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Pucci G, Grillo A, Dalakleidi KV, Fraenkel E, Gkaliagkousi E, Golemati S, Guala A, Hametner B, Lazaridis A, Mayer CC, Mozos I, Pereira T, Veerasingam D, Terentes-Printzios D, Agnoletti D. Atrial Fibrillation and Early Vascular Aging: Clinical Implications, Methodology Issues and Open Questions-A Review from the VascAgeNet COST Action. J Clin Med 2024; 13:1207. [PMID: 38592046 PMCID: PMC10931681 DOI: 10.3390/jcm13051207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/02/2024] [Accepted: 02/18/2024] [Indexed: 04/10/2024] Open
Abstract
Atrial fibrillation (AF), the most common cardiac arrhythmia, is associated with adverse CV outcomes. Vascular aging (VA), which is defined as the progressive deterioration of arterial function and structure over a lifetime, is an independent predictor of both AF development and CV events. A timing identification and treatment of early VA has therefore the potential to reduce the risk of AF incidence and related CV events. A network of scientists and clinicians from the COST Action VascAgeNet identified five clinically and methodologically relevant questions regarding the relationship between AF and VA and conducted a narrative review of the literature to find potential answers. These are: (1) Are VA biomarkers associated with AF? (2) Does early VA predict AF occurrence better than chronological aging? (3) Is early VA a risk enhancer for the occurrence of CV events in AF patients? (4) Are devices measuring VA suitable to perform subclinical AF detection? (5) Does atrial-fibrillation-related rhythm irregularity have a negative impact on the measurement of vascular age? Results showed that VA is a powerful and independent predictor of AF incidence, however, its role as risk modifier for the occurrence of CV events in patients with AF is debatable. Limited and inconclusive data exist regarding the reliability of VA measurement in the presence of rhythm irregularities associated with AF. To date, no device is equipped with tools capable of detecting AF during VA measurements. This represents a missed opportunity to effectively perform CV prevention in people at high risk. Further advances are needed to fill knowledge gaps in this field.
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Affiliation(s)
- Giacomo Pucci
- Unit of Internal Medicine, Santa Maria University Hospital, 05100 Terni, Italy
- Department of Medicine and Surgery, University of Perugia, 06125 Perugia, Italy
| | - Andrea Grillo
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Kalliopi V Dalakleidi
- Biomedical Simulations and Imaging (BIOSIM) Laboratory, School of Electrical and Computer Engineering, National Technical University of Athens, 15780 Athens, Greece
| | - Emil Fraenkel
- 1st Department of Internal Medicine, Faculty of General Medicine, Pavol Jozef Šafárik University, 04011 Košice, Slovakia
| | - Eugenia Gkaliagkousi
- 3rd Department of Internal Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, 54124 Thessaloniki, Greece
| | - Spyretta Golemati
- Medical School, National and Kapodistrian University of Athens, 10675 Athens, Greece
| | - Andrea Guala
- Vall d'Hebrón Research Institute (VHIR), 08035 Barcelona, Spain
- CIBER CV, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Bernhard Hametner
- AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, 1210 Vienna, Austria
| | - Antonios Lazaridis
- 3rd Department of Internal Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, 54124 Thessaloniki, Greece
| | - Christopher C Mayer
- AIT Austrian Institute of Technology, Center for Health & Bioresources, Medical Signal Analysis, 1210 Vienna, Austria
| | - Ioana Mozos
- Department of Functional Sciences-Pathophysiology, Center for Translational Research and Systems Medicine, "Victor Babes" University of Medicine and Pharmacy, 300173 Timisoara, Romania
| | - Telmo Pereira
- H&TRC-Health & Technology Research Center, Coimbra Health School, Polytechnic University of Coimbra, 3000-331 Coimbra, Portugal
- Laboratory for Applied Research in Health (Labinsaúde), Polytechnic University of Coimbra, 3000-331 Coimbra, Portugal
| | - Dave Veerasingam
- Department of Cardiothoracic Surgery, Galway University Hospitals, H91 YR71 Galway, Ireland
| | - Dimitrios Terentes-Printzios
- First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Davide Agnoletti
- Cardiovascular Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Cardiovascular Internal Medicine, Medical and Surgical Sciences Department, University of Bologna, 40138 Bologna, Italy
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2
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Lage JGB, Bortolotto AL, Scanavacca MI, Bortolotto LA, Darrieux FCDC. Arterial stiffness and atrial fibrillation: A review. Clinics (Sao Paulo) 2022; 77:100014. [PMID: 35248986 PMCID: PMC8903742 DOI: 10.1016/j.clinsp.2022.100014] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/30/2021] [Indexed: 01/07/2023] Open
Abstract
Arterial stiffness has been investigated as part of the physiopathology of arterial hypertension since the 1970s. Its role in increasing the "pulsatile load" imposed over the Left Ventricle (LV) has been intensely studied recently and has helped in understanding the mechanisms of Atrial Fibrillation (AF) in hypertensive patients. This paper aims to review the main evidence on this issue and establish possible mechanisms involved in the development of AF in patients with arterial stiffness. A PubMed search was performed, and selected articles were searched for references focusing on this topic. In the long term, lower blood pressure levels allow for arterial wall remodeling, leading to a lower stiffness index. To this day, however, there are no available treatments that directly promote the lowering of arterial wall stiffness. Most classes of anti-hypertensive drugs ‒ with stronger evidence for beta-blockers and diuretics ‒ could be effective in reducing arterial stiffness. There is strong evidence demonstrating an association between arterial stiffness and AF. New studies focusing on arterial stiffness and pre-fibrillatory stages would strengthen this causality relation.
