Long-term Prognosis of Paroxysmal Atrial Fibrillation and Predictors for Progression to Persistnt or Chronic Atrial Fibrillation in the Korean Population

Causal Association Between Alcohol Consumption and Atrial Fibrillation: A Mendelian Randomization Study

Previous observational studies presented a positive association between alcohol and atrial fibrillation (AF). However, previous studies using genetic polymorphisms on the causal relationship between alcohol consumption and AF have reported conflicting results. This study evaluated the causality between alcohol consumption and AF using the aldehyde dehydrogenase 2 (ALDH2) rs671 polymorphism. In 8,964 cohort participants, genetic analysis and Mendelian randomization analysis using the ALDH2 genotypes showed a significant causal association between alcohol consumption and AF in men.

Background and Objectives

Previous observational studies presented a positive association between alcohol and atrial fibrillation (AF). However, previous studies using genetic polymorphisms on the causal relationship between alcohol consumption and AF have reported conflicting results. This study aimed to evaluate the causality between alcohol consumption and AF using the aldehyde dehydrogenase 2 (ALDH2) rs671 polymorphism, which is the genetic variant with the most potent effect on drinking behavior.

Methods

A total of 8,964 participants from the Dong-gu Study were included in the present study. The causal association between alcohol consumption and AF was evaluated through a Mendelian randomization (MR) analysis using the ALDH2 rs671 polymorphism as an instrumental variable.

Results

No significant relationship between alcohol consumption and AF was found in the observational analysis. However, the genetic analysis using the ALDH2 polymorphism showed a significant association in men. In the MR analysis, genetically predicted daily alcohol consumption was positively related to AF.

Conclusions

MR analysis revealed a significant association between the amount of alcohol consumption and AF, which suggests that the association may be causal.

Is Progression From Paroxysmal to Sustained Atrial Fibrillation Bad News?

Atrial fibrillation (AF) is the most common sustained arrhythmia and associated with increased morbidity and mortality resulting from thromboembolism and heart failure. AF often presents initially as paroxysmal and may progress to a sustained form over time. Sustained forms of AF may be associated with increased symptoms and cardiovascular morbidity, and AF progression may be associated with increased risk of clinically adverse events and outcomes. The present review discusses the clinical factors of arrhythmia progression and risk stratification available to assess the probability of AF progression. Furthermore, currently available treatment options for preventing AF progression are explored and evaluated.

The Association Between Left Ventricular Hypertrophy and the Occurrence and Prognosis of Atrial Fibrillation: A Meta-Analysis

Aims: The aim of this study was to perform a meta-analysis of studies of the association of left ventricular hypertrophy (LVH) and atrial fibrillation (AF), especially the predictive and prognostic role of LVH.

Methods and Results: We searched Medline, Embase, and the Cochrane Library from inception through 10 April 2020. A total of 16 cohorts (133,091 individuals) were included. Compared with the normal subjects, patients with LVH were more susceptible to AF (RR = 1.46, 95% CI, 1.32–1.60). In patients with AF and LVH, there was a higher risk of all-cause mortality during 3.95 years (RR = 1.60, 95% CI, 1.42–1.79), and these patients were more likely to progress to persistent or paroxysmal AF (RR = 1.45, 95% CI, 1.20–1.76) than were patients without LVH. After catheter ablation of AF, patients with LVH were more likely to recur (RR = 1.58, 95% CI, 1.27–1.95).

Conclusion: LVH is strongly associated with AF and has a negative impact on outcome in patients with AF.

Progression and clinical manifestations in screening-detected atrial fibrillation: A follow-up of the STROKESTOP study

BACKGROUND

There is a lack of data on atrial fibrillation (AF) progression after AF screening.

HYPOTHESIS

We studied the hypothesis that progression of AF subtype after AF screening was similar to the progression noted in clinical AF cases. We also studied predictors for AF progression and AF symptoms during 5-year follow-up.

METHODS

All participants from the STROKESTOP study with screening-detected AF were included in this prospective cohort study (n = 218). Deceased patients, patients with dementia and/or patients receiving institutional care were excluded (n = 31). Patients were interviewed at their visit regarding symptoms, treatment with oral anticoagulation and clinical events during follow-up and instructed to record ECG using a handheld ECG recording twice daily for two weeks.

RESULTS

A total of 187 patients were invited for follow-up and 120 (64%) participated. The mean age was 81.0 ± 0.6 years and 56 (47%) of the participants were women. The mean follow-up time was 5.3 ± 0.4 years. Among the participants with 5-year follow-up data available, 18% (22/120) were diagnosed with permanent AF at study entry, compared to 49/120 (41%) after five years (p < 0.001). Among patients with paroxysmal AF at study entry, 33/98 (34%) had progressed to permanent AF after five years. Among participants approximately half remained asymptomatic, whereas 48% reported predominantly mild symptoms. None of the components of CHA₂DS₂-VASc were significantly predictive of AF progression.

