockers (ARB) on the risk of AF. METHODS PubMed, Scopus, and Google Scholar databases were screened, and cross-citation was conducted for studies reporting AF in hypertensive patients on ACEi and ARB. Of 145 studies found till May 2023, 19 were included in this study. Binary random-effects models estimated the pooled odds ratios, I2 statistics assessed heterogeneity and sensitivity analysis was assessed using the leave-one-out method. RESULTS 153,559 hypertensive patients met the inclusion criteria. For incidental AF, ACEi and ARB showed a significant decrease in both unadjusted (OR 0.75, 95% CI [0.66- 0.85], I²=20.79%, p=0.29) and adjusted risks (OR 0.76, 95% CI [0.62-0.93], I²=88.41%, p<0.01). In recurrent AF, the unadjusted analysis showed no significant effect (OR 0.89, 95% CI [0.55-1.42], I²=78.44%, p<0.01), while the adjusted analysis indicated a reduced risk (OR 0.62, 95% CI [0.50-0.76], I²=65.71%, p<0.01). Leave-one-out sensitivity analysis confirmed these results. CONCLUSIONS ACEi and ARB considerably decrease the risk of incidental and recurrent AF in hypertensive patients, emphasizing the importance of treating clinical hypertension with these drugs.
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Affiliation(s)
| | | | | | | | | | - Nafisa Reyaz
- Jawaharlal Nehru Medical College and Hospital, Aligarh, India.
| | - Kalaivani Babu
- Sri Ramachandra Medical College and Research Center, Chennai, India.
| | | | | | | | | | - Rupak Desai
- Independent Outcomes Researcher, Atlanta, GA, USA.
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Fioranelli M, Spadafora L, Bernardi M, Roccia MG, Del Buono MG, Cacioli G, Biondi-Zoccai G. Impact of low-dose Brain-Derived Neurotrophic Factor (BDNF) on atrial fibrillation recurrence. Minerva Cardiol Angiol 2023; 71:673-680. [PMID: 37337698 DOI: 10.23736/s2724-5683.23.06324-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Atrial fibrillation is the most common arrhythmia worldwide and is associated with significant morbidity and mortality. Despite the effectiveness of catheter-based ablation, periprocedural complication and recurrences remain a concern. In this context, we aim to appraise the potential impact of brain-derived neurotrophic factor (BDNF) on reducing episodes of paroxysmal atrial fibrillation (PAF). METHODS 22 patients with an established diagnosis of PAF and without structural heart disease were considered. Every patient received 20 drops of GUNA-BDNF administered in the morning. During the 24 months of follow-up, the arrhythmic burden was measured by the average monthly duration of PAF episodes. RESULTS At the end of the follow-up period (24 months), data from 22 patients, of whom 17 men and five women, were analyzed. The arrhythmic burden, measured in terms of average monthly duration of PAF episodes, was found significantly reduced after the administration of low dose BDNF (9.5 vs. 65.3 minutes per month, P<0.001). A total of 17 out of 22 patients saw their arrhythmic burden eliminated or consistently reduced, furthermore two patients underwent a drastic reduction of the average monthly duration of AF (more than 200 minutes compared to the baseline). Only four patients, despite the administration of BDNF, still experienced an arrhythmic burden of 20 minutes or more. Considering the age groups, the major reduction was observed in people aged 70 or more, who were also the most represented in the sample. These results are coherent with the poor literature currently available. CONCLUSIONS BDNF low dose therapy has shown to have an impacting role in reducing the arrhythmic burden and recurrences of AF, with a particular effectiveness in patients over 70 and without structural heart disease. We should welcome this work, despite it limitations. Further clinical and molecular studies are needed before-considering BDNF low dose as a tool against PAF.
