Atrial fibrillation versus. atrial myopathy in thrombogenesis: Two sides of the same coin?

Trends in Cardiovascular Medicine, Journal Year: 2025, Volume and Issue: unknown

Published: Jan. 1, 2025

Language: Английский

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Rethinking Stroke Prevention in Atrial Fibrillation: One Size Does not Fit All

Journal of Cardiovascular Electrophysiology, Journal Year: 2025, Volume and Issue: unknown

Published: Jan. 14, 2025

The cornerstone of stroke prevention in atrial fibrillation (AF) lies thromboembolic risk stratification, typically assessed through simple clinical scoring systems such as the CHA2DS2-VASc score [1-4]. latest 2024 ESC guidelines for management AF proposed sexless CHA2DS2-VA (Level Evidence: C) to assist decisions on anticoagulation therapy "in absence other locally validated alternatives," "inclusion gender complicates practice both healthcare professionals and patients" "omits individuals who identify nonbinary, transgender, or are undergoing sex hormone therapy" [2, 5]. Long-term oral (OAC) is recommended patients with scores 2 (three females) higher, while it should be considered those 1 (two [1, 2]. Risk like CHA2DS2-VA(Sc) regarded simplifications reductionist, aid decision-making. Indeed, not all elements within carry an equivalent stroke. It essential clarify that female independent factor but rather a modifier, its contribution becomes significant only when at least one additional present [6, 7]. varies notably among single non-sex-related factor, greatest observed aged 65–74 years diagnosed diabetes mellitus, followed by vascular disease congestive heart failure [8]. For instance, male patient arterial hypertension, hazard ratio (HR) ischemic was 1.681 (95% CI: 1.333–2.120; p < 0.001), years, HR 3.085 2.790–3.410; 0.001). Both have 1, they exhibit completely different Also, common sense man age 65 going substantially lower compared 74, yet point score. do include every conceivable dynamic nature factors [9], nor account ethnic differences [10, 11]. Another important issue burden difficult define, also assess our daily requires long-term rhythm monitoring. Until now, can precisely cardiac implantable electronic devices loop recorders. External monitoring low compliance rate patients, data from smartwatches smartphones interpreted caution their sensitivity specificity detection still debated. Recent advancements wearable technology artificial intelligence (AI) improved accuracy assessment. example, FDA-cleared History algorithm Apple Watch enables researchers analyze research purposes. These innovations hold promise integrating consumer-grade wearables into practice, enhancing utility current (2024) [2] ACC/AHA/ACCP/HRS (2023) [1] recommend administration OAC irrespective arrhythmia recurrence profile, burden, type (paroxysmal, persistent, permanent). However, recent studies shed light relevance defined extent frequency episodes, refining prediction. Additionally, some after first symptomatic episode AF, even no [12]. temporal link between indicates might play roles causing strokes, having may [13]. Although device-detected frequently lacks clear relationship stroke, identified association, indicating potential causality certain instances [14, 15]. Importantly, solely affected patient's characteristics myopathy. In words, per se cause 1997, Zipes used term "atrial myopathy" time explain how causes tachycardia-induced cardiomyopathy (myopathy) results electrophysiological anatomical remodeling atria [16]. development myopathy driven pathophysiological mechanisms involving tissue damage caused various aging, obesity, disease. numerous genetic mutations been contribute [17]. predispositions increase oxidative stress, activate inflammatory pathways, stimulate renin-angiotensin-aldosterone system, leading greater wall stretch [18]. changes ultimately initiate tachyarrhythmias, [19]. On hand, particularly minimal comorbidities, experience without functional impact underlying While frequent condition associated crucial acknowledge occur independently specific circumstances, paroxysmal "lone AF" triggered pulmonary vein activity. Instances successful treatment isolation (PVI) highlight originates Atrial form substrate progression leads endothelial dysfunction stasis, thereby creating prothrombotic state [20]. question whether if remains unanswered. large cohort utilizing transthoracic echocardiography (TTE) magnetic resonance (CMR) demonstrated increased left (LA) volumes reduced LA function linked new-onset AF. atrium taken assessment newly decision prescribing based presence failure, > pathophysiology thrombosis complex multifactorial [21]. At present, AF-treatment imaging. ARCADIA trial [22] embolic undetermined source (ESUS) cardiopathy indicate apixaban did