C-reactive protein elevation in patients with atrial arrhythmias: inflammatory mechanisms and persistence of atrial fibrillation

Segmental evaluation of predictive value of left atrial epicardial adipose tissue following catheter ablation for atrial fibrillation

BACKGROUND

Left atrial epicardial adipose tissue (LA-EAT) is associated with the recurrence of atrial tachyarrhythmias (AF/AT) after catheter ablation for atrial fibrillation (AF). However, no previous studies have assessed the predictive value of segment-specific LA-EAT volumes for AF/AT recurrence. This study aimed to assess the relationship between segmental LA-EAT volume and AF/AT recurrence.

METHODS

This study included 350 consecutive patients who underwent initial AF ablation (53.7 % paroxysmal AF (PAF)). Preoperative multidetector row computed tomography assessed LA-EAT, categorized into three segments: anterior-EAT, posterior-EAT, and interatrial septal adipose tissue (IAS-AT).

RESULTS

During a mean follow-up period of 351 ± 109 days, 56 patients (16.0 %) experienced AF/AT recurrence. The mean LA-EAT volume was 20.7 ± 11.1 ml and LA-EAT ≥26.8 ml was an independent risk factor for AF/AT recurrence (HR 2.21, 95 % confidence interval (CI): 1.24-3.93, P = 0.007). Receiver operating characteristic analyses revealed the area under the curve for IAS-AT was 0.669 (95 % CI: 0.596-0.743) with an optimal cut-off point of 1.3 ml (sensitivity 76.8 %; specificity 50.0 %), significantly outperforming the anterior- and posterior-EAT in predicting recurrent AF/AT. Multivariate analysis indicated IAS-AT was an independent predictor of AF/AT recurrence in patients with persistent AF (PeAF) (HR 3.52, 95 % CI: 1.52-8.13, P = 0.003), but not in patients with PAF.

CONCLUSIONS

LA-EAT predicts AF/AT recurrence after AF ablation, with IAS-AT proving significantly more effective than other LA-EAT segments in predicting recurrence. Notably, IAS-AT emerged as an independent predictor of AF/AT recurrence in patients with PeAF but not in those with PAF.

MicroRNAs and other biomarkers of atrial fibrillation in ischemic stroke patients

This study aimed to evaluate the ability of selected microRNAs as biomarkers of atrial fibrillation (AF) in ischemic stroke patients in comparison with other established biochemical biomarkers. A prospective case-control study of consecutive ischemic stroke patients with AF admitted to a comprehensive stroke center was conducted. The control group consisted of patients with ischemic stroke with no AF detected on prolonged (at least 3 weeks) Holter ECG monitoring. As potential biomarkers of AF, we analyzed the plasma levels of microRNAs (miR-21, miR-29b, miR-133b, miR-142-5p, miR-150, miR-499, and miR-223-3p) and 13 biochemical biomarkers at admission. The predictive accuracy of biomarkers was assessed by calculating the area under the receiver operating characteristic curve. The data of 117 patients were analyzed (61 with AF, 56 with no AF, 46% men, median age 73 years, median National Institutes of Health Stroke Scale 6). Biochemical biomarkers (N-terminal pro-B-type natriuretic peptide [NT-proBNP], high-sensitivity cardiac troponin I, fibrinogen, C-reactive protein, eGFR, and total triglycerides) were significantly associated with AF. NT-proBNP had the best diagnostic performance for AF with area under the receiver operating characteristic curve 0.92 (95%, CI 0.86-0.98); a cutoff value of >528 ng/L had a sensitivity of 79% and a specificity of 97%. None of the other biomarkers, including microRNAs, was associated with AF. Conventional biochemical biomarkers (NT-proBNP, high-sensitivity cardiac troponin I, fibrinogen, C-reactive protein, eGFR, and triglycerides), but not microRNAs (miR-21, miR-29b, miR-133b, miR-142-5p, miR-150, miR-499, and miR-223-3p) were significantly associated with AF in our ischemic stroke cohort.

Fibroblast growth factor 5 as a target for atrial fibrillation treatment: Evidence from mendelian randomization

BACKGROUND

Previous studies have found that inflammatory proteins are involved in the pathogenesis of atrial fibrillation (AF). We used mendelian randomization to explore the potential pathogenic inflammatory proteins of AF.

METHODS

This study adopts a Mendelian randomization design to primarily assess causal associations using the Wald ratio and the inverse variance weighting method. It leverages protein quantitative trait locus (pQTL) data encompassing 91 types of inflammatory proteins from 14,824 participants of European ancestry. The primary analysis phase utilizes AF GWAS data from 55,106 participants, with an additional 237,690 participants included in the validation stage. Sensitivity analyses, including reverse causality analysis, Bayesian colocalization analysis, and phenotype scanning, were conducted. Finally, the study explores potential targeted drugs.

RESULTS

The findings highlight a causal link between 7 inflammatory proteins and AF, with 2 showing positive correlations and 5 exhibiting negative correlations. Among these, fibroblast growth factor 5 (FGF5) emerges as particularly robust in sensitivity analysis. Colocalization analysis indicates a shared genetic variation between FGF5 and AF, supporting its potential as a targeted therapy for AF. Importantly, this causal relationship remains unaffected by reverse causality. Furthermore, significant pleiotropic effects were observed in phenotype scanning. Finally, the causal association between FGF5 and AF was successfully replicated during the validation phase.

CONCLUSION

FGF5 may become an intervention target for AF targeted therapy.

Implantable Cardioverter Defibrillator and Resynchronization Therapy in Patients With Overt Chronic Kidney Disease: JACC State-of-the-Art Review

Heart failure and chronic kidney disease are common and clinically important conditions that regularly coexist. Electrophysiologic changes of advanced heart failure often result in abnormal conduction, causing dyssynchronous contraction, and development of ventricular arrhythmias, which can lead to sudden cardiac arrest. In the last 2 decades, implantable cardioverter-defibrillator and cardiac resynchronization therapy devices have been developed to address these complications. However, when the coexisting chronic kidney disease is advanced, the associated pathophysiologic cardiovascular changes can alter the efficacy and safety of those interventions and complicate the management. This review explores the impact of comorbid advanced heart failure and advanced chronic kidney disease on the efficacy and safety of implantable cardioverter-defibrillator and cardiac resynchronization therapy, the currently available evidence, and potential future directions.

Exploring the effect of lifestyle behaviors and socioeconomic status on atrial fibrillation: the mediating role of 91 inflammatory cytokines

Background

Atrial fibrillation (AF) is one of the most prevalent cardiac arrhythmias and has a significant economic and social burden. Whether it is associated with lifestyle behaviors and socioeconomic status is currently poorly understood. This study aimed to explore the relationship among these factors and determine the role of inflammatory cytokines.

Method

We investigated the causal effects of lifestyle behaviors and socioeconomic status on AF using bidirectional two-sample Mendelian randomization (MR). Instrumental variables were obtained from a publicly available genome-wide association study. A two-step MR was conducted to determine the mediating role of 91 inflammatory cytokines. Inverse variance weighted was used as the main method with four supplementary MR methods. To obtain more robust results, several sensitivity analyses were conducted.

Result

The results indicated that seven of the lifestyle behaviors [smoking initiation, vegetable intake, coffee consumption (cups/day), dozing, lifetime smoking index, napping, and alcohol abuse] were potential risk factors for AF. One socioeconomic status, education attainment (years of education), was causally associated with a decreased risk of AF. Moreover, we found that thymic stromal lymphopoietin, CD40l receptor, C-X-C motif chemokine 6, and C-X-C motif chemokine 11 levels mediated the causal effect, at proportions of 13.6%, 4.1%, 4.3%, and 6.9%, respectively.

Conclusion

Our findings provide insight into the relationship between lifestyle behaviors, socioeconomic status, and AF. Inflammatory cytokines are potential mediators of this relationship.

[Arrhythmia in sleep apnea]

BACKGROUND

Sleep apnea is a widespread and yet still underdiagnosed condition. Various studies from the past have provided evidence that there is a link between sleep apnea and various cardiovascular diseases, including arrhythmias.

OBJECTIVE

The aim of this article is to provide an overview of the current study situation and to point out possible consequences relevant to everyday life.

MATERIAL AND METHODS

A systematic search was carried out in various databases using the keywords sleep apnea (OSAS/SA) and arrhythmias/dysrhythmias.

RESULTS

There are several pathophysiological links between sleep-related breathing disorders and cardiac arrhythmias, the most important of which appear to be intrathoracic pressure, increased adrenergic tone as well as recurrent hypoxia and hypercapnia. This results in an increased occurrence of clinically relevant arrhythmias, such as atrial fibrillation, symptomatic bradycardia, high-grade atrioventricular (AV) blocks as well as ventricular arrhythmias in patients with untreated sleep apnea. These pathologies also appear to be positively influenced by the treatment of sleep apnea.

CONCLUSION

A close correlation between sleep apnea and cardiac arrhythmias is undisputed. Large randomized studies in this respect are so far rare but it is undisputed that a thorough search should be carried out for sleep apnea and consistently treated in patients with a history of cardiac disease as this can have a relevant influence on the treatment and ultimately the prognosis of the patient.