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Affiliation(s)
| | - Luigi Spadafora
- Department of Clinical Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University, Rome, Italy -
| | - Marco Bernardi
- Department of Clinical Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Maria G Roccia
- Department of Human Sciences, Guglielmo Marconi University, Rome, Italy
| | | | - Giulio Cacioli
- Institute for Systemic Integrated Therapies, Rome, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
- Mediterranea Cardiocentro, Naples, Italy
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3
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Lorenzo-Almorós A, Casado Cerrada J, Álvarez-Sala Walther LA, Méndez Bailón M, Lorenzo González Ó. Atrial Fibrillation and Diabetes Mellitus: Dangerous Liaisons or Innocent Bystanders? J Clin Med 2023; 12:jcm12082868. [PMID: 37109205 PMCID: PMC10142815 DOI: 10.3390/jcm12082868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/27/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in adults and diabetes mellitus (DM) is a major risk factor for cardiovascular diseases. However, the relationship between both pathologies has not been fully documented and new evidence supports the existence of direct and independent links. In the myocardium, a combination of structural, electrical, and autonomic remodeling may lead to AF. Importantly, patients with AF and DM showed more dramatic alterations than those with AF or DM alone, particularly in mitochondrial respiration and atrial remodeling, which alters conductivity, thrombogenesis, and contractile function. In AF and DM, elevations of cytosolic Ca2⁺ and accumulation of extra cellular matrix (ECM) proteins at the interstitium can promote delayed afterdepolarizations. The DM-associated low-grade inflammation and deposition/infiltration of epicardial adipose tissue (EAT) enforce abnormalities in Ca2+ handling and in excitation-contraction coupling, leading to atrial myopathy. This atrial enlargement and the reduction in passive emptying volume and fraction can be key for AF maintenance and re-entry. Moreover, the stored EAT can prolong action of potential durations and progression from paroxysmal to persistent AF. In this way, DM may increase the risk of thrombogenesis as a consequence of increased glycation and oxidation of fibrinogen and plasminogen, impairing plasmin conversion and resistance to fibrinolysis. Additionally, the DM-associated autonomic remodeling may also initiate AF and its re-entry. Finally, further evidence of DM influence on AF development and maintenance are based on the anti-arrhythmogenic effects of certain anti-diabetic drugs like SGLT2 inhibitors. Therefore, AF and DM may share molecular alterations related to Ca2+ mobility, mitochondrial function and ECM composition that induce atrial remodeling and defects in autonomic stimulation and conductivity. Likely, some specific therapies could work against the associated cardiac damage to AF and/or DM.
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Affiliation(s)
- Ana Lorenzo-Almorós
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, 28007 Madrid, Spain
| | - Jesús Casado Cerrada
- Internal Medicine Department, Hospital Universitario de Getafe, 28095 Madrid, Spain
| | - Luis-Antonio Álvarez-Sala Walther
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, 28007 Madrid, Spain
| | - Manuel Méndez Bailón
- Internal Medicine Department, Hospital Universitario Clinico San Carlos, 28040 Madrid, Spain
| | - Óscar Lorenzo González
- Laboratory of Diabetes and Vascular Pathology, Instituto de Investigaciones Sanitarias-Fundación Jiménez Díaz, Universidad Autónoma, 28040 Madrid, Spain
- Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM) Network, 28040 Madrid, Spain
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4
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Su Y, Huang J, Sun S, He T, Wang T, Fan M, Yu H, Yan J, Yao L, Xia Y, Zhang M, Zheng Y, Luo X, Zhang Y, Lu M, Zou M, Liu C, Chen Y. Restoring the Autonomic Balance in an Atrial Fibrillation Rat Model by Electroacupuncture at the Neiguan Point. Neuromodulation 2022:S1094-7159(22)01366-6. [PMID: 36522251 DOI: 10.1016/j.neurom.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Autonomic nervous activity imbalance plays an important role in atrial fibrillation (AF). AF can be treated by acupuncture at the Neiguan point (PC6), but the mechanism remains elusive. Here, we investigated autonomic nervous system activity in electroacupuncture (EA) at PC6 in a rat AF model. MATERIAL AND METHODS In this study, we established a rat AF model via tail vein injection with ACh-CaCl2 for ten consecutive days with or without EA at PC6. AF inducibility and heart rate variability (HRV) were assessed by electrocardiogram. Next, we completed in vivo recording of the activity of cervical sympathetic and vagal nerves, respectively. Finally, the activities of brain regions related to autonomic nerve regulation were assessed by c-Fos immunofluorescence and multichannel recording. RESULTS EA at PC6 decreased AF inducibility and prevented changes in HRV caused by ACh-CaCl2 injection. Meanwhile, EA at PC6 reversed the increased sympathetic and decreased vagal nerve activity in AF rats. Furthermore, EA treatment downregulated increased c-Fos expression in brain regions, including paraventricular nucleus, rostral ventrolateral medulla, and dorsal motor nucleus of the vagus in AF, while c-Fos expression in nucleus ambiguus was upregulated with EA. CONCLUSION The protective effect of EA at PC6 on AF is associated with balance between sympathetic and vagal nerve activities.
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Affiliation(s)
- Yang Su
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jing Huang
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shengxuan Sun
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Teng He
- Research Institute of Acupuncture and Moxibustion, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Taiyi Wang
- Research Institute of Acupuncture and Moxibustion, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Mengyue Fan
- Research Institute of Acupuncture and Moxibustion, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Huanhuan Yu
- Research Institute of Acupuncture and Moxibustion, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Jinglan Yan
- Research Institute of Acupuncture and Moxibustion, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Lin Yao
- Research Institute of Acupuncture and Moxibustion, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yucen Xia
- Research Institute of Acupuncture and Moxibustion, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Meng Zhang
- Research Institute of Acupuncture and Moxibustion, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yuanjia Zheng
- Research Institute of Acupuncture and Moxibustion, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xiaoyan Luo
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuewen Zhang
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Manqi Lu
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Meixia Zou
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Cunzhi Liu
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Chaoyang District, Beijing, China
| | - Yongjun Chen
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China; Research Institute of Acupuncture and Moxibustion, Shandong University of Traditional Chinese Medicine, Jinan, China; Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Guangzhou, China.