significantly reduce likelihood another aspirin cryptogenic evidence Nevertheless, study, characterized P-wave terminal force surpassing 5000 μV × ms electrocardiogram lead V1, serum N-terminal pro-B-type natriuretic peptide level exceeding 250 pg/mL, diameter index 3 cm/m2 higher echocardiogram. majority met enrollment criteria level, though it's worth noting this biomarker limitations due lack association illness issues. far concerned, we distinguish terms "clinical" "subclinical AF." "Clinical refers asymptomatic documented 12-lead ECG devices, usually arbitrarily 30 s tracing [2]. subclinical symptoms attributable whom has previously detected entire tracing. mainly episodes—atrial high-rate episodes (AHRE) insertable monitors two entities (clinical AF) affects decision-making OAC. Specifically, "clinical indication case further analysis ASSERT study duration 24 h [23]. reported shorter thresholds MOST (MOde Selection Trial) [24], death found 2.5 times experienced lasting longer than 5 min. Similarly, TRENDS (A Prospective Study Clinical Significance Arrhythmias Detected Implanted Device Diagnostics) [25] correlates overall fibrillation. personalization according risk. Two recently published trials (NOAH-AFNET 6 ARTESIA) attempted answer beneficial not. NOAH-AFNET [26] tested effectiveness safety anticoagulants AF/atrial min factor. showed edoxaban occurrence systemic embolism, cardiovascular AT, major bleeding. findings remained consistent regardless AHRE This indicated 48 automatically prompt physicians start therapy. Conversely, ARTESIA [27] fibrillation/AHRE, embolism aspirin, although carried bleeding fatal referenced studies, often exhibited what would predicted modified intention-to-treat population trial, annual incidence 1.1% receiving placebo 0.9% treated edoxaban. ARTESiA rates were 1.0% 0.6% [28]. A meta-analysis combining reduction (RR: 0.68; 95% 0.50–0.92; I² = 0%). estimated absolute three fewer events 1000 patient-years fewer) data, 10 baseline estimates observational meta-analyses Consequently, these observations raised doubts about established approach initiating AHRE. Notably definitely population. Considering above observations, size does fit especially AF/AHRE. personalized seems attractive. answered "what changed during last reconsider therapeutic approach?." now therapies rapid onset offset action plenty options patients. evolution intelligence, remote technologies, including recorders, smartwatches, smartphones, enabled continuous surveillance facilitating timely interventions. combination new era makes tailored AT promising [29]. feasible, effective, safe. IMPACT [30] which failed demonstrate superiority over conventional partly attributed use vitamin K antagonists portion had delay achieving anticoagulation, likely contributed outcomes. Subsequent trials, REACT.COM [31] TACTIC-AF [32], embraced adjusting individual profiles. revealed reductions compromising efficacy, employing NOACs. TACTIC single-arm powered prevention. Their benefits require validation larger, randomized trials. REACT-AF [33] (NCT 05836987) will compare standard smartwatch-guided 5350 Participants group wear detect receive notifications take anticoagulant medication necessary. aims efficacy approach, primary endpoints mortality, secondary focusing If successful, method could offer strategies One most challenging populations (CHA2DS2-VA(Sc) females), strictly indicated. Guidelines intermediate (ESC, IIa, C; ACC/AHA/ACCP/HRS, 2a, A) taking preferences, risk, selected [34]. More specifically, high [35] (e.g., HAS-BLED Score ≥ 3) (episodes h) candidates (pill-in-pocket) Despite advancements, challenges persist implementing "pill-in-pocket" (Figure 1). precise threshold defining unknown, necessitating define Moreover, interplay myopathy, thrombogenesis underscores need holistic beyond scores. Looking ahead, large-scale warranted validate interventions appendage occlusion isolation. Furthermore, management, compliance, cost-effectiveness necessitate careful consideration integration advanced technologies routine care. growth science machine learning approaches raises possibility "real time" stratification [36, 37]. As navigate terrain, collaboration clinicians, researchers, developers pivotal realizing full medicine management. P.E.P. reports consultancy Boehringer Ingelheim investigator Bayer-sponsored OCEANIC-AF study. G.Y.H.L. consultant speaker BMS/Pfizer, Ingelheim, Daiichi-Sankyo, Anthos. No fees received personally. He National Institute Health Care Research (NIHR) Senior Investigator co-PI AFFIRMO project multimorbidity (grant agreement No. 899871), TARGET digital twins 101136244) ARISTOTELES chronic long conditions 101080189), funded EU's Horizon Europe & Innovation program. support available corresponding author upon reasonable request.