Atrial cardiomyopathy revisited-evolution of a concept: a clinical consensus statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asian Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS)

AIMS

The concept of "atrial cardiomyopathy" (AtCM) had been percolating through the literature since its first mention in 1972. Since then, publications using the term were sporadic until the decision was made to convene an expert working group with representation from four multinational arrhythmia organizations to prepare a consensus document on atrial cardiomyopathy in 2016 (EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication). Subsequently, publications on AtCM have increased progressively.

METHODS AND RESULTS

The present consensus document elaborates the 2016 AtCM document further to implement a simple AtCM staging system (AtCM stages 1-3) by integrating biomarkers, atrial geometry, and electrophysiological changes. However, the proposed AtCM staging needs clinical validation. Importantly, it is clearly stated that the presence of AtCM might serve as a substrate for the development of atrial fibrillation (AF) and AF may accelerates AtCM substantially, but AtCM per se needs to be viewed as a separate entity.

CONCLUSION

Thus, the present document serves as a clinical consensus statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asian Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS) to contribute to the evolution of the AtCM concept.

Neutrophil-activating Peptide 2 as a Novel Modulator of Fibrin Clot Properties in Patients with Atrial Fibrillation

Neutrophil-activating peptide 2 (NAP-2, CXCL7), a platelet-derived neutrophil chemoattractant, is involved in inflammation. We investigated associations between NAP-2 levels, neutrophil extracellular traps (NETs) formation, and fibrin clot properties in atrial fibrillation (AF). We recruited 237 consecutive patients with AF (mean age, 68 ± 11 years; median CHA2DS2VASc score of 3 [2-4]) and 30 apparently healthy controls. Plasma NAP-2 concentrations were measured, along with plasma fibrin clot permeability (Ks) and clot lysis time (CLT), thrombin generation, citrullinated histone H3 (citH3), as a marker of NETs formation, and 3-nitrotyrosine reflecting oxidative stress. NAP-2 levels were 89% higher in AF patients than in controls (626 [448-796] vs. 331 [226-430] ng/ml; p < 0.0001). NAP-2 levels were not associated with demographics, CHA2DS2-VASc score, or the AF manifestation. Patients with NAP-2 in the top quartile (> 796 ng/ml) were characterized by higher neutrophil count (+ 31.7%), fibrinogen (+ 20.8%), citH3 (+ 86%), and 3-nitrotyrosine (+ 111%) levels, along with 20.2% reduced Ks and 8.4% prolonged CLT as compared to the remaining subjects (all p < 0.05). NAP-2 levels were positively associated with fibrinogen in AF patients (r = 0.41, p = 0.0006) and controls (r = 0.65, p < 0.01), along with citH3 (r = 0.36, p < 0.0001) and 3-nitrotyrosine (r = 0.51, p < 0.0001) in the former group. After adjustment for fibrinogen, higher citH3 (per 1 ng/ml β = -0.046, 95% CI -0.029; -0.064) and NAP-2 (per 100 ng/ml β = -0.21, 95% CI -0.14; -0.28) levels were independently associated with reduced Ks. Elevated NAP-2, associated with increased oxidative stress, has been identified as a novel modulator of prothrombotic plasma fibrin clot properties in patients with AF.

Exploring the bidirectional relationship between sleep disorders and atrial fibrillation: implications for risk stratification and management

BACKGROUND

Atrial fibrillation (AF) is characterized by the absence of p-waves on ECG and irregular rhythm. It often presents with palpitations either palpitations may occur acutely over a short period or intermittently over several years. Other cardinal symptoms of atrial fibrillation include fatigue, dyspnea, and lightheadedness; it is important however to note that most affected individuals are asymptomatic. Concurrently, sleep disorders such as obstructive sleep apnea (OSA), insomnia, narcolepsy, and circadian rhythm disorders which are a group of conditions associated with the body's internal clock that affect the timing of sleep and alertness, are raising concerns due to their potential associations to arrhythmias. This review explores the bidirectional relationship between AF and sleep disorders, highlighting their implications for risk stratification and management strategies.

MAIN BODY

The narrative approach of this review synthesizes evidence from numerous studies obtained through meticulous literature searches. Specific sleep disorders with a bidirectional relationship with AF are the focus, with scrutiny on the prevalence of this connection. The examination delves into the pathophysiology of sleep-related autonomic dysregulation and inflammation, emphasizing potential management modalities. Various meta-analysis cohorts have highlighted a strong connection between sleep disorders and atrial fibrillation (AF). Patients with sleep disorders, especially OSA, have a higher likelihood of developing AF, and conversely, those with AF are more prone to sleep disorders. This impact is not limited to development, as sleep disorders also contribute to the progression of AF, with AF, in turn, negatively impacting sleep duration and quality. Sleep disorders may play an important role in atrial remodeling as well as electrophysiological abnormalities, rendering the atrial tissue more susceptible to arrhythmogenesis. The narrative review suggests that treating sleep disorders could not only improve sleep quality but also reduce risk factors associated with atrial fibrillation. The effective management of sleep disorders emerges as a potential challenge in preventing and treating atrial fibrillation.

CONCLUSION

In conclusion, this narrative study highlights the bidirectional relationship between sleep disorders and atrial fibrillation. There is a positive correlation, affecting the development, progression, and management of atrial fibrillation. The detrimental impact of sleep disorders on atrial remodeling and electrophysiological abnormalities underscores the significance of their diagnosis and treatment. Education about the importance of sleep and the benefits of sleep disorder treatment becomes imperative for patients with AF and sleep disorders.

Longitudinal analysis of echocardiographic and cardiac biomarker variables in dogs with atrial fibrillation: The optimal rate control in dogs with atrial fibrillation II study

BACKGROUND

Rate control (RC; meanHRHolter ≤ 125 bpm) increases survival in dogs with atrial fibrillation (AF). The mechanisms remain unclear.

HYPOTHESIS/OBJECTIVES

Investigate echocardiographic and biomarker differences between RC and non-RC (NRC) dogs. Determine if changes post-anti-arrhythmic drugs (AAD) predict successful RC in subsequent Holter monitoring. Evaluate if early vs late RC affects survival.

ANIMALS

Fifty-two dogs with AF.

METHODS

Holter-derived mean heart rate, echocardiographic and biomarker variables from dogs receiving AAD were analyzed prospectively at each re-evaluation and grouped into RC or NRC. The primary endpoint was successful RC. Between group comparisons of absolute values, magnitude of change from admission to re-evaluations and end of study were performed using Mann-Whitney tests or unpaired t-tests. Logistic regression explored variables associated with inability to achieve RC at subsequent visits. Kaplan-Meier survival analysis was used to compare survival time of early vs late RC.

RESULTS

At visit 2, 11/52 dogs were RC; at visit 3, 14/52 were RC; and at visit 4, 4/52 were RC. At the end of study, 25/52 remained NRC. At visit 2, both groups had increased cardiac dimensions, but NRC dogs had larger dimensions; biomarkers did not differ. At the end of study, RC showed decreased cardiac dimensions and end-terminal pro-brain natriuretic peptide (NT-proBNP) compared with NRC. No variables were useful at predicting RC success in subsequent visits. Survival analysis found no differences between early vs late RC.

CONCLUSIONS AND CLINICAL IMPORTANCE

The RC dogs had decreased cardiac dimensions and NT-proBNP, suggesting HR-mediated reverse-remodeling might benefit survival, even with delayed RC achievement. Pursuit of RC is crucial despite initial failures.

Is there a link between atrial fibrillation and Helicobacter pylori infections?

BACKGROUND

Atrial fibrillation (AF) is the most common rhythm disturbance seen in clinical practice. Evidence emerged that suggested inflammation was associated with risk of AF. Helicobacter pylori (HP) cause gastric and esophageal inflammation, as well as systemic and vascular inflammation. These local and systemic inflammatory effects may increase the risk of AF. The pathogenesis of atrial fibrillation (AF) remains unknown. However, many recent studies point to an association between AF and inflammation because of a demonstrable significant correlation between the dysrhythmia and various biomarkers of inflammation. Given the suggested involvement of inflammation with this dysrhythmia, an initiating factor for inflammation has been sought. Chronic bacterial infection is the most likely event to initiate and maintain an inflammatory process. Recently, bacterial infections have been hypothesized to be involved in the pathogenesis of AF, and Helicobacter pylori and Chlamydia pneumoniae are two bacteria that have aroused interest. The aim of this study was to compare the prevalence of H. Pylori infection, proven by gastric biopsy, between AF patients and control group and the role of CRP, MPV, age and sex in patients with HP associated AF.

METHODS

We investigated one hundred eighty patients with HP in whom gastroscopy was done and/or urea breathe test because of dyspepsia and epigastric discomfort for eventual detecting the presence of H. pylori infection, and the prevalence of fibrillation in patients with HP, and whether age, sex, inflammatory markers are different in the two groups. The study was enrolled in the Department of Internal Medicine, Ziv Medical Center, Safed, Israel, from 2015 until 2019.

RESULTS

The prevalence is more pronounced in men with both atrial fibrillation and H. pylori, in terms of age we see that the incidence of atrial fibrillation is more relative in the older age P<0.001. There is no statistically significant difference in the inflammatory marker MPV between the two groups P<0.005. The levels of high-sensitivity C-reactive protein (hs-CRP) have been shown to be higher among patients with H. pylori with AF compared with the control group HP without AF statistically significant P<0.001.

CONCLUSIONS

There is a correlation between HP and AF, AF is more related to age and to an increased inflammation marker CRP in patients diagnosed with HP.