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Pang M, Li Z, Sun L, Zhao N, Hao L. A nomogram for predicting atrial fibrillation detected after acute ischemic stroke. Front Neurol 2022; 13:1005885. [PMID: 36313507 PMCID: PMC9614087 DOI: 10.3389/fneur.2022.1005885] [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: 08/05/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background Atrial fibrillation detected after stroke (AFDAS) is associated with an increased risk of ischemic stroke (IS) recurrence and death. Early diagnosis can help identify strategies for secondary prevention and improve prognosis. However, there are no validated predictive tools to assess the population at risk for AFDAS. Therefore, this study aimed to develop and validate a predictive model for assessing the incidence of AFDAS after acute ischemic stroke (AIS). Methods This study was a multicenter retrospective study. We collected clinical data from 5332 patients with AIS at two hospitals between 2014.01 and 2021.12 and divided the development and validation of clinical prediction models into a training cohort (n = 3173) and a validation cohort (n = 2159). Characteristic variables were selected from the training cohort using the least absolute shrinkage and selection operator (LASSO) algorithm and multivariable logistic regression analysis. A nomogram model was developed, and its performance was evaluated regarding calibration, discrimination, and clinical utility. Results We found the best subset of risk factors based on clinical characteristics and laboratory variables, including age, congestive heart failure (CHF), previous AIS/transient ischemia attack (TIA), national institutes of health stroke scale (NIHSS) score, C-reactive protein (CRP), and B-type natriuretic peptide (BNP). A predictive model was developed. The model showed good calibration and discrimination, with calibration values of Hosmer-Lemeshow χ2 = 4.813, P = 0.732 and Hosmer-Lemeshow χ2 = 4.248, P = 0.834 in the training and validation cohorts, respectively. The area under the ROC curve (AUC) was 0.815, 95% CI (0.777–0.853) and 0.808, 95% CI (0.770–0.847). The inclusion of neuroimaging variables significantly improved the performance of the integrated model in both the training cohort (AUC. 0.846 (0.811–0.882) vs. 0.815 (0.777–0.853), P = 0.001) and the validation cohort (AUC: 0.841 (0.804–0.877) vs. 0.808 (0.770–0.847), P = 0.001). The decision curves showed that the integrated model added more net benefit in predicting the incidence of AFDAS. Conclusion Predictive models based on clinical characteristics, laboratory variables, and neuroimaging variables showed good calibration and high net clinical benefit, informing clinical decision-making in diagnosing and treating patients with AFDAS.
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Affiliation(s)
- Ming Pang
- Neuroelectrophysiology Room, Function Department, Cangzhou Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Cangzhou, China
| | - Zhuanyun Li
- Department of Emergency Medicine, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lin Sun
- Neuroelectrophysiology Room, Function Department, Cangzhou Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Cangzhou, China
| | - Na Zhao
- Department of Neurology, Cangzhou Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Cangzhou, China
| | - Lina Hao
- Neuroelectrophysiology Room, Function Department, Cangzhou Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Cangzhou, China
- *Correspondence: Lina Hao
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Roman S, Patel K, Hana D, Guice KC, Patel J, Stadnick C, Basta A, Khouzam RN. Rate versus rhythm control for atrial fibrillation: from AFFIRM to EAST-AFNET 4 - a paradigm shift. Future Cardiol 2022; 18:354-353. [PMID: 35255732 DOI: 10.2217/fca-2021-0034] [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: 11/21/2022] Open
Abstract
The clinical choice between rate or rhythm control therapies has been debated over the years. In 2002, the AFFIRM trial demonstrated that the rhythm-control strategy had no survival advantage over the rate-control strategy. Eighteen years later, EAST-AFNET 4 showed that the rhythm-control approach is better than rate control in reducing adverse cardiovascular outcomes in patients with a recent diagnosis of atrial fibrillation (AF). During the time between AFFIRM and EAST-AFNET 4, rhythm control understanding, specifically ablation, improved, while rate-control strategies remained the same possibly leading to the change in results seen in EAST-AFNET 4. This review seeks to evaluate the rate- and rhythm-control strategies, focusing on the important clinical trials in the past two decades. These trials have shown great advancement in AF management; however, the search for the best approach to controlling AF and minimizing the burden of symptoms is still a work in progress and needs further research.