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Affiliation(s)
- João Gabriel Batista Lage
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.
| | - Alexandre Lemos Bortolotto
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Mauricio Ibrahim Scanavacca
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Luiz Aparecido Bortolotto
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
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3
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Yamagishi SI, Sotokawauchi A, Matsui T. Pathological Role of Advanced Glycation End Products (AGEs) and their Receptor Axis in Atrial Fibrillation. Mini Rev Med Chem 2019; 19:1040-1048. [PMID: 30854960 DOI: 10.2174/1389557519666190311140737] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/28/2019] [Accepted: 03/02/2019] [Indexed: 12/12/2022]
Abstract
Accumulating evidence has shown that the incidence of atrial fibrillation (AF) is higher in patients with diabetes, especially those with poor glycemic control or long disease duration. Nonenzymatic glycation of amino acids of proteins, lipids, and nucleic acids has progressed under normal aging process and/or diabetic condition, which could lead to the formation and accumulation of advanced glycation end products (AGEs). AGEs not only alter the tertiary structure and physiological function of macromolecules, but also evoke inflammatory and fibrotic reactions through the interaction of cell surface receptor for AGEs (RAGE), thereby being involved in aging-related disorders. In this paper, we briefly review the association of chronic hyperglycemia and type 1 diabetes with the risk of AF and then discuss the pathological role of AGE-RAGE axis in AF and its thromboembolic complications.
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Affiliation(s)
- Sho-Ichi Yamagishi
- Department of Pathophysiology and Therapeutics of Diabetic Vascular Complications, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Ami Sotokawauchi
- Department of Pathophysiology and Therapeutics of Diabetic Vascular Complications, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Takanori Matsui
- Department of Pathophysiology and Therapeutics of Diabetic Vascular Complications, Kurume University School of Medicine, Kurume 830-0011, Japan
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4
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Verdecchia P, Angeli F, Reboldi G. Hypertension and Atrial Fibrillation: Doubts and Certainties From Basic and Clinical Studies. Circ Res 2019; 122:352-368. [PMID: 29348255 DOI: 10.1161/circresaha.117.311402] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Hypertension and atrial fibrillation (AF) are 2 important public health priorities. Their prevalence is increasing worldwide, and the 2 conditions often coexist in the same patient. Hypertension and AF are strikingly related to an excess risk of cardiovascular disease and death. Hypertension ultimately increases the risk of AF, and because of its high prevalence in the population, it accounts for more cases of AF than other risk factors. Among patients with established AF, hypertension is present in about 60% to 80% of individuals. Despite the well-known association between hypertension and AF, several pathogenetic mechanisms underlying the higher risk of AF in hypertensive patients are still incompletely known. From an epidemiological standpoint, it is unclear whether the increasing risk of AF with blood pressure (BP) is linear or threshold. It is uncertain whether an intensive control of BP or the use of specific antihypertensive drugs, such as those inhibiting the renin-angiotensin-aldosterone system, reduces the risk of subsequent AF in hypertensive patients in sinus rhythm. Finally, in spite of the observational evidence suggesting a progressive relation between BP levels and the risk of thromboembolism and bleeding in patients with hypertension and AF, the extent to which BP should be lowered in these patients, including those who undergo catheter ablation, remains uncertain. This article summarizes the main basic mechanisms through which hypertension is believed to promote AF. It also explores epidemiological data supporting an evolutionary pathway from hypertension to AF, including the emerging evidence favoring an intensive BP control or the use of drugs, which inhibit the renin-angiotensin-aldosterone system to reduce the risk of AF. Finally, it examines the impact of non-vitamin K antagonist oral anticoagulants compared with warfarin in relation to hypertension.