Impact of initial high sensitivity C-reactive protein on outcomes in nonvalvular atrial fibrillation: an observational study

Aim: The index study aimed to investigate the clinical impact of initial high-sensitivity C-reactive protein (hs-CRP) on outcomes in nonvalvular atrial fibrillation (AF). Methods: Single-center, prospective, observational study recruiting all recently diagnosed treatment-naive AF patients. Hs-CRP was measured at baseline and patients were followed for 24 months. Results: A total of 126 patients with a mean age of 66.2 (±12.0) years were enrolled. The composite outcome of major adverse cardiac or cerebrovascular events (MACCE) occurred in 19 (17.7%) at 24 months. Raised initial hs-CRP emerged as an independent predictor of MACCE on regression analysis (OR: 1.569, 95% CI: 1.289-1.912; p < 0.001). Conclusion: Raised hs-CRP was an independent predictor of MACCE at 24 months. It allows for early identification of high-risk patients.

Circulating adipose tissue proteins involved in atrial fibrillation: An explorative scoping review

Obesity increases the risk of atrial fibrillation (AF), potentially through proteins secreted by adipose tissue (AT) that affect atrial electrical and structural remodeling. We aim to give a comprehensive overview of circulating AT proteins involved in inflammation and fibrosis, that are associated with prevalent AF (paroxysmal or persistent) and the risk on developing new-onset AF. These include adipokines, defined as proteins enriched in AT as adiponectin, but also proteins less specific to AT. We systematically performed an explorative search for studies reporting associations between proteins secreted from cells residing in the AT and AF, and additionally assessed the effect of obesity on these proteins by a secondary search. The AT proteins involved in inflammation were mostly increased in patients with prevalent and new-onset AF, and with obesity, while the AT enriched adipokines were mostly not associated with AF. This review provides insight into circulating adipose tissue proteins involved in AF substrate formation.

An inflammation resolution-promoting intervention prevents atrial fibrillation caused by left ventricular dysfunction

AIMS

Recent studies suggest that bioactive mediators called resolvins promote an active resolution of inflammation. Inflammatory signalling is involved in the development of the substrate for atrial fibrillation (AF). The aim of this study is to evaluate the effects of resolvin-D1 on atrial arrhythmogenic remodelling resulting from left ventricular (LV) dysfunction induced by myocardial infarction (MI) in rats.

METHODS AND RESULTS

MI was produced by left anterior descending coronary artery ligation. Intervention groups received daily intraperitoneal resolvin-D1, beginning before MI surgery (early-RvD1) or Day 7 post-MI (late-RvD1) and continued until Day 21 post-MI. AF vulnerability was evaluated by performing an electrophysiological study. Atrial conduction was analysed by using optical mapping. Fibrosis was quantified by Masson's trichrome staining and gene expression by quantitative polymerase chain reaction and RNA sequencing. Investigators were blinded to group identity. Early-RvD1 significantly reduced MI size (17 ± 6%, vs. 39 ± 6% in vehicle-MI) and preserved LV ejection fraction; these were unaffected by late-RvD1. Transoesophageal pacing induced atrial tachyarrhythmia in 2/18 (11%) sham-operated rats, vs. 18/18 (100%) MI-only rats, in 5/18 (28%, P < 0.001 vs. MI) early-RvD1 MI rats, and in 7/12 (58%, P < 0.01) late-RvD1 MI rats. Atrial conduction velocity significantly decreased post-MI, an effect suppressed by RvD1 treatment. Both early-RvD1 and late-RvD1 limited MI-induced atrial fibrosis and prevented MI-induced increases in the atrial expression of inflammation-related and fibrosis-related biomarkers and pathways.

CONCLUSIONS

RvD1 suppressed MI-related atrial arrhythmogenic remodelling. Early-RvD1 had MI sparing and atrial remodelling suppressant effects, whereas late-RvD1 attenuated atrial remodelling and AF promotion without ventricular protection, revealing atrial-protective actions unrelated to ventricular function changes. These results point to inflammation resolution-promoting compounds as novel cardio-protective interventions with a particular interest in attenuating AF substrate development.

Impact of Comorbid Sleep-Disordered Breathing and Atrial Fibrillation on the Long-Term Outcome After Ischemic Stroke

BACKGROUND

Sleep-disordered breathing (SDB) and atrial fibrillation (AF) are highly prevalent in patients with stroke and are recognized as independent risk factors for stroke. Little is known about the impact of comorbid SDB and AF on long-term outcomes after stroke.

METHODS

In this prospective cohort study, 353 patients with acute ischemic stroke or transient ischemic attacks were analyzed. Patients were screened for SDB by respiratory polygraphy during acute hospitalization. Screening for AF was performed using a 7-day ECG up to 3× in the first 6 months. Follow-up visits were scheduled at 1, 3, 12, 24, and 36 months poststroke. Cox regression models adjusted for various factors (age, sex, body mass index, hypertension, diabetes, dyslipidemia, and heart failure) were used to assess the impact of comorbid SDB and AF on subsequent death or cerebro-cardiovascular events.

RESULTS

Among 353 patients (299 ischemic stroke and 54 transient ischemic attacks), median age, 67 (interquartile range, 57-74) years with 63% males. Moderate-to-severe SDB (apnea-hypopnea index score, ≥15/h) was present in 118 (33.4%) patients. Among the 56 (15.9%) patients with AF, 28 had comorbid moderate-to-severe SDB and AF. Over 36 months, there were 12 deaths and 67 recurrent cerebro-cardiovascular events. Patients with comorbid moderate-to-severe SDB and AF had a higher risk of subsequent death or cerebro-cardiovascular events compared with those with only moderate-to-severe SDB without AF (hazard ratio, 2.49 [95% CI, 1.18-5.24]) and to those without moderate-to-severe SDB or AF (hazard ratio, 2.25 [95% CI, 1.12-4.50]). However, no significant difference was found between the comorbid moderate-to-severe SDB and AF group and the group with only AF without moderate-to-severe SDB (hazard ratio, 1.64 [95% CI, 0.62-4.36]).

CONCLUSIONS

Comorbid moderate-to-severe SDB and AF significantly increase the risk of long-term mortality or recurrent cerebro-cardiovascular events after acute ischemic stroke. Considering both conditions as cumulative and modifiable cerebro-cardiovascular risk factors is of interest for the management of acute stroke.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02559739.

Causal associations between atrial fibrillation and breast cancer: A bidirectional Mendelian randomization analysis

BACKGROUND

Previous observational studies indicated that atrial fibrillation may increase the risk of breast cancer. Following a breast cancer diagnosis, the chance of developing atrial fibrillation may increase as well. However, it is uncertain whether the link is causal or just due to confounding factors.

OBJECTIVE

Using bidirectional Mendelian randomization (MR) analysis, we sought to assess the bidirectional causal relationship between atrial fibrillation and breast cancer from a genetic level.

METHODS

Large genome-wide association studies yielded summary-level data for atrial fibrillation and breast cancer. The preliminary estimate was inverse variance weighted (IVW) under a random model. MR-Egger, weighted median, simple mode, weighted mode, and multivariable MR (adjusting body mass index, smoking, and alcohol drinking) were performed as sensitivity analyses.

RESULTS

Genetically predicted atrial fibrillation presented no statistically significant association with overall breast cancer (odds ratio [OR] = 1.00; 95% confidence interval [CI]: 0.97-1.04; p = 0.79), estrogen receptor (ER) + (OR = 1.00; 95% CI: 0.96-1.03; p = 0.89) or ER- subtypes (OR = 1.00; 95% CI: 0.97-1.04; p = 0.89). Similarly, genetically predicted overall breast cancer (OR = 1.01; 95% CI: 0.98-1.04; p = 0.37), ER+ (OR = 1.02; 95% CI: 0.99-1.05; p = 0.16) or ER- (OR = 0.98; 95% CI: 0.93-1.02; p = 0.32) subtypes had no causal effect on atrial fibrillation. Sensitivity analyses yielded similar results. Individual single nucleotide polymorphism had little effect on the total estimate. We did not observe any evidence of horizontal pleiotropy.

CONCLUSIONS

Our bidirectional MR studies revealed that there may be no causal links between atrial fibrillation and breast cancer.

Drug-induced atrial fibrillation. A narrative review of a forgotten adverse effect

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with an increased morbidity and mortality. There is clinical evidence that an increasing number of cardiovascular and non-cardiovascular drugs, mainly anticancer drugs, can induce AF either in patients with or without pre-existing cardiac disorders, but drug-induced AF (DIAF) has not received the attention that it might deserve. In many cases DIAF is asymptomatic and paroxysmal and patients recover sinus rhythm spontaneously, but sometimes, DIAF persists, and it is necessary to perform a cardioversion. Furthermore, DIAF is not mentioned in clinical guidelines on the treatment of AF. The risk of DIAF increases in elderly and in patients treated with polypharmacy and with risk factors and comorbidities that commonly coexist with AF. This is the case of cancer patients. Under these circumstances ascribing causality of DIAF to a given drug often represents a clinical challenge. We review the incidence, the pathophysiological mechanisms, risk factors, clinical relevance, and treatment of DIAF. Because of the limited information presently available, further research is needed to obtain a deeper insight into DIAF. Meanwhile, it is important that clinicians are aware of the problem that DIAF represents, recognize which drugs may cause DIAF, and consider the possibility that a drug may be responsible for a new-onset AF episode.