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Affiliation(s)
- Sherif Roman
- Department of Medicine, St Joseph's University Medical Center, NJ 07503, USA
| | - Kevin Patel
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - David Hana
- Department of Medicine, Loyola University Medical Center/Trinity - Mercy Hospital, IL 60616, USA
| | - Kenneth C Guice
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Jay Patel
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Christopher Stadnick
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Amir Basta
- Department of Medicine, Ain Shams University, Cairo, 1181, Egypt
| | - Rami N Khouzam
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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7
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Jiang C, Zhao D, Tang K, Wang Y, Li X, Jia P, Xu Y, Han B. Effectiveness and Safety of Cryoablation in Patients With Atrial Fibrillation Episodes of <24 h Duration: A Propensity-Matched Analysis. Front Cardiovasc Med 2021; 8:724378. [PMID: 34765651 PMCID: PMC8576169 DOI: 10.3389/fcvm.2021.724378] [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: 06/13/2021] [Accepted: 09/24/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Paroxysmal atrial fibrillation (AF) is closely related to pathophysiologic processes and clinical outcomes. However, it is uncertain whether cryoablation of pulmonary veins isolation is effective and safe for patients with symptomatic and drug refractory AF episodes of <24-h duration. Methods: The patients were designed into Group A (253 patients with paroxysmal AF episodes of <24-h duration) and Group B (253 patients with paroxysmal AF lasting for 24 h or longer) on a 1:1 basis by identical propensity scores. Mortality, stroke/transient ischemic attack (TIA), and complications relevant to the cryoablation procedure were compared, and recurrence of atrial tachyarrhythmia was analyzed for clinical independent predictors. Results: The rate of atrial tachyarrhythmia recurrence was 21.74% in Group A and 30.04% in Group B, respectively (P = 0.042). At 12-month follow-up from the procedure, lower incidences of stroke/TIA endpoint of the patients were observed in Group A compared with Group B by Kaplan–Meier analysis [HR 0.34 (0.13–0.87), P = 0.025]. No significant differences in mortality and complications relevant to the cryoablation procedure were observed between Group A and Group B. Moreover, adjusted multivariable Cox regression analysis showed that <24-h paroxysmal AF type (HR 0.644, 95% CI: 0.455–0.913, P = 0.014) and left atrium diameter (LAD) (>40 mm) (HR 1.696, 95% CI: 1.046–2.750, P = 0.032) were independently associated with the incidence of recurrence of atrial tachyarrhythmia in the study. Conclusion: Our findings indicated that <24-h paroxysmal AF type was obviously associated with an increased success rate of cryoablation and reduced incidence of stroke/TIA during the follow-up period. Therefore, there is superior effectiveness and similar safety in patients with AF episodes of <24-h duration compared with patients with longer paroxysmal AF duration.
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Affiliation(s)
- Chunying Jiang
- Department of Cardiology, Shanghai Tenth Clinical Medical School of Nanjing Medical University, Shanghai Tenth People's Hospital, Shanghai, China.,Department of Cardiology, The Xuzhou School of Clinical Medicine of Nanjing Medical University, Xuzhou Central Hospital, Xuzhou, China
| | - Dongdong Zhao
- Department of Cardiology, Shanghai Tenth Clinical Medical School of Nanjing Medical University, Shanghai Tenth People's Hospital, Shanghai, China
| | - Kai Tang
- Department of Cardiology, Shanghai Tenth Clinical Medical School of Nanjing Medical University, Shanghai Tenth People's Hospital, Shanghai, China
| | - Yiqian Wang
- Department of Cardiology, Shanghai Tenth Clinical Medical School of Nanjing Medical University, Shanghai Tenth People's Hospital, Shanghai, China
| | - Xiang Li
- Department of Cardiology, Shanghai Tenth Clinical Medical School of Nanjing Medical University, Shanghai Tenth People's Hospital, Shanghai, China
| | - Peng Jia
- Department of Cardiology, Shanghai Tenth Clinical Medical School of Nanjing Medical University, Shanghai Tenth People's Hospital, Shanghai, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth Clinical Medical School of Nanjing Medical University, Shanghai Tenth People's Hospital, Shanghai, China
| | - Bing Han
- Department of Cardiology, The Xuzhou School of Clinical Medicine of Nanjing Medical University, Xuzhou Central Hospital, Xuzhou, China
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Hanna P, Buch E, Stavrakis S, Meyer C, Tompkins JD, Ardell JL, Shivkumar K. Neuroscientific therapies for atrial fibrillation. Cardiovasc Res 2021; 117:1732-1745. [PMID: 33989382 PMCID: PMC8208752 DOI: 10.1093/cvr/cvab172] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/13/2021] [Indexed: 02/06/2023] Open
Abstract
The cardiac autonomic nervous system (ANS) plays an integral role in normal cardiac physiology as well as in disease states that cause cardiac arrhythmias. The cardiac ANS, comprised of a complex neural hierarchy in a nested series of interacting feedback loops, regulates atrial electrophysiology and is itself susceptible to remodelling by atrial rhythm. In light of the challenges of treating atrial fibrillation (AF) with conventional pharmacologic and myoablative techniques, increasingly interest has begun to focus on targeting the cardiac neuraxis for AF. Strong evidence from animal models and clinical patients demonstrates that parasympathetic and sympathetic activity within this neuraxis may trigger AF, and the ANS may either induce atrial remodelling or undergo remodelling itself to serve as a substrate for AF. Multiple nexus points within the cardiac neuraxis are therapeutic targets, and neuroablative and neuromodulatory therapies for AF include ganglionated plexus ablation, epicardial botulinum toxin injection, vagal nerve (tragus) stimulation, renal denervation, stellate ganglion block/resection, baroreceptor activation therapy, and spinal cord stimulation. Pre-clinical and clinical studies on these modalities have had promising results and are reviewed here.