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Affiliation(s)
- Paolo Verdecchia
- From the Struttura Complessa di Medicina, Dipartimento di Medicina, Ospedale di Assisi, Italy (P.V.); and Struttura Complessa di Cardiologia e Fisiopatologia Cardiovascolare, Dipartimento di Cardiologia (F.A.) and Dipartimento di Medicina Interna (G.R.), Università di Perugia, Italy.
| | - Fabio Angeli
- From the Struttura Complessa di Medicina, Dipartimento di Medicina, Ospedale di Assisi, Italy (P.V.); and Struttura Complessa di Cardiologia e Fisiopatologia Cardiovascolare, Dipartimento di Cardiologia (F.A.) and Dipartimento di Medicina Interna (G.R.), Università di Perugia, Italy
| | - Gianpaolo Reboldi
- From the Struttura Complessa di Medicina, Dipartimento di Medicina, Ospedale di Assisi, Italy (P.V.); and Struttura Complessa di Cardiologia e Fisiopatologia Cardiovascolare, Dipartimento di Cardiologia (F.A.) and Dipartimento di Medicina Interna (G.R.), Università di Perugia, Italy
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5
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Zhang Q, Cong M, Wang N, Li X, Zhang H, Zhang K, Jin M, Wu N, Qiu C, Li J. Association of angiotensin-converting enzyme 2 gene polymorphism and enzymatic activity with essential hypertension in different gender: A case-control study. Medicine (Baltimore) 2018; 97:e12917. [PMID: 30335025 PMCID: PMC6211892 DOI: 10.1097/md.0000000000012917] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Angiotensin-converting enzyme 2 (ACE2) plays an important role in the development of essential hypertension (EH). The aim of this study was to investigate the relationship of ACE2 gene polymorphisms and enzymatic activity with EH in the northeastern Chinese Han population. 34 single-nucleotide polymorphism (SNP) loci of ACE2 were detected in 1024 EH patients and 956 normotensive (NT) controls by Sequenom Mass-ARRAY RS1000. Five SNPs (rs1514283, rs4646155, rs4646176, rs2285666, and rs879922) in ACE2 gene were determined to significantly associate with EH in female participants, while no SNP locus was linked to male group. Specifically, it was the first time to report that rs4646155 was significantly associated with EH in females. Furthermore, the correlation between ACE2 activity and clinical parameters were performed by Pearson correlation analysis in EH patients. We found that the ACE2 activity level was negatively correlated with body mass index (BMI), DBP, and pulse pressure, and significantly positively with ACE2 concentration, blood glucose and estrogen level in female EH patients. These results demonstrated that the genetic variants of ACE2 played vital roles in the development of EH. And the serum ACE2 activity can predict the development of cardiac dysfunction in EH patients.
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Affiliation(s)
- Qi Zhang
- Institute of Medicine and Drug Research, Qiqihar Medical University, Qiqihar, Heilongjiang Province
| | - Mingyu Cong
- Institute of Medicine and Drug Research, Qiqihar Medical University, Qiqihar, Heilongjiang Province
| | - Ningning Wang
- Institute of Medicine and Drug Research, Qiqihar Medical University, Qiqihar, Heilongjiang Province
| | - Xueyan Li
- Institute of Medicine and Drug Research, Qiqihar Medical University, Qiqihar, Heilongjiang Province
| | - Hao Zhang
- Institute of Medicine and Drug Research, Qiqihar Medical University, Qiqihar, Heilongjiang Province
| | - Keyong Zhang
- Institute of Medicine and Drug Research, Qiqihar Medical University, Qiqihar, Heilongjiang Province
| | - Ming Jin
- Institute of Medicine and Drug Research, Qiqihar Medical University, Qiqihar, Heilongjiang Province
| | - Nan Wu
- Institute of Medicine and Drug Research, Qiqihar Medical University, Qiqihar, Heilongjiang Province
| | - Changchun Qiu
- Institute of Medicine and Drug Research, Qiqihar Medical University, Qiqihar, Heilongjiang Province
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, P. R. China
| | - Jingping Li
- Institute of Medicine and Drug Research, Qiqihar Medical University, Qiqihar, Heilongjiang Province
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Colussi G, Catena C, Fagotto V, Darsiè D, Brosolo G, Bertin N, Sechi LA. Atrial fibrillation and its complications in arterial hypertension: The potential preventive role of ω-3 polyunsaturated fatty acids. Crit Rev Food Sci Nutr 2018; 59:1937-1948. [PMID: 29381383 DOI: 10.1080/10408398.2018.1434126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Atrial fibrillation (AF) is the most common type of arrhythmia in the general population with a prevalence that reaches one third of patients with arterial hypertension. Several risk factors frequently associated with hypertension predispose the myocardium to AF by inducing atrial inflammation and fibrosis and altering atrial electrical and mechanical characteristics. AF influences the quality of life of hypertensive patients since it increases incidence of stroke and other thromboembolic events, and mortality. Polyunsaturated fatty acids of the ω-3 family (ω-3 PUFA) have been demonstrated to be beneficial in cardiovascular disease prevention by reducing plasma lipids and blood pressure levels and decreasing the risk of sudden death. These fatty acids can act as potent anti-inflammatory and anti-arrhythmic agents. Many studies have investigated a possible preventive effect of ω-3 PUFA on incident AF reporting contradictory results. This article overviews the evidence currently available on this important topic and provides some conclusive remarks on the possibility that these fatty acids could be beneficial in hypertensive patients.