Heart rate fragmentation and brain MRI markers of small vessel disease in MESA

INTRODUCTION

Heart rate (HR) fragmentation indices quantify breakdown of HR regulation and are associated with atrial fibrillation and cognitive impairment. Their association with brain magnetic resonance imaging (MRI) markers of small vessel disease is unexplored.

METHODS

In 606 stroke-free participants of the Multi-Ethnic Study of Atherosclerosis (mean age 67), HR fragmentation indices including percentage of inflection points (PIP) were derived from sleep study recordings. We examined PIP in relation to white matter hyperintensity (WMH) volume, total white matter fractional anisotropy (FA), and microbleeds from 3-Tesla brain MRI completed 7 years later.

RESULTS

In adjusted analyses, higher PIP was associated with greater WMH volume (14% per standard deviation [SD], 95% confidence interval [CI]: 2, 27%, P = 0.02) and lower WM FA (-0.09 SD per SD, 95% CI: -0.16, -0.01, P = 0.03).

DISCUSSION

HR fragmentation was associated with small vessel disease. HR fragmentation can be measured automatically from ambulatory electrocardiogram devices and may be useful as a biomarker of vascular brain injury.

Percutaneous Left Atrial Appendage Closure in Patients with Non-Valvular Atrial Fibrillation and End-Stage Renal Disease on Hemodialysis: A Case Series

Non-valvular atrial fibrillation (NVAF) is the most common cardiac arrhythmia in the general population, and its prevalence increases among patients with chronic kidney disease (CKD) undergoing hemodialysis. This population presents high risk of both hemorrhagic and thrombotic events, with little evidence regarding the use of oral anticoagulation treatment (OAT) and multiple complications arising from it; however, stroke prevention with percutaneous left atrial appendage closure (LAAC) is an alternative to be considered. We retrospectively describe the safety and efficacy of percutaneous LAAC in eight patients with NVAF and CKD on hemodialysis during a 12-month follow-up. The mean age was 78.8 years (range 64-86; SD ± 6.7), and seven patients were male. The mean CHA2DS2-VASC and HAS-BLED scores were high, 4.8 (SD ± 1.5) and 3.8 (SD ± 1.3), respectively. Seventy-five percent of the patients were referred for this intervention due to a history of major bleeding, with gastrointestinal bleeding being the most common type, while the remaining twenty-five percent of the patients were referred because of a high risk of bleeding. The percutaneous LAAC procedure was successfully completed in 100% of the patients, with complete exclusion of the appendage without complications or leaks exceeding 5 mm. There was one death not related to the procedure four days after the intervention. Among the other seven patients, no deaths, cardioembolic events or major bleeding were reported during the follow-up period. In our sample, percutaneous LAAC appears to be a safe and effective alternative to anticoagulation in patients with NVAF and CKD on hemodialysis.

Short- and Long-Term Outcomes of Patients with Postoperative Arrhythmia after Liver Surgery

BACKGROUND

New-onset postoperative arrhythmia (PA) has previously been described as a pivotal risk factor for postoperative morbidity and mortality after visceral surgery. However, there is a lack of data concerning liver surgery. The incidence and impact of new-onset postoperative arrhythmia after liver surgery was, therefore, analyzed in a monocentric study.

METHODS

In total, n = 460 patients (221 female, 239 male) who underwent liver surgery between January 2012 and April 2020 without any prior arrhythmia in their medical history were included in this retrospective analysis. Clinical monitoring started with the induction of anesthesia and was terminated with discharge from the intensive care unit (ICU) or intermediate care unit (IMC). Follow-up included documentation of complications during the hospital stay, as well as long-term survival analysis.

RESULTS

Postoperative arrhythmia after liver surgery was observed in 25 patients, corresponding to an incidence of 5.4%. The occurrence of arrhythmia was significantly associated with intraoperative complications (p < 0.05), liver fibrosis/cirrhosis (p < 0.05), bile fistula/bile leakage/bilioma (p < 0.05), and organ failure (p < 0.01). Survival analysis showed a significantly poorer overall survival of patients who developed postoperative arrhythmia after liver surgery (p < 0.001).

CONCLUSIONS

New-onset postoperative arrhythmia after liver surgery has an incidence of only 5.4% but is significantly associated with higher postoperative morbidity and poorer overall survival.

The Association Between S100A12 Protein and C-Reactive Protein with Malignant Ventricular Arrhythmias Following Acute Myocardial Infarction in the Elderly

Objective

To investigate the association of S100A12 protein and C-reactive protein (CRP) with the onset of malignant ventricular arrhythmias (MVA) after acute myocardial infarction (AMI) in the elderly.

Methods

A total of 159 elderly AMI patients admitted to Chongming Hospital affiliated to Shanghai University of Medicine & Health Sciences from January 2018 to January 2023 were enrolled in the study. CRP levels were determined using an automatic biochemical analyzer, and S100A12 levels were measured using enzyme-linked immunosorbent assay (ELISA). Patients were categorized based on the Lown classification into groups without MVA and with MVA. Univariate analysis was initially performed to identify independent variables, followed by multivariate logistic regression to determine the risk factors for malignant ventricular arrhythmias post-AMI. The predictive value of S100A12 protein and CRP for malignant ventricular arrhythmias after acute myocardial infarction in the elderly was analyzed using the receiver operating characteristic (ROC) curve.

Results

Among the 159 patients with AMI, 27 (17%) had MVA. Multivariate logistic regression analysis indicated that both S100A12 protein and CRP could be independent risk factors for malignant ventricular arrhythmias following acute myocardial infarction in the elderly (p < 0.05). The area under the ROC curve showed the area under the curve (AUC) for S100A12 protein to be 0.7147, for CRP 0.7356, and for the combined diagnosis 0.8350 (p < 0.05).

Conclusion

S100A12 protein and CRP are independent risk factors for MVA after MI in the elderly. The combined application of S100A12 protein and CRP has higher diagnostic sensitivity and specificity.

Aging and atrial fibrillation: A vicious circle

Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia observed in clinical practice. Its prevalence increases dramatically with advancing age. This review article discusses the recent advances in studies investigating the relationship between aging and AF and the possible underlying mechanisms.

The relationship of atrial fibrillation with left atrial size in patients with essential hypertension

Atrial fibrillation (AF) is the most common sustained arrhythmia and it is a major public health problem worldwide. Hypertension is one of the major risk factors for the development of AF. This study is carried out to determine the prevalence and independent risk factors for atrial fibrillation (AF) in hypertensive patients and to evaluate the relationship of AF with left atrial size. This is a retrospective observational cross - sectional study that used a retrospective electronic chart review of all admitted patients to cardiology department at King Abdullah university hospital (KAUH) in Irbid, Jordan, with a diagnosis of hypertension along with various acute cardiac admissions, including AF during 1-year period (January 1st to December 31 of 2021). Risk factors for AF (age, sex, DM, coronary artery disease, valvular heart disease, Cor-pulmonale, obstructive sleep apnea, and congestive cardiac failure) were retrieved from electronic charts of the patients. A total of 958 patients were admitted to the coronary care unit (CCU) and intermediate care unit (IMCU) during a 1-year period. Among them, 276 had 2 or 3 admissions. The main reason of admission was acute coronary syndrome (n = 491), heart failure (n = 180), and AF (n = 144), indicating AF prevalence of 15%. However, there were 40 patients with combined causes. All patients in the study (n = 958) were diagnosed with hypertension, including patients with atrial fibrillation (n = 144). The mean age of patients was 61.4 (± 11.46) years, and approximately two thirds of them were males (65.4%). The binary logistic regression model demonstrated a significant statistical relationship of age, left atrial size, coronary artery disease, left ventricular ejection fraction, left ventricular dimensions in systole and diastole, and heart failure with the occurrence of AF after controlling for gender, smoking, and diabetes. Findings indicate that left atrial size plays a significant role in the development of AF in patients with hypertension. However, the prevalence of AF significantly increased with advancing age in both sexes because of increased left ventricular hypertrophy, which leads to increased left atrial size.

Loss of Mptx2 alters bacteria composition and intestinal homeostasis potentially by impairing autophagy

A recent single-cell survey of the small-intestinal epithelium suggests that mucosal pentraxin 2 (Mptx2) is a new Paneth cell marker, but its function and involved mechanism in the Paneth cell are still unknown. Therefore, we create Mptx2 knockout (Mptx2-/-) mice to investigate its precise effects on intestinal homeostasis using models of lipopolysaccharide (LPS), methicillin-resistant Staphylococcus aureus (MRSA) peritoneal infection, and dextran sulfate sodium (DSS)-induced intestinal injury and inflammation. We here find that Mptx2 is selectively expressed in Paneth cells in the small intestines of mice. Mptx2-/- mice have increased susceptibility to intestinal inflammation and injured. Mptx2 deficiency reduces Paneth cell count and expression of antimicrobial factors, leading to altered intestinal bacteria composition. Loss of Mptx2 aggravates MRSA infection-induced damage in the intestine while decreasing autophagy in Paneth cells. Mptx2-/- mice are more vulnerable to LPS-induced intestinal possibly due to inhibition of the autophagy/endoplasmic reticulum (ER) stress pathway. Mptx2-/- mice are susceptible to DSS-induced colitis that could be ameliorated by treatment with gentamicin or vancomycin antibiotics. In conclusion, Mptx2 is essential to maintain intestinal homeostasis potentially via regulation of autophagy in Paneth cells.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Detection and modification of biomarkers of inflammation determining successful rhythm control in patients with atrial fibrillation

INTRODUCTION

Multiple pathophysiological mechanisms are involved in the pathogenesis of atrial fibrillation (AF). Growing evidence suggests that both local and systemic inflammation plays a key role even in early stages and its progression towards persisting and permanent AF. Rhythm control therapy via pulmonary vein isolation or cardioversion is the cornerstone of AF therapy for most symptomatic patients, yet arrhythmia recurrence after treatment is still common, especially in patients with persistent AF.