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Affiliation(s)
- Peter Hanna
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Neurocardiology Research Program of Excellence, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Molecular, Cellular & Integrative Physiology Program, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Eric Buch
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 1100 N Lindsay Ave, Oklahoma City, OK 73104, USA
| | - Christian Meyer
- Division of Cardiology, cardiac Neuro- and Electrophysiology Research Consortium (cNEP), EVK Düsseldorf, Teaching Hospital University of Düsseldorf, Kirchfeldstraße 40, 40217 Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cardiac Neuro- and Electrophysiology Research Consortium (cNEP), University of Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany
| | - John D Tompkins
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Neurocardiology Research Program of Excellence, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Jeffrey L Ardell
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Neurocardiology Research Program of Excellence, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Molecular, Cellular & Integrative Physiology Program, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Kalyanam Shivkumar
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Neurocardiology Research Program of Excellence, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Molecular, Cellular & Integrative Physiology Program, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
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9
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Liao TW, Lo LW, Lin YJ, Chang SL, Hu YF, Wu CI, Chung FP, Chao TF, Liao JN, Chen SA. Autonomic modulation before and after paroxysmal atrial fibrillation events in patients with ischemic heart disease. Ann Noninvasive Electrocardiol 2020; 25:e12767. [PMID: 32452603 DOI: 10.1111/anec.12767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/29/2020] [Accepted: 04/09/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The autonomic activity plays a critical role in generating paroxysmal atrial fibrillation (PAF). This study aimed to evaluate the changes in the autonomic nerve activity before and after PAF events in patients with and without ischemic heart disease (IHD). METHODS The study included 49 patients (71.43 ± 12.24 years old, 26 males) with PAF events lasting more than 30 s during 24-hr ambulatory Holter monitoring. The 20-min intervals before and after PAF events were divided into eight segments of 5 min each. Heart rate variability (HRV) analyses of the time and frequency domains were applied to each time segment. RESULTS Patients with IHD had significant increases in the root mean square successive differences (r-MSSD, p = .008) and HF component (p = .04), followed by a significant increase in the LF/HF ratio (p = .02) preceding the onset of PAF. Patients without IHD had only a significant increase in the r-MSSD (p = .045) preceding the onset of PAF. During the termination of PAF events, patients in both the IHD and control groups had a significantly decreased r-MSSD and HF, respectively. CONCLUSION Ischemic heart disease causes a sympathovagal imbalance in the initiation of PAF. Decreased parasympathetic activity regulated the termination of PAF in both the IHD and control groups. The modification of the autonomic nervous system (ANS) activity should be individualized due to the autonomic complexity in AF arrhythmogenesis and termination.
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Affiliation(s)
- Ting-Wei Liao
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li-Wei Lo
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Lin Chang
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Feng Hu
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-I Wu
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Fa-Po Chung
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Tze-Fan Chao
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Jo-Nan Liao
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Ann Chen
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
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10
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Luo B, Yan Y, Zeng Z, Zhang Z, Liu H, Liu H, Li J, Huang W, Wu J, He Y. Connexin 43 reduces susceptibility to sympathetic atrial fibrillation. Int J Mol Med 2018; 42:1125-1133. [PMID: 29717772 DOI: 10.3892/ijmm.2018.3648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 04/24/2018] [Indexed: 11/06/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia reported in clinical practice. Connexin 43 (Cx43) is a member of the connexin protein family, which serves important roles in signal transduction in vivo. The aim of the present study was to investigate the role of Cx43 in the induction and maintenance of atrial fibrillation by using an animal model of sympathomimetic atrial fibrillation. Cx43 was successfully knocked down in the myocardium with gene‑specific small interfering (si)RNA via lentiviral infection. A total of 25 dogs were randomly and evenly divided into five groups: Normal (N), rapid atrial pacing (RAP), isoproterenol (ISO) + RAP, RAP + Cx43 siRNA and ISO + RAP + Cx43 siRNA. The mRNA and protein levels, as well as the distribution of Cx43 on the cell membrane, were gradually decreased in each group compared with the N group following treatment (P<0.05). The induction rate of the atrial effective refractory period was not significantly affected in the RAP and RAP + Cx43 siRNA groups, whereas it was significantly reduced in the ISO + RAP and ISO + RAP + Cx43 siRNA groups compared with the N group (P<0.05). The induction rate of AF was gradually increased in the RAP + Cx43 siRNA, ISO + RAP and ISO + RAP + Cx43 siRNA groups compared with the N group (P<0.05). The expression of nerve growth factor (NGF) and tyrosine hydroxylase (TH) was gradually increased in the ISO + RAP and ISO + RAP + Cx43 siRNA groups compared with their respective controls (RAP and RAP + Cx43 siRNA groups, respectively). However, no significant difference in the levels of NGF and TH was observed between the RAP, RAP + Cx43 siRNA, ISO + RAP and ISO + RAP + Cx43 siRNA groups. The mitochondrial morphology in each group was notably altered compared with the N group. The mitochondrial reactive oxygen species production and apoptotic index were gradually increased in each group compared with the N group (P<0.05). The results of the present study suggest that Cx43 reduces susceptibility to AF. Downregulation of Cx43 mediates the induction and maintenance of sympathetic AF.