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Affiliation(s)
- GianLuca Colussi
- a Division of Internal Medicine, Department of Medicine , University of Udine , Udine , Italy
| | - Cristiana Catena
- a Division of Internal Medicine, Department of Medicine , University of Udine , Udine , Italy
| | - Valentina Fagotto
- a Division of Internal Medicine, Department of Medicine , University of Udine , Udine , Italy
| | - Daniele Darsiè
- a Division of Internal Medicine, Department of Medicine , University of Udine , Udine , Italy
| | - Gabriele Brosolo
- a Division of Internal Medicine, Department of Medicine , University of Udine , Udine , Italy
| | - Nicole Bertin
- a Division of Internal Medicine, Department of Medicine , University of Udine , Udine , Italy
| | - Leonardo A Sechi
- a Division of Internal Medicine, Department of Medicine , University of Udine , Udine , Italy
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7
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Wang Q, Tan K, Xia H, Gao Y. Association of pulse pressure with left ventricular geometry and function in elderly nonhypertensive patients with diabetes: A 3D speckle tracking echocardiography study. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:416-425. [PMID: 28543090 DOI: 10.1002/jcu.22484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 01/31/2017] [Accepted: 03/05/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE The aims of this study were to investigate and compare the left ventricular (LV) geometry and function in elderly nonhypertensive type 2 diabetic patients with normal (NPP, <60 mm Hg) and with high (HPP, ≥60 mmHg) 24-hour pulse pressure, and to explore the independent predictors of LV strain values in these patients. METHODS A total of 76 elderly nonhypertensive type 2 diabetic patients with normal (≥55%) LV ejection fraction (LVEF) were included, 36 of whom had HPP. The control group included 40 age- and sex-matched healthy volunteers with normal NPP. Conventional echocardiography and three-dimensional speckle-tracking echocardiography (3DSTE) were performed and LV global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS), and global radial strain (GRS) were measured. RESULTS Significant differences in the two-dimensional LV geometry were found among the three groups (p = 0.015), and concentric geometry was most prevalent in the diabetic patients with HPP. The diabetic patients with NPP only showed significantly lower GLS than the controls (p < 0.05). However, the diabetic patients with HPP showed significantly lower LVEF and severely lower strain values in all directions than the controls and the diabetic patients with NPP (p < 0.01or p < 0.05 or p < 0.001). Fasting plasma glucose, HPP, and body mass index were independently associated with all strain parameters in diabetic patients. CONCLUSIONS The combination of conventional echocardiography and 3DSTE could detect LV subclinical abnormalities in nonhypertensive type 2 diabetic patients with NPP and HPP. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:416-425, 2017.
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Affiliation(s)
- Qingqing Wang
- Department of Ultrasound, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Kaibin Tan
- Department of Ultrasound, Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Hongmei Xia
- Department of Ultrasound, Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Yunhua Gao
- Department of Ultrasound, Xinqiao Hospital, The Third Military Medical University, Chongqing, China
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Bonapace S, Rossi A, Cicoira M, Targher G, Marino P, Benfari G, Mugnai G, Arcaro G, Vassanelli C. Echocardiographically Derived Pulse Wave Velocity and Diastolic Dysfunction Are Associated with an Increased Incidence of Atrial Fibrillation in Patients with Systolic Heart Failure. Echocardiography 2016; 33:1024-31. [PMID: 27277158 DOI: 10.1111/echo.13230] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Chronic heart failure (CHF) is an established risk factor of atrial fibrillation (AF), but the prognostic value of cardiac and hemodynamic parameters in assessing the risk of developing AF among patients with CHF is less defined. METHODS AND RESULTS We followed an outpatients cohort of CHF patients secondary to left ventricular (LV) systolic dysfunction, who were free of AF at baseline. All patients underwent clinical evaluation, comprehensive echocardiography, and blood drawing in the same morning. Aortic pulse wave velocity (aPWV), a measure of aortic stiffness, was determined by Doppler echocardiography. A total of 77 patients (age 63 ± 9 years; 79% male) with mean LVEF (34 ± 8%) formed the study population. Fifteen patients developed incidental AF. At baseline, CHF patients who developed AF during follow-up had higher E-wave velocity (75 ± 2 cm/sec vs. 60 ± 2 cm/sec; P = 0.02), higher difference duration between mitral and pulmonary vein A velocity (A'-A), (10 ± 35 msec vs. 43 ± 44 msec P = 0.02), aPWV (7.1 ± 2.6 vs. 5.3 ± 1.9 m/sec P = 0.004), and furosemide dosage (110 ± 145 mg vs. 49 ± 48 mg P = 0.01) than those remaining free from AF. The two groups of patients did not significantly differ in terms of NYHA, LV volumes, ejection fraction, left atrial volume, creatinine, hemoglobin, renin, epinephrine, amino-terminal propeptide of type III and I procollagens, ACE inhibitor, and β-blocker dose (P > 0.1 for all). Notably, higher aPWV (P = 0.01) and longer A-A' duration (P = 0.04) were associated with an increased incidence of AF, independently of potential confounders. CONCLUSIONS Increased aortic stiffness and LV diastolic dysfunction are strong predictors of new onset of AF among patients with systolic CHF.
