Atrial fibrillation: Epidemiology, pathophysiology, and clinical complications (literature review)

Relationship between sodium-glucose cotransporter 2 inhibitors and atrial fibrillation recurrence after pulmonary vein isolation in patients with type 2 diabetes and persistent atrial fibrillation

BACKGROUND

The impact of sodium-glucose cotransporter 2 (SGLT2) inhibitors on the postoperative recurrence of atrial fibrillation (AF) in patients with persistent AF undergoing an initial radiofrequency ablation is not yet established. The objective of this study is to assess the impact of SGLT2 inhibitors on the recurrence of AF after radiofrequency ablation in patients with type 2 diabetes complicated persistent AF.

METHODS

A total of 182 patients with type 2 diabetes and persistent AF, who underwent their first radiofrequency ablation for AF at our center, were enrolled and divided into two groups: the SGLT2 inhibitor group and the non-SGLT2 inhibitor group. The main outcome of the follow-up was the postoperative recurrence of AF.

RESULTS

A total of 49 participants experienced AF recurrence. The use of SGLT2 inhibitors in patients with type 2 diabetes who underwent AF ablation was associated with a significantly lower risk of AF recurrence (adjusted hazard ratio: 0.65; 95% confidence interval: 0.28-0.83; p < .01).

CONCLUSIONS

The use of SGLT2 inhibitors is associated with a decreased risk of arrhythmia recurrence after AF ablation in patients with type 2 diabetes complicated with persistent AF.

Ablation Compared to Pharmacological Treatment for the Reduction of Atrial Fibrillation Recurrence: A Meta-Analysis

Atrial fibrillation (AF) is one of the most common heart arrhythmias, and due to its variable presentation, detecting and treating AF appropriately can reduce some of its serious complications. Among treatment options, surgical ablation and antiarrhythmic drug therapy are two of the most widely used choices. A systematic review and meta-analysis were conducted to examine the rates of AF recurrence in those treated with ablation compared to pharmacological treatment. Google Scholar and PubMed were searched for study trials published within the last decade that calculated the recurrence of AF symptoms in patient groups that received ablation or pharmacological treatment. Selected studies were analyzed in RevMan 5.4 software (The Cochrane Collaboration, London, England, UK), and each study's odds ratio and overall odds ratio were calculated using a 95% confidence interval. A total of seven studies with 2324 patients were analyzed for the meta-analysis, with 1162 patients receiving ablation and 1162 patients receiving pharmacological treatment. There was a statistically significant decrease in the recurrence of AF in the ablation group compared to the pharmacological treatment group, with a pooled odds ratio of 0.24 (CI 95% 0.14-0.39). AF treated with ablation was more effective in reducing AF recurrence than general pharmacological treatment.

Development and trends in research on hypertension and atrial fibrillation: A bibliometric analysis from 2003 to 2022

BACKGROUND

This study aimed to comprehensively analyze research related to hypertension and atrial fibrillation, 2 common cardiovascular diseases with significant global public health implications, using bibliometric methods from 2003 to 2022.

METHODS

From the Web of Science Core Collection database, literature on the theme of hypertension and atrial fibrillation was retrieved. Subsequently, comprehensive bibliometric analyses were conducted across multiple dimensions utilizing software tools such as VOSviewer, Citespace, Pajek, Scimago Graphica, and ClusterProfiler. These analyses encompassed examinations of the literature according to country/region, institution, authors, journals, citation relationships, and keywords.

RESULTS

It revealed an increasing interest and shifting focus in research over the years. The analysis covered 7936 relevant publications, demonstrating a gradual rise in research activity regarding hypertension combined with atrial fibrillation over the past 2 decades, with a stable growth trend in research outcomes. Geographically, Europe and the Americas, particularly the United States, have shown the most active research in this field, while China has also gained importance in recent years. Regarding institutional contributions, internationally renowned institutions such as the University of Birmingham and the Mayo Clinic have emerged as core forces in this research direction. Additionally, Professor Lip Gregory, with his prolific research output, has stood out among numerous scholars. The American Journal of Cardiology has become a primary platform for publishing research related to hypertension and atrial fibrillation, highlighting its central role in advancing knowledge dissemination in this field. The research focus has shifted from exploring the pathophysiological mechanisms to investigating the treatment of complications and risk factors associated with hypertension and atrial fibrillation. Future research will focus on in-depth exploration of genetic and molecular mechanisms, causal relationship exploration through Mendelian randomization studies, and the application of machine learning techniques in prediction and treatment, aiming to promote the development of precision medicine for cardiovascular diseases.