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Affiliation(s)
- Beibei Luo
- Department of Geriatric Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - Yifei Yan
- Department of Geriatric Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - Zhiyu Zeng
- Department of Geriatric Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - Zhengnan Zhang
- Department of Geriatric Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - Haide Liu
- Department of Geriatric Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - Hao Liu
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - Jinyi Li
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - Weiqiang Huang
- Department of Geriatric Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - Jiangtao Wu
- Department of Geriatric Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
| | - Yan He
- Department of Geriatric Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530000, P.R. China
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11
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The complexity of atrial fibrillation newly diagnosed after ischemic stroke and transient ischemic attack: advances and uncertainties. Curr Opin Neurol 2018; 30:28-37. [PMID: 27984303 PMCID: PMC5321114 DOI: 10.1097/wco.0000000000000410] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose of review Atrial fibrillation is being increasingly diagnosed after ischemic stroke and transient ischemic attack (TIA). Patient characteristics, frequency and duration of paroxysms, and the risk of recurrent ischemic stroke associated with atrial fibrillation detected after stroke and TIA (AFDAS) may differ from atrial fibrillation already known before stroke occurrence. We aim to summarize major recent advances in the field, in the context of prior evidence, and to identify areas of uncertainty to be addressed in future research. Recent findings Half of all atrial fibrillations in ischemic stroke and TIA patients are AFDAS, and most of them are asymptomatic. Over 50% of AFDAS paroxysms last less than 30 s. The rapid initiation of cardiac monitoring and its duration are crucial for its timely and effective detection. AFDAS comprises a heterogeneous mix of atrial fibrillation, possibly including cardiogenic and neurogenic types, and a mix of both. Over 25 single markers and at least 10 scores have been proposed as predictors of AFDAS. However, there are considerable inconsistencies across studies. The role of AFDAS burden and its associated risk of stroke recurrence have not yet been investigated. Summary AFDAS may differ from atrial fibrillation known before stroke in several clinical dimensions, which are important for optimal patient care strategies. Many questions remain unanswered. Neurogenic and cardiogenic AFDAS need to be characterized, as it may be possible to avoid some neurogenic cases by initiating timely preventive treatments. AFDAS burden may differ in ischemic stroke and TIA patients, with distinctive diagnostic and treatment implications. The prognosis of AFDAS and its risk of recurrent stroke are still unknown; therefore, it is uncertain whether AFDAS patients should be treated with oral anticoagulants.
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12
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Paquet M, Cerasuolo JO, Thorburn V, Fridman S, Alsubaie R, Lopes RD, Cipriano LE, Salamone P, Melling CWJ, Khan AR, Sedeño L, Fang J, Drangova M, Montero-Odasso M, Mandzia J, Khaw AV, Racosta JM, Paturel J, Samoilov L, Stirling D, Balint B, Jaremek V, Koschinsky ML, Boffa MB, Summers K, Ibañez A, Mrkobrada M, Saposnik G, Kimpinski K, Whitehead SN, Sposato LA. Pathophysiology and Risk of Atrial Fibrillation Detected after Ischemic Stroke (PARADISE): A Translational, Integrated, and Transdisciplinary Approach. J Stroke Cerebrovasc Dis 2017; 27:606-619. [PMID: 29141778 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/22/2017] [Accepted: 09/24/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND It has been hypothesized that ischemic stroke can cause atrial fibrillation. By elucidating the mechanisms of neurogenically mediated paroxysmal atrial fibrillation, novel therapeutic strategies could be developed to prevent atrial fibrillation occurrence and perpetuation after stroke. This could result in fewer recurrent strokes and deaths, a reduction or delay in dementia onset, and in the lessening of the functional, structural, and metabolic consequences of atrial fibrillation on the heart. METHODS The Pathophysiology and Risk of Atrial Fibrillation Detected after Ischemic Stroke (PARADISE) study is an investigator-driven, translational, integrated, and transdisciplinary initiative. It comprises 3 complementary research streams that focus on atrial fibrillation detected after stroke: experimental, clinical, and epidemiological. The experimental stream will assess pre- and poststroke electrocardiographic, autonomic, anatomic (brain and heart pathology), and inflammatory trajectories in an animal model of selective insular cortex ischemic stroke. The clinical stream will prospectively investigate autonomic, inflammatory, and neurocognitive changes among patients diagnosed with atrial fibrillation detected after stroke by employing comprehensive and validated instruments. The epidemiological stream will focus on the demographics, clinical characteristics, and outcomes of atrial fibrillation detected after stroke at the population level by means of the Ontario Stroke Registry, a prospective clinical database that comprises over 23,000 patients with ischemic stroke. CONCLUSIONS PARADISE is a translational research initiative comprising experimental, clinical, and epidemiological research aimed at characterizing clinical features, the pathophysiology, and outcomes of neurogenic atrial fibrillation detected after stroke.