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Affiliation(s)
| | - Andrea Rossi
- Section of Cardiology, University of Verona, Verona, Italy
| | | | - Giovanni Targher
- Section of Endocrinology, Diabetes and Metabolism, University of Verona, Verona, Italy
| | - Paolo Marino
- Clinical Cardiology and Cardiology Department, University of Eastern Piemonte, Novara, Italy
| | | | - Giacomo Mugnai
- Section of Cardiology, University of Verona, Verona, Italy
| | - Guido Arcaro
- Division of Internal Medicine, Sacred Heart Hospital, Negrar, Negrar, Italy
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Chen LY, Leening MJG, Norby FL, Roetker NS, Hofman A, Franco OH, Pan W, Polak JF, Witteman JCM, Kronmal RA, Folsom AR, Nazarian S, Stricker BH, Heckbert SR, Alonso A. Carotid Intima-Media Thickness and Arterial Stiffness and the Risk of Atrial Fibrillation: The Atherosclerosis Risk in Communities (ARIC) Study, Multi-Ethnic Study of Atherosclerosis (MESA), and the Rotterdam Study. J Am Heart Assoc 2016; 5:e002907. [PMID: 27207996 PMCID: PMC4889172 DOI: 10.1161/jaha.115.002907] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 04/08/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND We evaluated the association of carotid intima-media thickness (cIMT), carotid plaque, carotid distensibility coefficient (DC), and aortic pulse wave velocity (PWV) with incident atrial fibrillation (AF) and their role in improving AF risk prediction beyond the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE)-AF risk score. METHODS AND RESULTS We analyzed data from 3 population-based cohort studies: Atherosclerosis Risk in Communities (ARIC) Study (n=13 907); Multi-Ethnic Study of Atherosclerosis (MESA; n=6640), and the Rotterdam Study (RS; n=5220). We evaluated the association of arterial indices with incident AF and computed the C-statistic, category-based net reclassification improvement (NRI), and relative integrated discrimination improvement (IDI) of incorporating arterial indices into the CHARGE-AF risk score (age, race, height weight, systolic and diastolic blood pressure, antihypertensive medication use, smoking, diabetes, previous myocardial infarction, and previous heart failure). Higher cIMT (meta-analyzed hazard ratio [95% CI] per 1-SD increment, 1.12 [1.08-1.16]) and presence of carotid plaque (1.30 [1.19-1.42]) were associated with higher AF incidence after adjustment for CHARGE-AF risk-score variables. Lower DC and higher PWV were associated with higher AF incidence only after adjustment for the CHARGE-AF risk-score variables excepting height, weight, and systolic and diastolic blood pressure. Addition of cIMT or carotid plaque marginally improved CHARGE-AF score prediction as assessed by the relative IDI (estimates, 0.025-0.051), but not when assessed with the C-statistic and NRI. CONCLUSIONS Higher cIMT, presence of carotid plaque, and greater arterial stiffness are associated with higher AF incidence, indicating that atherosclerosis and arterial stiffness play a role in AF etiopathogenesis. However, arterial indices only modestly improve AF risk prediction.
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Affiliation(s)
- Lin Y Chen
- Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN
| | - Maarten J G Leening
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands Department of Cardiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Faye L Norby
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Nicholas S Roetker
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Albert Hofman
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wei Pan
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Joseph F Polak
- Department of Radiology, Tufts University School of Medicine, Boston, MA
| | - Jacqueline C M Witteman
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Richard A Kronmal
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA
| | - Aaron R Folsom
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Saman Nazarian
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bruno H Stricker
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands Department of Internal Medicine, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands Inspectorate for Health Care, Utrecht, The Netherlands
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington, Seattle, WA Cardiovascular Health Research Unit, University of Washington, Seattle, WA
| | - Alvaro Alonso
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
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10
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Goodson ML, Packard AEB, Buesing DR, Maney M, Myers B, Fang Y, Basford JE, Hui DY, Ulrich-Lai YM, Herman JP, Ryan KK. Chronic stress and Rosiglitazone increase indices of vascular stiffness in male rats. Physiol Behav 2016; 172:16-23. [PMID: 27040922 DOI: 10.1016/j.physbeh.2016.03.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 03/14/2016] [Accepted: 03/26/2016] [Indexed: 11/20/2022]
Abstract
Prolonged and/or frequent exposure to psychological stress responses may lead to deterioration of organs and tissues, predisposing to disease. In agreement with this, chronic psychosocial stress is linked to greater cardiovascular risk, including increased incidence of atherosclerosis, myocardial ischemia, coronary heart disease, and death. Thus the association between stress and cardiovascular dysfunction represents an important node for therapeutic intervention in cardiovascular disease. Here we report that 2weeks of chronic variable stress (CVS) increased indices of vascular stiffness, including increased collagen deposition in the aortic adventitia and increased resting pulse pressure, in male rats. Thus CVS may represent a useful rodent model for stress-associated CVD, especially for aging populations for which widening pulse pressure is a well-known risk factor. Additionally, we report that the thiazolidinedione Rosiglitazone (RSG) blunts chronic stress-associated increases in circulating corticosterone. Despite this, RSG was not protective against adverse cardiovascular outcomes associated with chronic stress. Rather RSG itself is associated with increased pulse pressure, and this is exacerbated by chronic stress-highlighting that chronic stress may represent an additional contributor to RSG-associated cardiovascular risk.