CONCLUSION

In conclusion, this study provides a comprehensive overview of the developmental trajectory of research on hypertension and atrial fibrillation, presenting novel insights into trends and future research directions, thus offering information support and guidance for research in this crucial field of cardiovascular medicine.

Analyses of lncRNA and mRNA profiles in recurrent atrial fibrillation after catheter ablation

BACKGROUND

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide. Catheter ablation has become a crucial treatment for AF. However, there is a possibility of atrial fibrillation recurrence after catheter ablation. Our study sought to elucidate the role of lncRNA‒mRNA regulatory networks in late AF recurrence after catheter ablation.

METHODS

We conducted RNA sequencing to profile the transcriptomes of 5 samples from the presence of recurrence after AF ablation (P-RAF) and 5 samples from the absence of recurrence after AF ablation (A-RAF). Differentially expressed genes (DEGs) and long noncoding RNAs (DE-lncRNAs) were analyzed using the DESeq2 R package. The functional correlations of the DEGs were assessed through Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses. A protein‒protein interaction (PPI) network was constructed using STRING and Cytoscape. We also established a lncRNA‒mRNA regulatory network between DE-lncRNAs and DEGs using BEDTools v2.1.2 software and the Pearson correlation coefficient method. To validate the high-throughput sequencing results of the hub genes, we conducted quantitative real-time polymerase chain reaction (qRT‒PCR) experiments.

RESULTS

A total of 28,528 mRNAs and 42,333 lncRNAs were detected. A total of 96 DEGs and 203 DE-lncRNAs were identified between the two groups. GO analysis revealed that the DEGs were enriched in the biological processes (BPs) of "regulation of immune response" and "regulation of immune system process", the cellular components (CCs) of "extracellular matrix" and "cell‒cell junction", and the molecular functions (MFs) of "signaling adaptor activity" and "protein-macromolecule adaptor activity". According to the KEGG analysis, the DEGs were associated with the "PI3K-Akt signaling pathway" and "MAPK signaling pathway." Nine hub genes (MMP9, IGF2, FGFR1, HSPG2, GZMB, PEG10, GNLY, COL6A1, and KCNE3) were identified through the PPI network. lncRNA-TMEM51-AS1-201 was identified as a core regulator in the lncRNA‒mRNA regulatory network, suggesting its potential impact on the recurrence of AF after catheter ablation through the regulation of COL6A1, FGFR1, HSPG2, and IGF2.

CONCLUSIONS

The recurrence of atrial fibrillation after catheter ablation may be associated with immune responses and fibrosis, with the extracellular matrix playing a crucial role. TMEM51-AS1-201 has been identified as a potential key target for AF recurrence after catheter ablation.

New-onset atrial fibrillation following arteriovenous fistula increases adverse clinical events in dialysis patients with end-stage renal disease

Background

End-stage renal disease (ESRD) patients have a high potential cardiovascular burden, and cardiovascular disease (CVD) is the leading cause of death in maintenance haemodialysis (MHD) patients. Arteriovenous fistula (AVF) is the preferred vascular access for MHD patients, but AVF significantly affects the haemodynamics of the cardiovascular system, leading to or exacerbating CVD, including atrial fibrillation (AF). This study aimed to evaluate the impact of AVF on cardiac function, especially of the left atrium (LA), in patients with ESRD and to further explore the relationship between AVF establishment and the occurrence of AF.

Methods

We selected 1,107 ESRD patients on haemodialysis using AVF and 550 patients with tunneled-cuffed catheters (TCC) admitted between January 2016 and December 2022 for follow-up to compare the rate of AF between the two groups. A total of 153 patients in the AVF group with complete information (clinical data, echocardiographic and biochemical indices, and other data) were enrolled and retrospectively analysed for risk factors for the development of AF and were followed up for adverse clinical outcomes (including all-cause death, cardiac death, readmission due to heart failure, and stroke).