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Affiliation(s)
- Maryse Paquet
- Stroke, Dementia and Heart Disease Laboratory, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Joshua O Cerasuolo
- Stroke, Dementia and Heart Disease Laboratory, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Victoria Thorburn
- Stroke, Dementia and Heart Disease Laboratory, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Vulnerable Brain Laboratory, Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Sebastian Fridman
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Rasha Alsubaie
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Renato D Lopes
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Lauren E Cipriano
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Ivey Business School, Western University, London, Ontario, Canada
| | - Paula Salamone
- Laboratory of Experimental, Psychology and Neuroscience (LPEN), Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University; National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
| | - C W James Melling
- School of Kinesiology, Faculty of Health Sciences, Western University, London, ON, Canada
| | - Ali R Khan
- Robarts Research Institute, Department of Medical Biophysics & Medical Imaging, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Lucas Sedeño
- Laboratory of Experimental, Psychology and Neuroscience (LPEN), Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University; National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Maria Drangova
- Robarts Research Institute, Department of Medical Biophysics & Medical Imaging, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Manuel Montero-Odasso
- Gait and Brain Lab, Parkwood Institute and Lawson Health Research Institute, London, Ontario, Canada; Division of Geriatric Medicine and Dentistry, Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Jennifer Mandzia
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Alexander V Khaw
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Juan M Racosta
- Autonomic Disorders Laboratory, Clinical Neurological Sciences Department, Schulich School of Medicine & Dentistry, London Health Sciences Center, Western University, London, ON, Canada
| | - Justin Paturel
- Autonomic Disorders Laboratory, Clinical Neurological Sciences Department, Schulich School of Medicine & Dentistry, London Health Sciences Center, Western University, London, ON, Canada
| | - Lucy Samoilov
- Stroke, Dementia and Heart Disease Laboratory, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Devin Stirling
- Stroke, Dementia and Heart Disease Laboratory, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Brittany Balint
- Stroke, Dementia and Heart Disease Laboratory, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Vulnerable Brain Laboratory, Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Victoria Jaremek
- Stroke, Dementia and Heart Disease Laboratory, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Vulnerable Brain Laboratory, Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Marlys L Koschinsky
- Robarts Research Institute, Department of Physiology and Pharmacology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Michael B Boffa
- Department of Biochemistry, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Kelly Summers
- Department of Microbiology and Immunology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Agustín Ibañez
- Laboratory of Experimental, Psychology and Neuroscience (LPEN), Institute of Cognitive and Translational Neuroscience (INCyT), INECO Foundation, Favaloro University, Buenos Aires, Argentina; National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina; Universidad Autónoma del Caribe, Barranquilla, ColombiaCenter for Social and Cognitive Neuroscience (CSCN), School of Psychology, Universidad Adolfo Ibáñez, Santiago, Chile; Centre of Excellence in Cognition and its Disorders, Australian Research Council (ACR), Macquarie University, Sydney, New South Wale, Australia
| | - Marko Mrkobrada
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Gustavo Saposnik
- Stroke Outcomes Research Center, Division of Neurology, Department of Medicine, St. Michael's Hospital and Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Kurt Kimpinski
- Autonomic Disorders Laboratory, Clinical Neurological Sciences Department, Schulich School of Medicine & Dentistry, London Health Sciences Center, Western University, London, ON, Canada
| | - Shawn N Whitehead
- Vulnerable Brain Laboratory, Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Luciano A Sposato
- Stroke, Dementia and Heart Disease Laboratory, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Clinical Neurological Sciences at London Health Sciences Centre, Department of Epidemiology and Biostatistics, Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
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13
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Piña PG, Chicos AB. Early Cardioversion in Atrial Fibrillation: Earlier Is Better, but Not Always and (Maybe) Not Immediately. Curr Atheroscler Rep 2017; 19:3. [PMID: 28108860 DOI: 10.1007/s11883-017-0638-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia in humans. One of its important features is the tendency to become more persistent over time, even in the absence of underlying progressive heart disease. Conversion and maintenance of sinus rhythm by pharmacological or electrical methods become increasingly difficult the longer the arrhythmia persists. Electrical, mechanical, structural, and autonomic remodeling processes have been implicated in the mechanisms of AF initiation, perpetuation, and progression. Prevention or reversal of these remodeling processes can halt the progression of the disease. Cardioversion is a powerful tool and rhythm control is a widely used strategy in the management of AF. However, important questions remain unanswered regarding not only if, but also when to perform cardioversion. There are observations from past trials and clinical situations that support attempting to restore sinus rhythm, but further prospective randomized clinical trials are needed. Optimal timing of cardioversion remains somewhat uncertain, but it appears to be some time after the first few hours and before the first few months: the earlier, the better, but not always, and maybe not immediately, and it has to be tailored to the clinical situation and its many variables. This review is intended to summarize the evidence supporting early intervention for the prevention of remodeling in patients with AF.