MATERIAL AND METHODS

In this review, we summarize the current state of knowledge of biomarkers of inflammation with prognostic value in patients with atrial fibrillation as well as anti-inflammatory medication with potential benefits after rhythm control therapy.

RESULTS AND DISCUSSION

Both onset of AF, progression and arrhythmia recurrence after rhythm control therapy can be caused by local and systemic inflammation. Various inflammatory biomarkers have been established to predict treatment success. Furthermore, additional anti-inflammatory therapy may significantly improve success rates.

Right atrial wall inflammation detected by 18F-FDG PET/CT may be significantly associated with persistent atrial fibrillation: a prospective case-control study

AIM

Atrial fibrillation (AF) is a progressive disease from paroxysmal to persistent, and persistent AF (PerAF) had worse prognosis. AF has potential link with inflammation, but it is not clear whether PerAF or paroxysmal AF (ParAF) is more closely related to inflammation. On the basis of inhibiting myocardial physiological uptake, 18F-fluorodeoxyglucosepositron emission tomography/computed tomography (18F-FDG PET/CT) is an established imaging modality to detect cardiac inflammation. We aimed to decipher the association between AF and atrial inflammatory activity by 18F-FDG PET/CT.

METHODS

Thirty-five PerAF patients were compared to age and sex matched ParAF group with baseline 18F-FDG PET/CT scans prior to radiofrequency catheter ablation (RFCA) in the prospective case-control study. High-fat and low-carbohydrate diet and prolonged fast (HFLC+Fast) was applied to all AF patients before PET/CT. Then 22 AF patients with positive right atrial (RA) wall FDG uptake (HFLC+Fast) were randomly selected and underwent HFLC+Fast+heparin the next day. The CHA2DS2-VASc score was calculated to evaluate the risk of stroke. Clinical data, ECG, echocardiography, and atrial 18F-FDG uptake were compared.

RESULTS

PerAF patients had significantly higher probability of RA wall positive FDG uptake and higher SUVmax than ParAF group [91.4% VS. 28.6%, P < 0.001; SUVmax: 4.10(3.20-4.90) VS. 2.60(2.40-3.10), P < 0.001]. Multivariate logistic regression analyses demonstrated that RA wall SUVmax was the independent influencing factor of PerAF (OR = 1.80, 95%CI 1.02-3.18, P = 0.04). In 22 AF patients with RA wall positive FDG uptake (HFLC+Fast), the "HFLC+Fast+Heparin" method did not significantly change RA wall FDG uptake evaluated by either quantitative analysis or visual analysis. High CHA2DS2-VASc score group had higher RA wall 18F-FDG uptake [3.35 (2.70, 4.50) vs, 2.8 (2.4, 3.1) P = 0.01].

CONCLUSIONS

RA wall FDG positive uptake was present mainly in PerAF. A higher RA wall 18F-FDG uptake was an independent influencing factor of PerAF. RA wall FDG uptake based on 18F-FDG PET/CT may indicate pathological inflammation.

TRIAL REGISTRATION

http://www.chictr.org.cn , ChiCTR2000038288.

A proteomic analysis of atrial fibrillation in a prospective longitudinal cohort (AGES-Reykjavik study)

AIMS

Atrial fibrillation (AF) is associated with high risk of comorbidities and mortality. Our aim was to examine causal and predictive relationships between 4137 serum proteins and incident AF in the prospective population-based Age, Gene/Environment Susceptibility-Reykjavik (AGES-Reykjavik) study.

METHODS AND RESULTS

The study included 4765 participants, of whom 1172 developed AF. Cox proportional hazards regression models were fitted for 4137 baseline protein measurements adjusting for known risk factors. Protein associations were tested for replication in the Cardiovascular Health Study (CHS). Causal relationships were examined in a bidirectional, two-sample Mendelian randomization analysis. The time-dependent area under the receiver operating characteristic curve (AUC)-statistic was examined as protein levels and an AF-polygenic risk score (PRS) were added to clinical risk models. The proteomic signature of incident AF consisted of 76 proteins, of which 63 (83%) were novel and 29 (38%) were replicated in CHS. The signature included both N-terminal prohormone of brain natriuretic peptide (NT-proBNP)-dependent (e.g. CHST15, ATP1B1, and SVEP1) and independent components (e.g. ASPN, AKR1B, and LAMA1/LAMB1/LAMC1). Nine causal candidates were identified (TAGLN, WARS, CHST15, CHMP3, COL15A1, DUSP13, MANBA, QSOX2, and SRL). The reverse causal analysis suggested that most AF-associated proteins were affected by the genetic liability to AF. N-terminal prohormone of brain natriuretic peptide improved the prediction of incident AF events close to baseline with further improvements gained by the AF-PRS at all time points.

CONCLUSION

The AF proteomic signature includes biologically relevant proteins, some of which may be causal. It mainly reflects an NT-proBNP-dependent consequence of the genetic liability to AF. N-terminal prohormone of brain natriuretic peptide is a promising marker for incident AF in the short term, but risk assessment incorporating a PRS may improve long-term risk assessment.

Inflammation, mitochondrial dysfunction and physical performance: a possible association in older patients with persistent atrial fibrillation-the results of a preliminary study

BACKGROUND

Atrial fibrillation (AF) is associated with chronic inflammation, a hallmark of ageing process. The aim of this study was to determine interleukin-6 (IL-6)-associated variables, also exploring acylcarnitines, expression of mitochondrial abnormalities.

METHODS

We evaluated 22 controls and 50 patients with persistent AF. IL-6 and acylcarnitines were measured with ELISA kits and mass spectrometry techniques.

RESULTS

IL-6 concentration (mean: 3.9 ± 3.1 pg/mL) was lower in controls and increased in AF patients, especially with heart failure. The CHA2DS2-VASc, the MMSE and the SPPB scores were 3.8 ± 1.6, 28 ± 2 and 9.4 ± 2.1. Thirteen acylcanitines correlated with IL-6. At multivariable analysis, IL-6 was directly associated with C4-OH-a short-chain acylcarnitine, fibrinogen and alanine aminotransferase values, and with hyperuricemia. An inverse association existed with calcium concentration and SPPB score.

CONCLUSIONS

In older AF patients, IL-6 correlated with acylcarnitines and lower physical performance. Alterations in energy production, reduced physical function and inflammation could contribute to frailty development.

Depression and atrial fibrillation in a reciprocal liaison: a neuro-cardiac link

OBJECTIVE

To explore the reciprocal relationship of depression and atrial fibrillation (AF).

METHODS

A literature search was conducted in Pub Med, Scopus, and Google Scholar using relevant terms for depression and AF and respective therapies.

RESULTS

There is evidence that depression is involved in the aetiology and prognosis of AF. AF, independently of its type, incurs a risk of depression in 20-40% of patients. Also, depression significantly increases cumulative incidence of AF (from 1.92% to 4.44% at 10 years); 25% increased risk of new-onset AF is reported in patients with depression, reaching 32% in recurrent depression. Hence, emphasis is put on the importance of assessing depression in the evaluation of AF and vice versa. Persistent vs paroxysmal AF patients may suffer from more severe depression. Furthermore, depression can impact the effectiveness of AF treatments, including pharmacotherapy, anticoagulation, cardioversion and catheter ablation.

CONCLUSIONS

A reciprocal association of depression and AF, a neurocardiac link, has been suggested. Thus, strategies which can reduce depression may improve AF patients' course and treatment outcomes. Also, AF has a significant impact on risk of depression and quality of life. Hence, effective antiarrhythmic therapies may alleviate patients' depressive symptoms. KEY POINTSAF, independently of its type of paroxysmal, permanent or chronic, appears to have mental besides physical consequences, including depression and anxietyA reciprocal influence or bidirectional association of depression and AF, a neurocardiac link, has been suggestedAF has considerable impact on the risk of depression occurrence with 20-40% of patients with AF found to have high levels of depressionAlso, depression significantly increases 10-year cumulative incidence and risk of AF from 1.92% to 4.44% in people without depression, and the risk of new-onset AF by 25-32%Emphasis should be placed on the importance of assessing depression in the evaluation of AF and vice versaPersistent/chronic AF patients may suffer from more severe depressed mood than paroxysmal AF patients with similar symptom burdenDepression and anxiety can impact the effectiveness of certain AF treatments, including pharmacotherapy, anticoagulation treatment, cardioversion and catheter ablationThus, strategies which can reduce anxiety and depression may improve AF patients' course and treatment outcomesAlso, effective antiarrhythmic therapies to control AF may alleviate patients' depressive mood.