Results

The incidence of new-onset AF was higher in the AVF group than the TCC group after dialysis access was established (16.30% vs. 5.08%, P < 0.001). Echocardiography showed that the LA anteroposterior diameter increased (P < 0.001) and the incidence of AF increased from 11.76% to 26.14% (P = 0.001) after AVF establishment. Multivariate logistic regression analysis showed that age and LA enlargement were independent risk factors for new-onset AF after AVF establishment (P < 0.05). Adverse clinical outcomes were more common in patients with AF than in patients without AF (P < 0.001). Multivariate Cox risk regression analysis suggested that new-onset AF (HR = 4.08, 95% CI: 2.00-8.34, P < 0.001) and left ventricular systolic dysfunction (HR = 2.42, 95% CI: 1.20-4.88, P = 0.01) after AVF establishment were independent risk factors for adverse clinical outcomes.

Conclusion

LA enlargement after AVF establishment is associated with a significant increase in the incidence of AF, in addition, AF which is as an important influential factor in patients with MHD combined other systemic diseases might increase adverse clinical events.

Clinical Trial Registration

(NCT06199609).

Does radiofrequency ablation procedural data improve the accuracy of identifying atrial fibrillation recurrence?

Radiofrequency ablation (RFA) using the CARTO 3D mapping system is a common approach for pulmonary vein isolation to treat atrial fibrillation (AF). Linkage between CARTO procedural data and patients' electronical health records (EHR) provides an opportunity to identify the ablation-related parameters that would predict AF recurrence. The objective of this study is to assess the incremental accuracy of RFA procedural data to predict post-ablation AF recurrence using machine learning model. Procedural data generated during RFA procedure were downloaded from CARTONET and linked to deidentified Mercy Health EHR data. Data were divided into train (70%) and test (30%) data for model development and validation. Automate machine learning (AutoML) was used to predict 1 year AF recurrence, defined as a composite of repeat ablation, electrical cardioversion, and AF hospitalization. At first, AutoML model only included Patients' demographic and clinical characteristics. Second, an AutoML model with procedural variables and demographical/clinical variables was developed. Area under receiver operating characteristic curve (AUROC) and net reclassification improvement (NRI) were used to compare model performances using test data. Among 306 patients, 67 (21.9%) patients experienced 1-year AF recurrence. AUROC increased from 0.66 to 0.78 after adding procedural data in the AutoML model based on test data. For patients with AF recurrence, NRI was 32% for model with procedural data. Nine of 10 important predictive features were CARTO procedural data. From CARTO procedural data, patients with lower contact force in right inferior site, long ablation duration, and low number of left inferior and right roof lesions had a higher risk of AF recurrence. Patients with persistent AF were more likely to have AF recurrence. The machine learning model with procedural data better predicted 1-year AF recurrence than the model without procedural data. The model could be used for identification of patients with high risk of AF recurrence post ablation.

A genetic exploration of the relationship between Posttraumatic Stress Disorder and cardiovascular diseases

Background and Aims

Experiencing a traumatic event may lead to Posttraumatic Stress Disorder (PTSD), including symptoms such as flashbacks and hyperarousal. Individuals suffering from PTSD are at increased risk of cardiovascular disease (CVD), but it is unclear why. This study assesses shared genetic liability and potential causal pathways between PTSD and CVD.

Methods

We leveraged summary-level data of genome-wide association studies (PTSD: N= 1,222,882; atrial fibrillation (AF): N=482,409; coronary artery disease (CAD): N=1,165,690; hypertension: N=458,554; heart failure (HF): N=977,323). First, we estimated genetic correlations and utilized genomic structural equation modeling to identify a common genetic factor for PTSD and CVD. Next, we assessed biological, behavioural, and psychosocial factors as potential mediators. Finally, we employed multivariable Mendelian randomization to examine causal pathways between PTSD and CVD, incorporating the same potential mediators.