CONCLUSIONS

The progression for screening-detected AF is like that of clinically detected AF. Half of the patients with screening-detected AF report symptoms over time, and symptoms were generally mild.

Quasi-Randomized Trial of Effects of Perioperative Oral Hygiene Instruction on Inpatients with Heart Diseases Using a Behavioral Six-Step Method

The assessor-blinded, parallel-design, quasi-randomized study (alternating allocation) aimed to determine the effects of the six-step method on postoperative numbers of oral bacteria, periodontal status, and atrial fibrillation (AF) among inpatients with heart diseases and periodontitis. Seventy inpatients who received preoperative periodontal treatment were quasi-randomly assigned to intervention and control groups at University Hospital. The intervention group received intensive oral hygiene instruction using a six-step method for 15 minutes per week and the control group received routine oral hygiene instruction. Significantly fewer oral bacteria were identified on the tongue at discharge compared with baseline in the intervention than the control group (ANCOVA) (large effect size, p = 0.02). Changes in scores for self-efficacy, plaque scores, probed pocket depth, and bleeding on probing between baseline and discharge were significantly greater in the intervention, than in the control group (p < 0.05). The period of postoperative AF (days) was significantly shorter in the intervention, than in the control group (p = 0.019). In conclusion, oral hygiene instruction using the six-step method decreased the numbers of oral bacteria on the tongue and improved self-efficacy, oral health behaviors, oral hygiene status, periodontal status, and period of postoperative AF among inpatients with periodontitis and heart diseases.

Impact of periodontitis as representative of chronic inflammation on long-term clinical outcomes in patients with atrial fibrillation

Objectives

Relationship between atrial fibrillation (AF) and inflammation was shown in previous studies. However, there was limited data about the association between the periodontitis and AF in the long-term follow-up. The aim of this study was to evaluate the impact of periodontitis on long-term clinical outcomes in patients with AF.

Methods

The Kosin University echocardiography, ECG and periodontitis database were reviewed from 2013 to 2015 to identify patients with AF. Those patients were divided into two groups according to the presence of periodontitis and clinical events including any arrhythmic attack, thromboembolic and bleeding and death were collected during a median of 18 months.

Results

Among 227 patients with AF, 47 (20.7%) patients had periodontitis. Major adverse cardiac events (MACE) were significantly higher in patients with periodontitis compared with those without periodontitis (p<0.001). Arrhythmias including AF, atrial tachycardia, atrial premature beat, ventricular tachycardia and ventricular premature beat also occurred in 44 (93.6%) patients, which was higher significantly higher incidence in patients with periodontitis than in those without periodontitis (p<0.001). In univariate analysis, age, CHA₂DS₂-VASc, left atrial volume index (LAVi) and periodontitis were significantly associated with arrhythmic events and MACE including bleeding events, thromboembolic events, arrhythmic events and mortality. In multivariate analysis, LAVi (p=0.005) and periodontitis (p<0.001) were independent risk factors for arrhythmic events and periodontitis (p<0.001) for MACE at the long-term follow-up.

Conclusions

The periodontitis as representative of chronic inflammation was an independent predictor of arrhythmic events and MACE in patients with AF.

Fluvastatin therapy could not decrease progression of paroxysmal atrial fibrillation in non-valvular disease patients

OBJECTIVE

This study aimed to evaluate whether fluvastatin therapy could decrease the probability of atrial fibrillation (AF) progression from paroxysmal AF to permanent AF and decrease the recurrence frequency of AF.

METHODS

Analyses were performed using two-tailed Student's t test or Mann-Whitney U tests. Categorical variables were compared with the χ2 statistics or Fisher's exact test. Patients with paroxysmal AF were randomized case-control, prospective into either the fluvastatin group (n=61) or control group (n=57). Patients were followed up for 24 months. The primary endpoint event was paroxysmal AF that progressed to permanent AF. Secondary endpoints were AF recurrence, cardiac dysfunction, stroke, or death.

RESULTS

There were no differences in AF progression (fluvastatin group, 8.19% vs. control group, 12.51%; p>0.05) and stroke (fluvastatin group. 6.55% vs.

CONTROL GROUP

8.77%; p>0.05). Patients in the fluvastatin group had a lower rate of AF recurrence (fluvastatin group, 24.59% vs. control group, 49.12%; p<0.05) and a lower rate of cardiac dysfunction (fluvastatin group, 6.55% vs. control group, 19.29%; p<0.05). Death did not occur in both the groups. After 1 week of fluvastatin therapy, C-reactive protein (CRP) and homocysteine (HCY) levels were lower in the fluvastatin group than in the control group. At 24 months of follow-up, CRP and HCY levels remained lower in the fluvastatin group than in the control group. The number of endothelial progenitor cells (EPCs) increased in the fluvastatin group compared with that in the control group (fluvastatin group, 72.27±12.49 counts/105 vs. control group, 57.45±8.24 counts/105, p=0.001).