Arrhythmias in Critically Ill Surgical and Non-surgical Patients: A National Propensity-Matched Study

BACKGROUND

Arrhythmias are common in critically ill patients, though the impact of arrhythmias on surgical patients is not well delineated. We aimed to characterize mortality following arrhythmias in critically ill patients.

METHODS

We performed a propensity-matched retrospective analysis of intensive care unit (ICU) patients from 2007 to 2017 in the Cerner Acute Physiology and Chronic Health Evaluation database. We compared outcomes between patients with and without arrhythmias and those with and without surgical indications for ICU admission. We also modeled predictors of arrhythmias in surgical patients.

RESULTS

467,951 patients were included; 97,958 (20.9%) were surgical patients. Arrhythmias occurred in 1.4% of the study cohorts. Predictors of arrhythmias in surgical patients included a history of cardiovascular disease (odds ratio [OR] 1.35, 95% confidence interval [CI95] 1.11-1.63), respiratory failure (OR 1.48, CI95 1.12-1.96), pneumonia (OR 3.17, CI95 1.98-5.10), higher bicarbonate level (OR 1.03, CI95 1.01-1.05), lower albumin level (OR 0.79, CI95 0.68-0.91), and vasopressor requirement (OR 27.2, CI95 22.0-33.7). After propensity matching, surgical patients with arrhythmias had a 42% mortality risk reduction compared to non-surgical patients (risk ratio [RR] 0.58, CI 95 0.43-0.79). Predicted probabilities of mortality for surgical patients were lower at all ages.

CONCLUSIONS

Surgical patients with arrhythmias are at lower risk of mortality than non-surgical patients. In this propensity-matched analysis, predictors of arrhythmias in critically ill surgical patients included a history of cardiovascular disease, respiratory complications, increased bicarbonate levels, decreased albumin levels, and vasopressor requirement. These findings highlight the differential effect of arrhythmias on different cohorts of critically ill populations.

Mechanisms and Prediction of Ischemic Stroke in Atrial Fibrillation Patients

Atrial fibrillation (AF) is the most common arrhythmia in adults worldwide and represents an important burden for patients, physicians, and healthcare systems. AF is associated with substantial mortality and morbidity, due to the disease itself and its specific complications, such as the increased risk of stroke and thromboembolic events associated with AF. The temporal relation between AF episodes and stroke is nonetheless incompletely understood. The factors associated with an increased thromboembolic risk remain unclear, as well as the stroke risk stratification. Therefore, in this review, we intend to expose the mechanisms and physiopathology leading to intracardiac thrombus formation and stroke in AF patients, together with the evidence supporting the causal hypothesis. We also expose the risk factors associated with increased risk of stroke, the current different risk stratification tools as well as future prospects for improving this risk stratification.

The Role of Biochemical Cardiac Markers in Atrial Fibrillation

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia. Proteins are a component of cardiac biomarkers containing cell structures that are released into the circulation when a myocardial injury occurs. They are essential in the diagnosis, risk assessment, and treatment of patients who have chest pain, are thought to have acute coronary syndrome, or are experiencing acute heart failure exacerbations. There are numerous biochemical cardiac markers, but this article summarizes the basic role of major biochemical cardiac markers, including cardiac natriuretic peptides, cardiac troponins, C-reactive protein (CRP), creatine kinase-MB, heart-type fatty acid-binding protein, ischemia-modified albumin, lipoprotein (a), osteopontin (OPN), and soluble suppression of tumorigenicity 2 (sST2), in AF. Atrial natriuretic peptide may serve as an indicator of atrial integrity, which may help to select appropriate treatment approaches for AF. Higher levels of N-terminal pro-B-type natriuretic peptide and brain natriuretic peptide are predictive of incidental AF. Increased troponin T release may indicate better clinical results following AF ablation. Similarly, CRP increases the risk of the AF-increasing calcium (Ca) influx in atrial myocytes, but not because of atrial fibrosis. Patients with postoperative AF have lower FABP3 gene expression in the atrium. Lipoprotein (a) (Lp[a]) may play a causative role in the onset of AF and impact various cardiac tissues. Clinical trials for Lp(a)-lowering drugs should assess their impact on preventing AF. Also, OPN was highly expressed in the circulation of AF patients and further increased with the progression of AF. sST2 was a reliable predictor of new-onset AF and can improve the accuracy of the AF risk model. There is a greater chance that these cardiac biomarkers might be employed to enhance clinical risk stratification in AF.

Atrial Fibrillation Ablation in Patients With Chronic Kidney Disease: A Review of Literature

Atrial fibrillation (AF) is a common arrhythmia among patients with chronic kidney disease (CKD), which leads to increased cardiovascular complications. Catheter ablation (CA) has emerged as an effective and safe treatment for AF in CKD patients. CA offers tailored treatment strategies and presents a safer alternative with fewer adverse outcomes than anti-arrhythmic agents. Although CKD patients undergoing ablation have similar complication rates to non-CKD patients, they face a higher risk of hospitalization due to heart failure. Furthermore, CA shows promise in improving kidney function, particularly in individuals who maintain sinus rhythm. Future research should address limitations by including advanced CKD patients, conducting longer-term follow-ups, and developing individualized treatment approaches.

Inflammatory Markers as Predictors of Atrial Fibrillation Recurrence: Exploring the C-Reactive Protein to Albumin Ratio in Cryoablation Patients

BACKGROUND

Atrial fibrillation (AF) is a common cardiac rhythm disorder associated with hemodynamic disruptions and thromboembolic events. While antiarrhythmic drugs are often recommended as the initial treatment, catheter ablation has emerged as a viable alternative. However, the recurrence of AF following ablation remains a challenge, and there is growing interest in exploring inflammatory markers as predictors of recurrence.

METHODS

This retrospective, cross-sectional analysis included 249 patients who underwent cryoablation for paroxysmal AF. The relationship between the 'C-reactive protein (CRP) to albumin ratio (CAR)' and AF recurrence was examined.

RESULTS

Two hundred and forty-nine patients with paroxysmal non-valvular atrial fibrillation were included. They were divided into two groups: those without recurrence (Group 1) and those with recurrence (Group 2). Significant differences were observed in age (57.2 ± 9.9 vs. 62.5 ± 8.4, p = 0.001) and left atrial size (4.0 ± 0.5 vs. 4.2 ± 0.7, p = 0.001) between the two groups. In blood parameters, significant differences were found in CRP (5.2 ± 1.3 vs. 9.4 ± 2.8, p < 0.001) and neutrophil counts (5.1 ± 2.2 vs. 6.7 ± 3.6, p = 0.001). In univariate regression analysis, age (OR: 1.058, CI: 1.024-1.093, p = 0.001), WBC count (OR: 1.201, CI: 1.092-1.322, p < 0.001), neutrophil count (OR: 1.239, CI: 1.114-1.378, p = 0.001), CAR (OR: 1.409, CI: 1.183-1.678, p < 0.001), and left atrial diameter (OR: 0.968, CI: 0.948-0.989, p = 0.002) showed significant associations with AF recurrence.

CONCLUSIONS

Inflammation plays a crucial role in the initiation and progression of AF. This study demonstrated that along with age, the CAR can serve as an independent predictor of AF recurrence following cryoablation.

New drug discovery of cardiac anti-arrhythmic drugs: insights in animal models

Cardiac rhythm regulated by micro-macroscopic structures of heart. Pacemaker abnormalities or disruptions in electrical conduction, lead to arrhythmic disorders may be benign, typical, threatening, ultimately fatal, occurs in clinical practice, patients on digitalis, anaesthesia or acute myocardial infarction. Both traditional and genetic animal models are: In-vitro: Isolated ventricular Myocytes, Guinea pig papillary muscles, Patch-Clamp Experiments, Porcine Atrial Myocytes, Guinea pig ventricular myocytes, Guinea pig papillary muscle: action potential and refractory period, Langendorff technique, Arrhythmia by acetylcholine or potassium. Acquired arrhythmia disorders: Transverse Aortic Constriction, Myocardial Ischemia, Complete Heart Block and AV Node Ablation, Chronic Tachypacing, Inflammation, Metabolic and Drug-Induced Arrhythmia. In-Vivo: Chemically induced arrhythmia: Aconitine antagonism, Digoxin-induced arrhythmia, Strophanthin/ouabain-induced arrhythmia, Adrenaline-induced arrhythmia, and Calcium-induced arrhythmia. Electrically induced arrhythmia: Ventricular fibrillation electrical threshold, Arrhythmia through programmed electrical stimulation, sudden coronary death in dogs, Exercise ventricular fibrillation. Genetic Arrhythmia: Channelopathies, Calcium Release Deficiency Syndrome, Long QT Syndrome, Short QT Syndrome, Brugada Syndrome. Genetic with Structural Heart Disease: Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia, Dilated Cardiomyopathy, Hypertrophic Cardiomyopathy, Atrial Fibrillation, Sick Sinus Syndrome, Atrioventricular Block, Preexcitation Syndrome. Arrhythmia in Pluripotent Stem Cell Cardiomyocytes. Conclusion: Both traditional and genetic, experimental models of cardiac arrhythmias' characteristics and significance help in development of new antiarrhythmic drugs.