Results

Significant genetic correlations were found between PTSD and CAD, HT, and HF (rg =0.21-0.32, p≤ 3.08 · 10-16), but not between PTSD and AF. Insomnia, smoking, alcohol dependence, waist-to-hip ratio, and inflammation (IL6, C-reactive protein) partly mediated these associations. Mendelian randomization indicated that PTSD causally increases CAD (IVW OR=1.53, 95% CIs=1.19-1.96, p=0.001), HF (OR=1.44, CIs=1.08-1.92, p=0.012), and to a lesser degree hypertension (OR=1.25, CIs=1.05-1.49, p=0.012). While insomnia, smoking, alcohol, and inflammation were important mediators, independent causal effects also remained.

Conclusions

In addition to shared genetic liability between PTSD and CVD, we present strong evidence for causal effects of PTSD on CVD. Crucially, we implicate specific lifestyle and biological mediators (insomnia, substance use, inflammation) which has important implications for interventions to prevent CVD in PTSD patients.

Comprehensive Cardiovascular Management of Myotonic Dystrophy Type 1 Patients: A Report from the Italian Neuro-Cardiology Network

Myotonic dystrophy is a hereditary disorder with systemic involvement. The Italian Neuro-Cardiology Network-"Rete delle Neurocardiologie" (INCN-RNC) is a unique collaborative experience involving neurology units combined with cardio-arrhythmology units. The INCN facilitates the creation of integrated neuro-cardiac teams in Neuromuscular Disease Centers for the management of cardiovascular involvement in the treatment of myotonic dystrophy type 1 (MD1).

The effects of daily dose of intense exercise on cardiac responses and atrial fibrillation

Atrial fibrillation (AF) is a supraventricular tachyarrhythmia that is strongly associated with cardiovascular (CV) disease and sedentary lifestyles. Despite the benefits of exercise on overall health, AF incidence in high-level endurance athletes rivals that of CV disease patients, suggesting a J-shaped relationship with AF. To investigate the dependence of AF vulnerability on exercise, we varied daily swim durations (120, 180 or 240 min day-1 ) in 7-week-old male CD1 mice. We assessed mice after performing equivalent amounts of cumulative work during swimming (i.e. ∼700 L O2  kg-1 ), as determined from O2 consumption rates (V ̇ O 2 ${\dot V_{{{\mathrm{O}}_2}}}$ ). The meanV ̇ O 2 ${\dot V_{{{\mathrm{O}}_2}}}$ during exercise increased progressively throughout the training period and was indistinguishable between the swim groups. Consistent with similar improvements in aerobic conditioning induced by swimming, skeletal muscle mitochondria content increased (P = 0.027) indistinguishably between exercise groups. Physiological ventricular remodelling, characterized by mild hypertrophy and left ventricular dilatation, was also similar between exercised mice without evidence of ventricular arrhythmia inducibility. By contrast, prolongation of daily swim durations caused progressive and vagal-dependent heart rate reductions (P = 0.008), as well as increased (P = 0.005) AF vulnerability. As expected, vagal inhibition prolonged (P = 0.013) atrial refractoriness, leading to reduced AF vulnerability, although still inducible in the 180 and 240 min swim groups. Accordingly, daily swim dose progressively increased atrial hypertrophy (P = 0.003), fibrosis (P < 0.001) and macrophage accumulation (P = 0.006) without differentially affecting the ventricular tissue properties. Thus, increasing daily exercise duration drives progressively adverse atrial-specific remodelling and vagal-dependent AF vulnerability despite robust and beneficial aerobic conditioning and physiological remodelling of ventricles and skeletal muscle. KEY POINTS: Previous studies have suggested that a J-shaped dose-response relationship exists between physical activity and cardiovascular health outcomes, with moderate exercise providing protection against many cardiovascular disease conditions, whereas chronic endurance exercise can promote atrial fibrillation (AF). We found that AF vulnerability increased alongside elevated atrial hypertrophy, fibrosis and inflammation as daily swim exercise durations in mice were prolonged (i.e. ≥180 min day-1 for 6 weeks). The MET-h week-1 (based on O2  measurements during swimming) needed to induce increased AF vulnerability mirrored the levels linked to AF in athletes. These adverse atria effects associated with excessive daily exercise occurred despite improved aerobic conditioning, skeletal muscle adaptation and physiological ventricular remodelling. We suggest that atrial-specific changes observed with exercise arise from excessive elevations in venous filling pressures during prolonged exercise bouts, which we argue has implications for all AF patients because elevated atrial pressures occur in most cardiovascular disease conditions as well as ageing which are linked to AF.