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Affiliation(s)
- M L Goodson
- Department of Neurobiology, Physiology, and Behavior, College of Biological Sciences, University of California, Davis, CA, United States
| | - A E B Packard
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - D R Buesing
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - M Maney
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - B Myers
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Y Fang
- Department of Neurobiology, Physiology, and Behavior, College of Biological Sciences, University of California, Davis, CA, United States
| | - J E Basford
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - D Y Hui
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Y M Ulrich-Lai
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - J P Herman
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Karen K Ryan
- Department of Neurobiology, Physiology, and Behavior, College of Biological Sciences, University of California, Davis, CA, United States; Department of Physiology and Membrane Biology, School of Medicine, University of California, Davis, CA, United States.
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11
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Alves-Cabratosa L, García-Gil M, Comas-Cufí M, Martí R, Ponjoan A, Parramon D, Blanch J, Ramos R. Diabetes and new-onset atrial fibrillation in a hypertensive population. Ann Med 2016; 48:119-27. [PMID: 26939743 DOI: 10.3109/07853890.2016.1144930] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIM The association of diabetes with new-onset atrial fibrillation (AF) remains controversial. Hypertension may partly explain the risk association ascribed to diabetes. We studied the role and characteristics of diabetes in hypertensive patients with no ischemic vascular disease. METHODS Records of 262,892 persons from the Information System for the Development of Research in Primary Care in Catalonia (Spain) were examined from July 2006 to December 2011. Included participants were ≥55-years-old and hypertensive with no ischemic heart disease, stroke, or peripheral artery disease. We used Cox proportional hazards regression to model incidences in the diabetic and non-diabetic subgroups of our population, and among diabetic patients, diabetes duration and pharmacological treatment, hemoglobin A1C, and body mass index. RESULTS New-onset AF incidence in diabetic patients was 13.3 per 1000 person-years (mean follow-up: 4.3 years). In non-diabetic patients, it was 10.4 per 1000 person-years (mean follow-up: 4.1 years). Diabetes hazard ratio (HR) for new-onset AF was 1.11 (95% confidence interval (CI): 1.06-1.16). Diabetic patients also diagnosed with obesity had an HR of 1.41 (95% CI: 1.22-1.64). CONCLUSION Diabetes was modestly associated with new-onset AF in hypertensive patients with no ischemic vascular disease. Among diabetic patients, only obesity reached significance in its association with this arrhythmia.
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Affiliation(s)
- Lia Alves-Cabratosa
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain
| | - Maria García-Gil
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain ;,b Translab Research Group, Department of Medical Sciences , School of Medicine, University of Girona , Girona , Spain
| | - Marc Comas-Cufí
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain
| | - Ruth Martí
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain ;,c Girona Biomedical Research Institute (IdibGi), Dr. Trueta University Hospital , Catalonia , Spain
| | - Anna Ponjoan
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain ;,c Girona Biomedical Research Institute (IdibGi), Dr. Trueta University Hospital , Catalonia , Spain
| | - Dídac Parramon
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain ;,d Primary Care Services, Girona, Catalan Institute of Health (ICS) , Catalonia , Spain
| | - Jordi Blanch
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain
| | - Rafel Ramos
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain ;,b Translab Research Group, Department of Medical Sciences , School of Medicine, University of Girona , Girona , Spain ;,d Primary Care Services, Girona, Catalan Institute of Health (ICS) , Catalonia , Spain
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12
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Ding X, Zheng X, Xing A, Wang D, Qi S, Wu Y, Li H, Wu S, Hong J. High risk factors of atrial fibrillation in type 2 diabetes: results from the Chinese Kailuan study. QJM 2015; 108:885-90. [PMID: 25713423 DOI: 10.1093/qjmed/hcv051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The pathophysiological mechanisms for atrial fibrillation (AF) vulnerability in diabetic patients are largely unclear. AIM To investigate the high risk factors of AF in Chinese Kailuan diabetes. DESIGN A retrospective review of AF in Chinese Kailuan diabetes. METHODS Research and statistic analysis on the clinical data of 9050 diabetic patients from Kailuan Coal Mine Group Corporation who participated in a health survey from July 2006 to October 2007. RESULTS Sixty diabetic patients (50 males and 10 females) were diagnosed with AF during the health checkup, with a prevalence of 0.66% (0.67% in males and 0.62% in females). Univariate analysis showed that patients with AF were older and had higher levels of serum uric acid (UA), pulse pressure, serum c-reactive protein and anti-hypertensive medication usage, but lower levels of fasting blood glucose and triglycerides (TG). Multivariate analysis indicated that older age (OR = 1.09; 95% CI: 1.06-1.12), increased UA (OR = 1.01; 95% CI: 1.00-1.01) and decreased TG (OR = 0.71; 95% CI: 0.55-0.92) were independent predictive factors of AF after adjusting for other variables. After gender stratification, age and UA remained as independent predictive factors of AF in both male and female patients. However, TG had an independent inverse association with AF in male patients only. CONCLUSIONS Age and UA are independent predictive factors of AF in both male and female diabetic patients. TG is inversely correlated with AF in male diabetic patients only.