CONCLUSION

Fluvastatin therapy could not decrease AF progression. However, it could decrease the recurrence frequency of paroxysmal AF and cardiac dysfunction. This may occur because of depressing inflammation and improving circulating EPCs.

Permanent atrial fibrillation impairs the function of circulating endothelial progenitor cells

OBJECTIVE

to determine whether functions of endothelial progenitor cells (EPCs) were impaired in patients with permanent atrial fibrillation (AF).

METHODS

35 patients with permanent AF (AF group) and 35 age and sex matched controls (control group) were collected. The numbers of circulating CD34⁺/KDR⁺ cells were determined with flow cytometry in the two groups. Cell proliferation, tube formation, nitric oxygen (NO) and vascular endothelial growth factor (VEGF) were assayed.

RESULTS

the numbers of CD34⁺/KDR⁺ cells were lower in the AF group than the control group (20.01 ± 12.66 /10⁵ vs 77.93 ± 58.93 /10⁵，p = 0.022). Colony formation unit (CFU) of EPCs were decreased in AF group compared to the control group（1.76 ± 0.59 CFU vs 3.45 ± 0.82 CFU, p = 0.0000). The AF group had lower cell proliferation ability than control group（0.401 ± 0.113 A vs 0.558 ± 0.130 A, p = 0.004). Tube formation ability was decreased in AF patients compared to controls（434.30 ± 96.22μm/mm² vs 568.09 ± 196.17μm/mm²，p = 0.041). AF patients had lower VEGF secretion than controls (27.35 ± 9.93 ng/L vs 41.86 ± 7.31 ng/L，p = 0.001），they also had lower NO secretion than controls（16.55 ± 6.92μmol/l vs 23.65 ± 5.48，p = 0.012).

CONCLUSIONS

proliferation, tube formation and paracrine of EPCs were reduced in patients with permanent AF.

Clinical significance of nutritional status in patients with atrial fibrillation: An overview of current evidence

BACKGROUND

Obesity is a well-known atherosclerosis risk factor; however, its role and the importance of undernutrition in atrial fibrillation (AF) pathogenesis are still not well understood. The aim of this study was to present the current state of knowledge on this issue in different groups of patients.

METHODS

Systematic review of papers published between 1980 and 2016.

RESULTS

The literature shows contradicting views regarding the impact of nutritional status on the risk, course, and complications of AF. On the one hand, it has been revealed that overweight, obesity, and high birth mass increase the risk of AF, and that their reduction is linked to an improved course of AF and reduced all-cause and cardiovascular mortality. On the other hand, a so-called obesity paradox has been found, which shows lower all-cause mortality in overweight patients with AF compared to those of normal weight or who are underweight. It has also been shown, although based on a small number of studies, that the relationship between nutritional status and risk of AF and its complication may be U-shaped, which means that not only patients with obesity, but also individuals with underweight, cachexia, and low birth weight may have an increased risk and poor outcome of AF.

CONCLUSIONS

The relationship between patients' nutritional status and the course of AF has become clearer but it requires further studies examining the importance of weight reduction on AF course.

Dual-chamber implantable cardioverter-defibrillator. Is it useful in patient with permanent atrial fibrillation?

In patients with permanent atrial fibrillation (AF) and implantable cardioverter–defibrillator (ICD) implant indication, a single‐chamber device is the choice because AF does not provide interesting information for the treatment. It is very unusual to find patients with permanent AF that coexist with atrial tachycardia with various degree of Atrioventricular block.

Impact of moderate to severe renal impairment on long-term clinical outcomes in patients with atrial fibrillation

BACKGROUND

The deleterious effect of renal impairment in non-valvular atrial fibrillation (AF) patients has recently been reported. We investigated the impact of moderate to severe renal impairment on long-term clinical outcomes in AF patients.

METHODS

A total of 2126 AF patients were enrolled and divided into two groups according to ≥ or <60mL/min estimated glomerular filtration rate (eGFR). Clinical outcomes including all-cause death, cardiac death, ischemic stroke (IS), bleeding, and admission for heart failure (HF) were analyzed.

RESULTS

Compared to the ≥60mL/min eGFR group, <60mL/min eGFR patients were older; had a higher proportion of females; were more likely to have diabetes, hypertension, and history of stroke; and had higher CHADS₂, CHA₂DS₂-VAS_c, and HAS-BLED scores. During the follow-up period (median 6.23 years), all-cause death, bleeding, admission for HF, and progression to persistent or permanent AF were significantly increased in the <60mL/min eGFR group compared to the ≥60mL/min eGFR group. After multivariate Cox regression analyses, <60mL/min eGFR increased the risk of all-cause death [hazard ratio (HR): 1.84; 95% confidence interval (CI): 1.03-3.28, p=0.04] and bleeding (HR: 1.28; 95% CI: 1.04-1.57, p=0.02). IS was only significantly increased in the <60mL/min eGFR group not receiving antithrombotic treatment.

CONCLUSION

Moderate to severe renal impairment is a poor prognostic factor of long-term clinical outcomes in AF patients.