Risk Factors for Atrial Fibrillation in the Dog: A Systematic Review

Different risk factors for atrial fibrillation (AF) development have been identified in numerous studies on humans, but this information is less clearly available on the dog. The aim of this systematic review is to determine the risk factors for AF in the dog. Following the PRISMA 2020 guidelines, we conducted a comprehensive search using the Web of Science and Scopus databases for articles reporting on cases of spontaneously occurring AF in dogs. The level of evidence was assessed using the Evidence Quality Grading System of the National Institute of Health. One thousand forty-three studies were initially identified, and twenty of them were included in this systematic review involving 2,359,275 dogs, of which 4807 showed spontaneously occurring AF. Genetics, for the Irish Wolfhound, increased body weight, and left atrial enlargement were the main risk factors for the development of AF in dogs with different cardiac diseases, particularly myxomatous mitral valve disease (MMVD) and dilated cardiomyopathy (DCM). However, some differences were found between these two cardiac diseases regarding additional risk factors. In particular, the presence of congestive heart failure and echocardiographic evidence of increased left atrial pressure or the presence of right atrial enlargement emerged as risk factors in dogs with MMVD or DCM, respectively. Furthermore, significant differences in risk factors were observed between dogs and humans. In particular, advanced age and male sex are not reliable indicators of an increased risk of AF in dogs.

Improved cerebral blood flow and hippocampal blood flow in stroke-free patients after catheter ablation of atrial fibrillation

INTRODUCTION

Atrial fibrillation (AF) is a risk factor for reduced cerebral blood flow (CBF) and cognitive dysfunction, even in stroke-free patients. We aimed to test the hypothesis that CBF and hippocampal blood flow (HBF), measured with arterial spin labeling magnetic resonance imaging (MRI), improve after catheter ablation of AF to achieve sinus rhythm (SR).

METHODS

A total of 84 stroke-free patients (63.1 ± 9.1 years; paroxysmal AF, n = 50; non-paroxysmal AF, n = 34) undergoing AF catheter ablation were included. MRI studies were done before, 3 months, and 12 months after the procedure with CBF and HBF measurements.

RESULTS

Baseline CBF and HBF values in 50 paroxysmal AF patients were used as controls. Baseline CBF was higher in patients with paroxysmal AF than with non-paroxysmal AF (100 ± 32% vs. 86 ± 28%, p = .04). Patients with non-paroxysmal AF had increased CBF 3 months after AF ablation (86 ± 28% to 99 ± 34%, p = .03). Differences in CBF and HBF were greater in the group with AF restored to SR (p < .01). Both CBF and HBF levels at 12 months were unchanged from the 3 months level. Successful rhythm control by catheter ablation was an independent predictor of an increase in CBF > 17.5%. The Mini-Mental State Examination score improved after ablation (p = .02).

CONCLUSION

SR restoration with catheter ablation was associated with improved CBF and HBF at 3 months, maintenance of blood flow, and improved cognitive function at 12 months.

Meta-analysis of the Current Research on the Relationship Between Blood Lipid Levels and the Occurrence of Atrial Fibrillation

BACKGROUND

There is still debate in the literature about the relationship between lipid profile and the occurrence of atrial fibrillation (AF). In order to assess the association between blood lipid profiles and incidence of AF, this review was conducted to perform a meta-analysis of all available studies.

METHODS

This review analysed all studies up to 28 February 2023 in PubMed, Google Scholar, and the Cochrane Library that included data regarding blood lipid levels and incidence of AF. For the purpose of calculating pooled estimates, the hazard ratios were extracted from all studies.