Language: Английский

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Left atrial reservoir strain as a predictor of cardiac dysfunction in a murine model of pressure overload

Acta Physiologica, Journal Year: 2025, Volume and Issue: 241(2)

Published: Jan. 16, 2025

Left atrial (LA) strain is emerging as a valuable metric for evaluating cardiac function, particularly under pathological conditions such pressure overload. This preclinical study investigates the predictive utility of LA on function in murine model subjected to overload, mimicking pathologies hypertension and aortic stenosis. High-resolution ultrasound was performed cohort mice (n = 16) evaluate left ventricular at baseline 2 4 weeks after transverse constriction (TAC). Acute adaptations were assessed subgroup 10) with 3 days post-TAC imaging. We report an increase max volume from 11.0 ± 4.3 μL 26.7 16.7 (p 0.002) decrease reservoir 20.8 5.4% 10.2 6.9% 0.001). In acute phase, dysfunction present < 0.001), prior alterations 0.856) or (LV) ejection fraction 0.120). correlated key indicators performance including (r 0.541, p longitudinal -0.637, rate 0.378, 0.007). Furthermore, markers structure (AUC 0.813, 0.003), 0.853, 0.884, 0.001) all predicted LV dysfunction. assessments provide reliable, non-invasive method early detection prediction

Language: Английский

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Atrial Cardiomyopathy: From Diagnosis to Treatment

Reviews in Cardiovascular Medicine, Journal Year: 2025, Volume and Issue: 26(1)

Published: Jan. 20, 2025

With a better understanding of the susceptibility to atrial fibrillation (AF) and thrombogenicity left atrium, concept cardiomyopathy (ACM) has emerged. The conventional viewpoint holds that AF-associated hemodynamic disturbances thrombus formation in appendage are primary causes cardiogenic embolism events. However, substantial evidence suggests relationship between AF is not so absolute, ACM may be an important, underestimated contributor Chronic inflammation, oxidative stress response, lipid accumulation, fibrosis leading form foundation for AF. Furthermore, persistent can exacerbate structural electrical remodeling, as well mechanical dysfunction atria, creating vicious cycle. To date, ACM, AF, remains unclear. Additionally, many clinicians still lack comprehensive ACM. In this review, we first appraise definition subsequently summarize noninvasive feasible diagnostic techniques criteria clinical practice. These include imaging modalities such echocardiography cardiac magnetic resonance imaging, electrocardiograms, serum biomarkers, existing practical criteria. Finally, discuss management strategies encompassing “upstream therapy” targeting risk factors, identifying providing appropriate anticoagulation patients at high stroke/systemic events, controlling heart rhythm along with potential substrate improvements.