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Affiliation(s)
- Paloma G Piña
- Clinical Cardiac Electrophysiology, Bluhm Cardiovascular Institute, Northwestern University, Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Alexandru B Chicos
- Clinical Cardiac Electrophysiology, Bluhm Cardiovascular Institute, Northwestern University, Feinberg School of Medicine, Chicago, IL, 60611, USA.
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14
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Lo LW, Chang HY, Scherlag BJ, Lin YJ, Chou YH, Lin WL, Chen SA, Po SS. Temporary Suppression of Cardiac Ganglionated Plexi Leads to Long-Term Suppression of Atrial Fibrillation: Evidence of Early Autonomic Intervention to Break the Vicious Cycle of "AF Begets AF". J Am Heart Assoc 2016; 5:JAHA.116.003309. [PMID: 27381759 PMCID: PMC5015371 DOI: 10.1161/jaha.116.003309] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Botulinum toxin (BTX), temporarily suppressing cholinergic transmission (<3 weeks), has been reported to suppress atrial fibrillation (AF) for ≥1 year. We aimed to investigate the mechanism underlying long-term suppression of AF caused by injecting BTX into major atrial ganglionated plexi (GPs). METHODS AND RESULTS Bilateral thoracotomies in anesthetized dogs allowed programmed stimulation at 4 pulmonary veins, biatrial appendages, and the superior vena cava to determine the effective refractory period (ERP) in the first operation. Group 1 (n=10) received BTX injection into all GPs; group 2 (n=7) received no injection. Groups 1 and 2 received rapid atrial pacing (800 bpm) 6 days a week. Group 3 (n=7) did not undergo thoracotomy or rapid atrial pacing to serve as controls for histological studies. A second operation and the same measurements were made 3 months later. During the first operation in group 1, ERPs of 4 pulmonary veins, but not biatrial appendages or superior vena cava, increased immediately after BTX injection. AF burdens increased significantly from the fifth week after the first operation in group 2 but not in group 1. In the second operation, ERPs remained unchanged compared with ERPs before BTX injection in group 1, whereas ERPs shortened significantly at all sites except the superior vena cava in group 2. There was no difference of autonomic nerve density between group 1 and group 3. The GP choline acetyltransferase (+) and atrial tyrosine hydroxylase (+) nerve densities were higher in group 2 than in group 1 and group 3. CONCLUSIONS Temporary suppression of major atrial GPs by BTX prevents autonomic remodeling and provides long-term suppression of AF, indicating the critical role of GPs in AF progression.
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Affiliation(s)
- Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Hung-Yu Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Benjamin J Scherlag
- Department of Medicine and Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Hui Chou
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Lun Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Sunny S Po
- Department of Medicine and Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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15
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Chun KJ, Hwang JK, Park SJ, On YK, Kim JS, Park KM. Electrical PR Interval Variation Predicts New Occurrence of Atrial Fibrillation in Patients With Frequent Premature Atrial Contractions. Medicine (Baltimore) 2016; 95:e3249. [PMID: 27057868 PMCID: PMC4998784 DOI: 10.1097/md.0000000000003249] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is associated with the autonomic nervous system (ANS), and fluctuation of autonomic tone is more prominent in patients with AF. As autonomic tone affects the heart rate (HR), and there is an inverse relationship between HR and PR interval, PR interval variation could be greater in patients with AF than in those without AF. The purpose of this study was to investigate the correlation between PR interval variation and new-onset AF in patients with frequent PACs.We retrospectively enrolled 207 patients with frequent PACs who underwent electrocardiographs at least 4 times during the follow-up period. The PR variation was calculated by subtracting the minimum PR interval from the maximum PR interval. The outcomes were new occurrence of AF and all-cause mortality during the follow-up period.During a median follow-up of 8.3 years, 24 patients (11.6%) developed new-onset AF. Univariate analysis showed that prolonged PR interval (PR interval > 200 ms, P = 0.021), long PR variation (PR variation > 36.5 ms, P = 0.018), and PR variation (P = 0.004) as a continuous variable were associated with an increased risk of AF. Cox regression analysis showed that prolonged PR interval (hazard ratio = 3.321, 95% CI 1.064-10.362, P = 0.039) and PR variation (hazard ratio = 1.013, 95% CI 1.002-1.024, P = 0.022) were independent predictors for new-onset AF. However, PR variation and prolonged PR interval were not associated with all-cause mortality (P = 0.465 and 0.774, respectively).PR interval variation and prolonged PR interval are independent risk factors for new-onset AF in patients with frequent PACs. However we were unable to determine a cut-off value of PR interval variation for new-onset AF.
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Affiliation(s)
- Kwang Jin Chun
- From the Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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