RESULTS

Fourteen studies including 19 cohorts with 3,990,484 patients were included in this meta-analysis. An elevation of one standard deviation in total cholesterol (TC) level was associated with an 8% reduction (HR=0.92, 0.88-0.96; p<0.01) in the risk of developing AF. Although increased low-density lipoprotein cholesterol levels were associated with a 7% reduction in the development of AF (HR=0.93, 0.87-1.00; p=0.04), there was high heterogeneity in the random effects model (I2=92%). Changes in high-density lipoprotein cholesterol and triglyceride levels were not found to be associated with AF risk in the pooled analysis. Dose-response meta-analysis showed that TC was inversely linearly associated with the risk of AF (p<0.001).

CONCLUSIONS

Higher TC levels were shown to be independently attributed to an increased risk of AF in individuals without cardiovascular disease. There was no association between the incidence of AF and triglyceride, high-density lipoprotein cholesterol, or low-density lipoprotein cholesterol blood levels.

Outcome of novel oral anticoagulant versus warfarin in frail elderly patients with atrial fibrillation: a systematic review and meta-analysis of retrospective studies

BACKGROUND

Frail patients with atrial fibrillation (AF) are thought to be at a higher risk for cerebral infarction and death than patients who are not frail, making preventive interventions important. Anticoagulants should be used in frailty patients with AF. However, there are limited data about anticoagulants in frail patients with AF. Therefore, we concucted this meta-analysis to find the best anticoagulation strategy.

METHODS

Systematic electronic searches were conducted on 4 July 2022 4 July 2022, in PubMed, Embase (Ovid), and Cochrane Library. Relevant and eligible cohort studies were included. A random-effects model was used to estimate the pooled Hazard ratio (HR) and 95% confidence intervals (CI). Furthermore, we performed a publication bias analysis and subgroup analysis to explore the source of heterogeneity.

RESULT

3 publications (10 cohorts, 188573 participants) met our inclusion criteria. The pooled analysis showed that ischemic strokes (HR: 0.75; 95%CI: 0.71 to 0.79; I2 = 60.2%), systemic embolism (HR: 0.75; 95%CI: 0.64 to 0.87; I  = 68.6%), major bleeding(HR: 0.76; 95%CI: 0.64 to 0.89; I2 = 97.4%), intracranial hemorrhage (HR: 0.57; 95%CI: 0.45 to 0.71; I2 = 54.6%) and cardiovascular death(HR: 0.61; 95%CI: 0.51 to 0.70; I2 = 83.2%) were lower in NOACs as compared with warfarin. Regarding gastrointestinal bleeding, meta-analysis showed no significant differences in the risk of gastrointestinal bleeding (HR: 0.97; 95%CI: 0.69 to 1.36; I2 = 95.9%).   .

CONCLUSION

NOAC was more effective and safety than warfarin in frail patients with AF.

Heart Failure Prevalence Rates and Its Association with Other Cardiovascular Diseases and Chronic Kidney Disease: SIMETAP-HF Study

INTRODUCTION AND OBJECTIVES

Heart failure (HF) is a major health problem that causes high mortality and hospitalization rates. This study aims to determine the HF prevalence rates in populations aged both ≥18 years and ≥50 years and to assess its association with cardiovascular diseases and chronic kidney disease.

METHODS

A cross-sectional observational study was conducted in a primary care setting, with a population-based random sample of 6588 people aged 18.0-102.8 years. Crude and adjusted prevalence rates of HF were calculated. The associations of renal and cardiometabolic factors with HF were assessed in both populations using univariate, bivariate and multivariate analysis.

RESULTS

The HF crude prevalence rates were 2.8% (95%CI: 2.4-3.2) in adults (≥18 years), and 4.6% (95%CI: 4.0-5.3) in the population aged ≥ 50 years, without significant differences between males and females in both populations. The age- and sex-adjusted prevalence rates were 2.1% (male: 1.9%; female: 2.3%) in the overall adult population, and 4.5% (male: 4.2%; female: 4.8%) in the population aged ≥ 50 years, reaching 10.0% in the population aged ≥ 70 years. Atrial fibrillation, hypertension, low estimated glomerular filtration rate (eGFR), coronary heart disease (CHD), stroke, sedentary lifestyle, and diabetes were independently associated with HF in both populations. A total of 95.7% (95%CI: 92.7-98.6) of the population with HF had an elevated cardiovascular risk.