Language: Английский

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Left Atrial Strain Value Versus Tissue Doppler Echocardiography and the Left Atrium Volume Index in the Evaluation of Left Ventricular Diastolic Function in Patients with Chronic Kidney Disease

Clinics and Practice, Journal Year: 2025, Volume and Issue: 15(2), P. 36 - 36

Published: Feb. 13, 2025

Background: In heart failure with preserved ejection fraction (HFpEF) and decreased (HFrEF), LA strain, an indicator of the filling discharge left atrium (LA), was recently identified as a sign diastolic dysfunction. Our objective to examine significance atrial (LA) strain relative tissue Doppler echocardiography volume index (LAVI) in evaluating ventricular (LV) performance individuals chronic kidney disease (CKD). Methods: A prospective cross-sectional study conducted on 220 outpatients CKD who fulfilled inclusion criteria were referred cardiology clinic at Tanta University for routine echocardiographic assessment during period 6 months (April September 2024). Based their estimated glomerular filtration rate (eGFR), patients divided into five groups: GFR ranges from 90 120 mL/min/1.73 m2 Group 1, 60 2, 30 3, 15 29 4, less than 5. All participants evaluated using measurements, such E/e ratio, systolic volumes, (LAVI), (EF). Results: conduit reservoir can significantly diagnose LV function (p < 0.001; AUC = 0.819 0.869, respectively) cutoffs ≤36 ≥23, 86% 95.5% sensitivity, 65% 60% specificity, 96.1% 96% PPV, 31.7% 57.1%, NPV respectively. An 0.926 observed LAVI among grade 1 vs. 0 (0.9 is considered excellent diagnosing without disease). Other markers had values 0.5-0.6 grades function, suggesting no discrimination disease. Conclusions: are independent that represent superior more sensitive approach dysfunction CKD, even early stages.

Language: Английский

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Atrial cardiomyopathy in cardiac amyloidosis: clinical imaging and manifestations

Deleted Journal, Journal Year: 2025, Volume and Issue: 2(1)

Published: March 4, 2025

Abstract Cardiac amyloidosis is a progressive infiltrative disease and an important cause of atrial arrhythmias, stroke heart failure. Abnormal amyloid fibril deposition throughout the leads to host clinical manifestations complications. Although abnormalities are typically regarded as consequence ventricular diastolic dysfunction or there emerging evidence that primary defects structure function may be present. An cardiomyopathy sign early cardiac disease, unrecognised independent marker worse prognosis. This review summarizes current specifically for in amyloidosis, with focus on imaging outcomes.

Language: Английский

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Left Atrium in Mitral Valve Prolapse: An Additional Piece to the Complex Puzzle

Circulation Cardiovascular Imaging, Journal Year: 2024, Volume and Issue: 17(6)

Published: June 1, 2024

Language: Английский

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Left Atrial Strain as a Predictor of Cardiac Dysfunction in a Murine Model of Pressure Overload

bioRxiv (Cold Spring Harbor Laboratory), Journal Year: 2024, Volume and Issue: unknown

Published: Sept. 10, 2024

Abstract Aim Left atrial (LA) strain is emerging as a valuable metric for evaluating cardiac function, particularly under pathological conditions such pressure overload. This preclinical study investigates the predictive utility of LA on function in murine model subjected to overload, mimicking pathologies hypertension and aortic stenosis. Methods High resolution ultrasound was performed cohort mice (n=16) evaluate left ventricular at baseline 2- 4-weeks after transverse constriction (TAC). Acute adaptations were assessed subgroup (n=10) with 3-days post TAC imaging. Results We report an increase max volume from 11.0 ± 4.3µL 26.7 16.7µL 4 weeks ( p =0.002) decrease 19.6 4.8% 10.1 6.3% =0.006). In acute phase, dysfunction present <0.001) prior alterations =0.856) or (LV) ejection fraction =0.120). correlated key indicators performance including (r=0.563, <0.001), longitudinal (r=-0.643, rate (r=0.387, =0.007). Furthermore, markers structure (AUC=0.858, (AUC=0.901 (AUC=0.878, all predicted LV dysfunction. Conclusion assessments provide reliable, non-invasive method early detection prediction

Language: Английский

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