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Affiliation(s)
- X Ding
- From the Department of Endocrinology and Metabolism, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - X Zheng
- Department of Cardiology, Kailuan General Hospital, Hebei Union University, Tangshan, China, From the Department of Endocrinology and Metabolism, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - A Xing
- Department of Cardiology, Kailuan General Hospital, Hebei Union University, Tangshan, China
| | - D Wang
- Department of Cardiology, Bethune International Peace Hospital, Shijiazhuang, China and
| | - S Qi
- Department of Cardiology, Kailuan General Hospital, Hebei Union University, Tangshan, China
| | - Y Wu
- Department of Cardiology, Kailuan General Hospital, Hebei Union University, Tangshan, China
| | - H Li
- Department of Cardiology, Kailuan General Hospital, Hebei Union University, Tangshan, China
| | - S Wu
- Department of Cardiology, Kailuan General Hospital, Hebei Union University, Tangshan, China
| | - J Hong
- Department of Internal Medicine, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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13
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Cremer A, Lainé M, Papaioannou G, Yeim S, Gosse P. Increased arterial stiffness is an independent predictor of atrial fibrillation in hypertensive patients. J Hypertens 2015; 33:2150-5. [DOI: 10.1097/hjh.0000000000000652] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Yu D, Simmons D. Association between pulse pressure and risk of hospital admissions for cardiovascular events among people with Type 2 diabetes: a population-based case-control study. Diabet Med 2015; 32:1201-6. [PMID: 25594137 DOI: 10.1111/dme.12693] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2015] [Indexed: 01/03/2023]
Abstract
AIM To investigate the association between pulse pressure and risk of hospitalization for cardiovascular events among people with Type 2 diabetes. METHODS A population-based case-control study was carried out using data from medical databases. A total of 588 people with Type 2 diabetes from 18 general practices in Cambridgeshire recorded a first hospitalization for a cardiovascular event between 2009 and 2011, and a total of 2920 age-matched, gender-matched and practice-matched control subjects with Type 2 diabetes were selected based on risk-set sampling. Pulse pressure was assessed before admission in 2008-2009. Further dose-response relationships between pulse pressure and risks were explored using spline models. RESULTS There was a non-linear relationship between pulse pressure and the risk of hospitalization for a cardiovascular event (P < 0.001 for linearity test). The pulse pressure associated with the lowest risk of hospitalization for a cardiovascular event was 61 (95% CI 57-63) mmHg. CONCLUSION In people with Type 2 diabetes, pulse pressure is a good predictor of risk of hospitalization for cardiovascular events. The risk is lowest with a pulse pressure of 57-63 mmHg.
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Affiliation(s)
- D Yu
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - D Simmons
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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15
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Siontis KC, Geske JB, Gersh BJ. Atrial fibrillation pathophysiology and prognosis: insights from cardiovascular imaging. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.115.003020. [PMID: 26022381 DOI: 10.1161/circimaging.115.003020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Konstantinos C Siontis
- From Department of Medicine (K.C.S.), Division of Cardiovascular Diseases (J.B.G., B.J.G.), Mayo Clinic College of Medicine, Rochester, MN
| | - Jeffrey B Geske
- From Department of Medicine (K.C.S.), Division of Cardiovascular Diseases (J.B.G., B.J.G.), Mayo Clinic College of Medicine, Rochester, MN
| | - Bernard J Gersh
- From Department of Medicine (K.C.S.), Division of Cardiovascular Diseases (J.B.G., B.J.G.), Mayo Clinic College of Medicine, Rochester, MN.
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16
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Diabetes mellitus and atrial fibrillation: Pathophysiological mechanisms and potential upstream therapies. Int J Cardiol 2015; 184:617-622. [PMID: 25770841 DOI: 10.1016/j.ijcard.2015.03.052] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/21/2015] [Accepted: 03/03/2015] [Indexed: 01/08/2023]
Abstract
Diabetes mellitus (DM) represents one of the most important risk factors for atrial fibrillation (AF) while AF is a strong and independent marker of overall mortality and cardiovascular morbidity in diabetic patients. Autonomic, electrical, electromechanical, and structural remodeling, including oxidative stress, connexin remodeling and glycemic fluctuations seem to be implicated in AF pathophysiology in the setting of DM. The present review highlights the association between DM and AF, provides a comprehensive overview of the responsible pathophysiological mechanisms and briefly discusses potential upstream therapies for DM-related atrial remodeling.