Association of soluble suppression of tumorigenicity 2 protein with new-onset atrial fibrillation in patients with acute ST-segment elevation myocardial infarction undergoing primary PCI

Background

Previous studies have indicated that the soluble suppression of tumorigenicity 2 protein (sST2) is associated with new-onset atrial fibrillation (NOAF) in patients diagnosed with coronary artery disease (CAD). However, the predictive value of sST2 in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) has not been well studied.

Methods

A total of 580 patients with STEMI undergoing primary PCI were consecutively recruited between January 2021 and January 2023. These patients were then categorized into two groups: the NOAF group and the no NOAF groups based on the presence of NOAF during admission. The concentration of sST2 in blood samples was measured in all patients. The clinical data from the two groups were prospectively analyzed to investigate the predictive factors of NOAF in patients with STEMI undergoing primary PCI.

Results

A total of 41 (7.1%) patients developed NOAF. The presence of NOAF has been found to be associated with various factors, including age, diabetes mellitus, hypertension, the left atrial (LA) diameter, N-terminal pro-brain natriuretic peptide, C-reactive protein (CRP), sST2, a Killip class of ≥2, and a final TIMI flow grade of <3. After including multiple factors, it was observed that LA diameter, CRP, sST2, a Killip class of ≥2, and a final TIMI flow grade of <3 remained significant risk factors for developing NOAF. The receiver operating characteristic (ROC) curve showed the following findings: (1) when the LA diameter exceeded 38.5 mm, the sensitivity and specificity values were observed to be 67.2% and 68.2%, respectively, and the area under the ROC curve (AUC) was 0.683 [95% confidence interval (CI): 0.545-0.732; p = 0.003]; (2) when the CRP level exceeded 8.59, the sensitivity and specificity values were observed to be 68.6% and 69.2%, respectively, and the AUC was 0.713 (95% CI: 0.621-0.778; p < 0.001); and (3) when the sST2 value exceeded 53.3, the sensitivity and specificity values were 79.2% and 68.7%, respectively, and the AUC was 0.799 (95% CI: 0.675-0.865; p < 0.001).

Conclusion

sST2 has been identified as an independent predictor of NOAF in patients with STEMI undergoing PCI.

Factors associated with complications in ST-elevation myocardial infarction: a single-center experience

BACKGROUND

ST-elevation myocardial infarction (STEMI) is a major public health problem. This study aimed to determine the prevalence and identify the determinants of STEMI-related complications in the Cardiology Intensive Care Unit of the Sud Francilien Hospital Center (SFHC).

METHODS

We retrospectively analyzed the data of 315 patients with STEMI aged ≥ 18 years. Logistic regression was used to identify factors independently associated with the occurrence of complications.

RESULTS

Overall, 315 patients aged 61.7 ± 13.4 years, of whom 261 were men, had STEMI during the study period. The hospital frequency of STEMI was 12.7%. Arrhythmias and acute heart failure were the main complications. Age ≥ 75 years (adjusted odds ratio [aOR], 5.18; 95% confidence interval [CI], 3.92-8.75), hypertension (aOR, 3.38; 95% CI, 1.68-5.82), and cigarette smoking (aOR, 3.52; 95% CI, 1.69-7.33) were independent determinants of acute heart failure. Meanwhile, diabetes mellitus (aOR, 1.74; 95% CI, 1.09-3.37), history of atrial fibrillation (aOR, 2.79; 95% CI, 1.66-4.76), history of stroke or transient ischemic attack (aOR, 1.99; 95% CI, 1.31-2.89), and low high-density lipoprotein-cholesterol (HDL-C) levels (aOR, 3.70; 95% CI, 1.08-6.64) were independent determinants of arrhythmias.

CONCLUSION

STEMI is a frequent condition at SFHC and is often complicated by acute heart failure and arrhythmias. Patients aged ≥ 75 years, those with hypertension or diabetes mellitus, smokers, those with a history of atrial fibrillation or stroke, and those with low HDL-C levels require careful monitoring for the early diagnosis and management of these complications.

Pericardial Inflammatory Mediators That Can Drive Postoperative Atrial Fibrillation in Cardiac Surgery Patients

Postoperative atrial fibrillation (POAF) is a common dysrhythmia that affects a significant number of patients undergoing cardiac surgery. Many studies aim to better understand this complex postsurgical complication by analysing circulating biomarkers in patients who develop POAF. More recently, the pericardial space was shown to contain inflammatory mediators that could trigger POAF. In this review we summarise recent studies that examine the immune mediators present in the pericardial space and their potential implications for the pathophysiology of POAF in cardiac surgery patients. Ongoing research in this area should better delineate the multifactorial etiology of POAF, where specific markers may be targeted to reduce the incidence of POAF and improve outcomes for this patient population.

ORal anticoaGulants in diAbetic and Nondiabetic patients with nOn-valvular atrial fibrillatioN (ORGANON)

BACKGROUND

Diabetes represents a pro-thrombotic condition.

OBJECTIVES

The primary objective was to evaluate the effects of Vitamin K Antagonist (VKA) compared to direct oral anticoagulants (DOACs) in diabetic and nondiabetic patients with non-valvular atrial fibrillation, newly diagnosed. The secondary objective was to evaluate the effects on the risk of bleeding.

METHODS

We enrolled 300 patients with newly diagnosed atrial fibrillation. One hundred and sixteen patients were taking warfarin, 31 acenocumarol, 22 dabigatran, 80 rivaroxaban, 34 apixaban, and 17 edoxaban. We evaluated: anthropometric parameters, glycated hemoglobin (HbA1c), fasting and post-prandial glucose (FPG, and PPG), lipid profile, Lp(a), small and dense low-density lipoprotein (SD-LDL), oxidized LDL (Ox-LDL), I-troponin (I-Tn), creatinine, transaminases, iron, red blood cells (RBC); hemoglobin (Hb), platelets (PLT), fibrinogen, D-dimer, anti-thrombin III, C-reactive protein (Hs-CRP), Metalloproteinases-2 (MMP-2), Metalloproteinases-9 (MMP-9), and incidence of bleeding.

RESULTS

We did not record any differences among nondiabetic patients between VKA and DOACs. However, when we considered diabetic patients, we found a slight, but significant improvement of triglycerides and SD-LDL. As regards incidence of bleeding, minor bleeding was more frequent in VKA diabetic group compared to DOACs diabetic group; furthermore, the incidence of major bleeding was higher with VKA in nondiabetic and diabetic group, compared to patients with DOACs. Among DOACs, we recorded a higher incidence of bleeding (minor and major) with dabigatran compared to rivaroxaban, apixaban and edoxaban in nondiabetic and diabetic patients.

CONCLUSION

DOACs seem to be metabolically favourable in diabetic patients. Regarding incidence of bleeding, DOACs with the exception of dabigatran, seem better than VKA in diabetic patients.

Screening of atrial fibrillation in dental practices: a qualitative feasibility study

OBJECTIVES

To increase the detection of unknown atrial fibrillation (AF), general practitioners have started screening their patients using small hand-held devices. It is thought that dental settings could be utilized for screening as they have regular access to patients. The aim of this study was to explore the perceptions of dental staff of screening for AF using a hand-held electronic device in primary dental care.

METHODS

The research took place in one large mixed NHS and private general dental practice. Views from staff including dentists, dental therapists, dental nurses, and managers were elicited via semi-structured interviews conducted face-to-face, audio recorded, and transcribed verbatim. Interviews continued until there were no new themes or patterns emerging from the data, and thematic saturation had been achieved.

RESULTS

Eleven participants were interviewed. The main themes generated were methodology for screening, acceptability for screening within the practice, attitudes to screening, and implementation of screening. Overall, participants were positive about implementing AF screening in a dental practice but expressed concerns about time and remuneration. Staff also gave encouraging feedback regarding the simplicity of the portable screening device.

CONCLUSIONS

Participants felt that AF screening in primary care dental practices was a good concept but may be challenging to implement in NHS Dentistry, especially due to the pandemic.

Statin versus ezetimibe-statin for incident atrial fibrillation among patients with type 2 diabetes mellitus with acute coronary syndrome and acute ischemic stroke

The objective was to assess the role of the combination approach with ezetimibe 10 mg/simvastatin 20 mg versus atorvastatin 40 mg in predicting atrial fibrillation (AF) in type 2 diabetes mellitus patients with acute coronary syndrome and acute ischemic stroke. The authors formed a cohort of diabetic patients with extensive vascular diseases between 2000 and 2018 using data from the National Health Insurance Research Database in Taiwan. AF was the outcome of interest in this study. Cox proportional hazards regression analysis was performed to estimate the hazard ratios and 95% confidence intervals in the analysis. After controlling for sex, age, comorbidities and medications, the patients coexisting with type 2 diabetes mellitus, acute coronary syndrome and acute ischemic stroke with ezetimibe 10 mg/simvastatin 20 mg treatment were not significantly at risk of AF, compared to the patients with atorvastatin 40 mg treatment (adjusted hazard ratio, 0.85; 95% confidence interval, 0.52-1.38). A similar effect for AF risk between ezetimibe 10 mg/simvastatin 20 mg and atorvastatin 40 mg users was observed in the current investigation.