CONCLUSIONS

This study reports that HF prevalence increases from 4.5% in the population over 50 years to 10% in the population over 70 years. The main clinical conditions that are HF-related are sedentary lifestyle, atrial fibrillation, hypertension, diabetes, low eGFR, stroke, and CHD.

Sex Related Differences in the Complex Relationship between Coffee, Caffeine and Atrial Fibrillation

This literature review aims to explore the data of articles published on the association between coffee, caffeine and atrial fibrillation and to analyze any differences between the two sexes. Several factors influence this complex relationship; genetic, environmental and psychosocial factors come into play in the pathophysiology of atrial fibrillation. These factors are expressed differently in women and men. However, the analysis of the literature has shown that comparison works between the two sexes are extremely rare. Most population-based and prospective studies either analyze aggregated data or focus on exclusively male or female populations. This results in a lack of information that could be useful in the prevention of and treatment approach to atrial fibrillation. It is necessary to deepen this issue with dedicated studies.

Focal Anticoagulation by Somatic Gene Transfer: Towards Preventing Cardioembolic Stroke

Cardioembolic stroke (CS) has emerged as a leading cause of ischaemic stroke (IS); distinguished by thrombi embolising to the brain from cardiac origins; most often from the left atrial appendage (LAA). Contemporary therapeutic options are largely dependent on systemic anticoagulation as a blanket preventative strategy, yet this does not represent a nuanced or personalised solution. Contraindications to systemic anticoagulation create significant unmedicated and high-risk cohorts, leaving these patients at risk of significant morbidity and mortality. Atrial appendage occlusion devices are increasingly used to mitigate stroke risk from thrombi emerging from the LAA in patients ineligible for oral anticoagulants (OACs). Their use, however, is not without risk or significant cost, and does not address the underlying aetiology of thrombosis and CS. Viral vector-based gene therapy has emerged as a novel strategy to target a spectrum of haemostatic disorders, achieving success through the adeno-associated virus (AAV) based therapy of haemophilia. Yet, thrombotic disorders, such as CS, have had limited exploration within the realm of AAV gene therapy approaches-presenting a gap in the literature and an opportunity for further research. Gene therapy has the potential to directly address the cause of CS by localised targeting of the molecular remodelling that serves to promote thrombosis.

Atrial fibrillation and coronary artery disease: An integrative review focusing on therapeutic implications of this relationship

The incidence of both atrial fibrillation (AF) and coronary artery disease (CAD) increases with advancing age. They share common risk factors and very often coexist. Evidence points to an intricate relationship between atrial tissue excitability and neuronal remodeling with ischemia at the microcirculatory level. In this review, we delineated this complex relationship, identified a common theme between the two, and discussed how the knowledge of this relationship translates into a positive and meaningful impact in patient management. Recent research indicates a high prevalence of CAD among AF patients undergoing coronary angiography. Further, the incidence of AF is much higher in those suffering from CAD compared to age-matched adults without CAD underlying this reciprocal relationship. CAD adversely affects AF by promoting progression via re-entry and increasing excitability of atrial tissue as a result of ischemia and electrical inhomogeneity. AF in turn accelerates atherosclerosis via endothelial dysfunctional and inflammation and together with enhanced thrombogenicity and hypercoagulability contribute to micro and macrothrombi throughout cardiovascular system. In a nutshell, the two form a vicious cycle wherein one disease promotes the other. Most AF recommendations focuses on rate/rhythm control and prevention of thromboembolism. Very few studies have discussed the importance of unmasking coexistent CAD and how the treatment of underlying ischemia will impact the burden of AF in these patients. Inflammation and endothelial dysfunction remain central to both disease processes and form a handsome therapeutic target in the management of the two diseases. The relationship between AF and CAD is complex and much more than mere coincidence. The two diseases share common risk factor and pathophysiology. Hence, it is impractical to treat them in isolation. Accordingly, we share the implications of managing underlying ischemia and inflammation to positively impact and improve quality of life among AF patients.