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17
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Miedel C, Leander K, de Faire U, Gigante B. Pulse pressure is not an independent predictor of incident atrial fibrillation in 60-year-old men and women. Ann Med 2015; 47:679-86. [PMID: 26555440 DOI: 10.3109/07853890.2015.1100321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIM To evaluate if pulse pressure (PP) is a risk predictor for atrial fibrillation (AF) in a longitudinal study of 60-year-old men and women from Stockholm (n = 4,232), free from AF at baseline, with primary end-point incident AF. METHODS AF diagnoses were obtained from the national hospital discharge register. The estimated risk of AF associated with increasing PP values was calculated according to PP values above median (>52.5 mmHg) and according to 1-SD increase (14 mmHg) in PP, using a crude and an adjusted Cox proportional hazard regression model. RESULTS During a mean follow-up of 13.6 years, 286 incident AF cases were recorded. The number of AF cases increased significantly with increasing PP quartile in men but not in women. PP values above median were associated with increased AF risk (crude HR 1.63, 95% CI 1.28-2.06; p < 0.001), but risk estimates were attenuated after adjustment for common AF risk factors. When PP was entered in the Cox regression model as a continuous variable, the risk of AF did not change by 1-SD PP increase (adjusted HR 1.04, 95% CI 0.91-1.20; p = 0.560). CONCLUSIONS PP seems not to be associated with incident AF in a Swedish population of 60-year-old men and women.
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Affiliation(s)
- Charlotte Miedel
- a Unit of Cardiovascular Epidemiology , Institute of Environmental Medicine, Karolinska Institutet , Stockholm , Sweden
| | - Karin Leander
- a Unit of Cardiovascular Epidemiology , Institute of Environmental Medicine, Karolinska Institutet , Stockholm , Sweden
| | - Ulf de Faire
- a Unit of Cardiovascular Epidemiology , Institute of Environmental Medicine, Karolinska Institutet , Stockholm , Sweden.,b Department of Cardiology , Karolinska University Hospital , Stockholm , Sweden
| | - Bruna Gigante
- a Unit of Cardiovascular Epidemiology , Institute of Environmental Medicine, Karolinska Institutet , Stockholm , Sweden.,c Division of Cardiovascular Medicine, Department of Clinical Sciences , Danderyd's Hospital Karolinska Institutet , Stockholm , Sweden
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18
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Roetker NS, Chen LY, Heckbert SR, Nazarian S, Soliman EZ, Bluemke DA, Lima JAC, Alonso A. Relation of systolic, diastolic, and pulse pressures and aortic distensibility with atrial fibrillation (from the Multi-Ethnic Study of Atherosclerosis). Am J Cardiol 2014; 114:587-92. [PMID: 24996553 DOI: 10.1016/j.amjcard.2014.05.041] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 05/13/2014] [Accepted: 05/13/2014] [Indexed: 01/19/2023]
Abstract
Previous research suggests that elevated pulse pressure (PP) is a risk factor for atrial fibrillation (AF) independently of mean arterial pressure (MAP). PP may serve as an indirect measure of aortic stiffness (reduced distensibility), but whether directly measured aortic distensibility is related to risk for AF has not yet been studied. This analysis included 6,630 participants aged 45 to 84 years from the Multi-Ethnic Study of Atherosclerosis. At baseline, blood pressure and other relevant covariates were measured using standardized protocols. Magnetic resonance imaging-based aortic distensibility was measured in 3,441 participants. Incident AF was identified from hospitalization discharge codes and Medicare claims. Multivariate Cox models were used to estimate the association of blood pressure components and aortic distensibility with AF risk. During a mean follow-up of 7.8 years, 307 AF events (137 among those with aortic distensibility measurements) were identified. In multivariate-adjusted models simultaneously including MAP and PP, each 1-SD increase in PP was associated with a 29% increased risk of AF (95% confidence interval 5% to 59%, p = 0.02), with MAP not being associated with increased AF risk. Overall, aortic distensibility was not consistently associated with AF risk: after removing outliers, each 1-SD increase in aortic distensibility was associated with a 9% increased risk of AF (95% confidence interval -22% to 51%, p = 0.63). In conclusion, in this large community-based cohort, we found that PP, but not MAP or aortic distensibility, was a significant risk factor for AF, emphasizing the importance of PP when assessing the risk for developing AF. Our results cast doubt on the clinical utility of aortic distensibility as a predictor for the development of AF.
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Affiliation(s)
- Nicholas S Roetker
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Lin Y Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington
| | - Saman Nazarian
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David A Bluemke
- Radiology and Imaging Sciences, National Institutes of Health, Bethesda, Maryland
| | - João A C Lima
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alvaro Alonso
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota.
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