Overview of Cardiac Arrhythmias and Treatment Strategies

Maintenance of normal cardiac rhythm requires coordinated activity of ion channels and transporters that allow well-ordered propagation of electrical impulses across the myocardium. Disruptions in this orderly process provoke cardiac arrhythmias that may be lethal in some patients. Risk of common acquired arrhythmias is increased markedly when structural heart disease caused by myocardial infarction (due to fibrotic scar formation) or left ventricular dysfunction is present. Genetic polymorphisms influence structure or excitability of the myocardial substrate, which increases vulnerability or risk of arrhythmias in patients. Similarly, genetic polymorphisms of drug-metabolizing enzymes give rise to distinct subgroups within the population that affect specific drug biotransformation reactions. Nonetheless, identification of triggers involved in initiation or maintenance of cardiac arrhythmias remains a major challenge. Herein, we provide an overview of knowledge regarding physiopathology of inherited and acquired cardiac arrhythmias along with a summary of treatments (pharmacologic or non-pharmacologic) used to limit their effect on morbidity and potential mortality. Improved understanding of molecular and cellular aspects of arrhythmogenesis and more epidemiologic studies (for a more accurate portrait of incidence and prevalence) are crucial for development of novel treatments and for management of cardiac arrhythmias and their consequences in patients, as their incidence is increasing worldwide.

Resolution of Roemheld Syndrome After Hiatal Hernia Repair and LINX Placement: Case Review

Roemheld syndrome, also known as gastrocardiac syndrome, was first studied as a relationship between gastrointestinal and cardiovascular symptoms through the vagus nerve. Several hypotheses have attempted to explain the pathophysiology of Roemheld syndrome, but the underlying process remains unclear. We present a clinically diagnosed case of Roemheld syndrome in a patient with a hiatal hernia whose gastrointestinal and cardiac symptoms were successfully treated with robotic assisted hernia repair, esophagogastroduodenoscopy (EGD), and LINX magnetic sphincter augmentation. Our case is a 60-year-old male with a history of esophageal stricture and hiatal hernia who presented with complaints of gastroesophageal reflux disease (GERD) and related arrhythmias for five years. The patient did not have a history of cardiovascular disease other than hypertension. The cause of the hypertension was assumed to be primary, as workup for possible pheochromocytoma was negative. Cardiac work-up revealed arrhythmias that were characterized as supraventricular tachycardia with intermittent pre-ventricular contractions (PVC); however, testing was unable to determine a cause for the arrhythmias. High-resolution manometry showed low pressure in the lower esophageal sphincter with normal esophageal motility. Further evaluation included a 96-hour Bravo test and DeMeester score of 31 was recorded, confirming mild GERD; however, EGD was unremarkable. Surgeons elected to perform a robotic assisted hiatal hernia repair, EGD, and magnetic sphincter augmentation. Four months following surgery, the patient denied symptoms of GERD or episodes of palpitation and subsequently weaned off proton pump inhibitors with continual lack of symptoms. GERD is a common complaint among the primary care setting; however, ventricular dysrhythmias among this population and a clinical diagnosis of Roemheld syndrome is unique. One hypothesis may be that protrusion of the stomach into the chest cavity may exacerbate current reflux, and the anatomical relationship between a herniated fundus and anterior vagal nerve may cause direct physical stimulation that is a more potent risk factor for the development of arrythmias. However, Roemheld Syndrome is a unique diagnosis, and the pathophysiology is still yet to be understood.

The association between C-peptide and atrial cardiomyopathy in nondiabetic adults: results from NHANES III

Serum C-peptide exhibits various biological activities. The relationship between C-peptide and atrial cardiomyopathy remains unknown. We aimed to investigate the association between C-peptide level and atrial cardiomyopathy in nondiabetic adults. Our study enrolled 4578 participants without diagnosed diabetes from the Third National Health and Nutrition Examination Survey (NHANES III). Atrial cardiomyopathy was defined as a deep terminal negative P wave in V1 below - 100 µV (more negative), according to the electrocardiogram. The participants were categorized into low C-peptide (≤ 1.46 nmol/L) and high C-peptide (> 1.46 nmol/L) groups, according to the receiver operating characteristic analysis. Odds ratio (OR) and 95% confidence interval (CI) for the association between C-peptide level and atrial cardiomyopathy were generated using multivariate logistic regression analysis. The prevalence of atrial cardiomyopathy was higher in the high C-peptide group than in the low C-peptide group (5.62% vs. 2.31%, P < 0.001, respectively). Multivariate logistic regression analysis showed that participants in the high C-peptide group had a 3.60-fold (95% CI 1.81-6.99) higher risk of atrial cardiomyopathy than those in the low C-peptide group. Per standard deviation increase in C-peptide was linked to a 1.20-fold (95% CI 1.00-1.41) higher risk in atrial cardiomyopathy. High C-peptide level might be an independent risk factor for atrial cardiomyopathy in nondiabetic adults.

Characterization of baseline clinical factors associated with incident worsening kidney function in patients with non-valvular atrial fibrillation: the Hokuriku-Plus AF Registry

Evidence suggests that atrial fibrillation (AF) could increase the risk of worsening kidney function (WKF) which is linked to an increased risk of stroke, bleeding, and death in AF patients. However, limited data exist regarding the factors that could lead to WKF in these patients. Therefore, we sought to identify the potential factors associated with the development of WKF in patients with non-valvular AF (NVAF). We analyzed prospectively recruited 1122 NVAF patients [men 71.9%, median age 73.0 years (interquartile range: 66.0-79.0)] with a baseline estimated glomerular filtration rate (eGFR) ≥ 15 mL/min/1.73 m² from the Hokuriku-Plus AF Registry. The primary outcome was incident WKF, defined as the %eGFR change from the baseline ≥ 30% during the follow-up period. We evaluated the association between baseline variables and incident WKF using univariate and multivariate Cox proportional hazard models. We also evaluated the non-linear association between the identified factors and incident WKF. During a median follow-up period of 3.0 years (interquartile range: 2.7-3.3), incident WKF was observed in 108 patients (32.6 per 1000 person-years). Compared to the patients without incident WKF, the patients with incident WKF were older and had a higher prevalence of heart failure (HF), diabetes mellitus (DM), and vascular disease at baseline. Those who experienced incident WKF also had higher diastolic blood pressure, lower hemoglobin, lower eGFR, higher B-type natriuretic peptide (BNP) and used warfarin more frequently. Upon multivariate analysis, age ≥ 75 years, HF, DM, and anemia were independently associated with incident WKF. Additionally, age and hemoglobin were linearly associated with the risk of incident WKF, whereas a J- or U-shaped association was observed for HbA1c and BNP. Age ≥ 75 years, HF, DM, and anemia were associated with the development of WKF in Japanese patients with NVAF. In patients with these risk factors, a careful monitoring of the kidney function and appropriate interventions may be important when possible.

Inflammatory signalling in atrial cardiomyocytes: a novel unifying principle in atrial fibrillation pathophysiology

Inflammation has been implicated in atrial fibrillation (AF), a very common and clinically significant cardiac rhythm disturbance, but its precise role remains poorly understood. Work performed over the past 5 years suggests that atrial cardiomyocytes have inflammatory signalling machinery - in particular, components of the NLRP3 (NACHT-, LRR- and pyrin domain-containing 3) inflammasome - that is activated in animal models and patients with AF. Furthermore, work in animal models suggests that NLRP3 inflammasome activation in atrial cardiomyocytes might be a sufficient and necessary condition for AF occurrence. In this Review, we evaluate the evidence for the role and pathophysiological significance of cardiomyocyte NLRP3 signalling in AF. We first summarize the evidence for a role of inflammation in AF and review the biochemical properties of the NLRP3 inflammasome, as defined primarily in studies of classic inflammation. We then briefly consider the broader evidence for a role of inflammatory signalling in heart disease, particularly conditions that predispose individuals to develop AF. We provide a detailed discussion of the available information about atrial cardiomyocyte NLRP3 inflammasome signalling in AF and related conditions and evaluate the possibility that similar signalling might be important in non-myocyte cardiac cells. We then review the evidence on the role of active resolution of inflammation and its potential importance in suppressing AF-related inflammatory signalling. Finally, we consider the therapeutic potential and broader implications of this new knowledge and highlight crucial questions to be addressed in future research.

Predictive Value of C2HEST Score for Atrial Fibrillation Recurrence Following Successful Cryoballoon Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation

The C2HEST score ((coronary artery disease (CAD) or chronic obstructive pulmonary disease (COPD) [C2, 1 point each]; hypertension [H, 1 point]; elderly [E, age ≥75 years, 2 points]; systolic heart failure [S, 2 points]; thyroid disease [T, hyperthyroidism, 1 point]) has been validated for predicting incidental atrial fibrillation (AF) in both the general population and patients with ischemic stroke. The present study evaluated the performance of this score in predicting AF recurrence in 252 patients following cryoballoon ablation (CRYO) for paroxysmal AF. The AF recurrence rate in 3-12 months following CRYO was 20,2%. The predictive value of the C2HEST score was significantly better than that of the CHA₂DS₂-VASc score ((congestive heart failure, hypertension, age (>65 = 1 point, >75 = 2 points), diabetes, previous stroke/transient ischemic attack (2 points), vascular disease, age 65-74 years, and sex category)) (area under curve [AUC]: .881 vs .741; P = .0017). C2HEST score of ≥2, increased atrial diameter, and E/e' ratio as well as, the presence of COPD and systolic heart failure (SHF) were independent predictors for AF recurrence (P < .05). In patients undergoing CRYO for paroxysmal AF, the C2HEST, a simple clinical score, could be useful to assess the risk of AF recurrence.