IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
Pacing Clin Electrophysiol. 2023 May;46(5):395-408. doi: 10.1111/pace.14697. Epub 2023 Apr 4.
Heart failure (HF) and atrial arrhythmias (AAs) are two clinical conditions that characterize the daily clinical practice of cardiologists. In this perspective review, we analyze the shared etiopathogenetic pathways of atrial arrhythmias, which are the most common cause of atrial arrhythmias-induced cardiomyopathy (AACM) and HF.
The aim is to explore the pathophysiology of these two conditions considering them as a "unicum", allowing the definition of a cardiovascular continuum where it is possible to predict the factors and to identify the patient phenotype most at risk to develop HF due to atrial arrhythmias.
Potentially eligible articles, identified from the Electronic database (PubMed), and related references were used for a literature search that was conducted between January 2022 and January 2023. Search strategies were designed to identify articles that reported atrial arrhythmias in association with heart failure and vice versa. For the search we used the following keywords: atrial arrhythmias, atrial fibrillation, heart failure, arrhythmia-induced cardiomyopathy, tachycardiomyopathy. We identified 620 articles through the electronic database search. Out of the 620 total articles we removed 320 duplicates, thus selecting 300 eligible articles. About 150 titles/abstracts were excluded for the following reasons: no original available data, no mention of atrial arrhythmias and heart failure crosstalk, very low quality analysis or evidence. We excluded also non-English articles. When multiple articles were published on the same topic, the articles with the most complete set of data were considered. We preferentially included all papers that could provide the best evidence in the field. As a result, the present review article is based on a final number of 104 references.
While the pathophysiology of AACM and Heart Failure with reduced ejection fraction (HFrEF) has been studied in detail over the years, the causal link between atrial arrhythmias and heart failure with Preserved Ejection Fraction (HFpEF) has been often subject of interest. HFpEF is strictly related to AAs, which has always been considered significant risk factor. In this review we described the pathophysiological links between atrial fibrillation and heart failure. Furthermore, we illustrated and discussed the preclinical and clinical predicting factors of AF and HFpEF, and the corresponding targets of the available therapeutic agents. Finally, we outlined the patient phenotype at risk of developing AF and HFpEF (Central Illustration).
In this review, we underline how these two clinical conditions (AF and HFpEF) represent a "unicum" and, therefore, should be considered as a single disease that can manifest itself in the same phenotype of patients but at different times. Furthermore, considering that today we have few therapeutic strategies to treat these patients, it would be good to make an early diagnosis in the initial stages of the disease or intervene even before the development of signs and symptoms of HF. This is possible only by paying greater attention to patients with predisposing factors and carrying out a targeted screening with the correct diagnostic methods. A systemic approach aimed at improving the immuno-metabolic profile of these patients by lowering the body mass index, threatening the predisposing factors, lowering the mean heart rate and reducing the sympathetic nervous system activation is the key strategy to reduce the clinical impact of this disease.
心力衰竭（HF）和心房心律失常（AA）是两种临床情况，它们是心脏病专家日常临床实践的特征。在本次观点综述中，我们分析了心房心律失常的共同发病机制，这是导致心房心律失常性心肌病（AACM）和心力衰竭（HF）的最常见原因。
目的是探讨这两种情况的病理生理学，将它们视为“统一体”，从而定义心血管连续体，可以预测导致 HF 的心房心律失常的因素，并确定风险最高的患者表型。
从电子数据库（PubMed）中检索到的潜在合格文章和相关参考文献被用于文献检索，检索时间为 2022 年 1 月至 2023 年 1 月。检索策略旨在确定报告心房心律失常与心力衰竭之间关联的文章，反之亦然。我们使用以下关键词进行搜索：心房心律失常、心房颤动、心力衰竭、心律失常性心肌病、心动过速性心肌病。我们通过电子数据库搜索共找到了 620 篇文章。在总共 620 篇文章中，我们删除了 320 篇重复文章，因此选择了 300 篇合格文章。大约 150 个标题/摘要因以下原因被排除：没有原始可用数据、没有提到心房心律失常和心力衰竭相互作用、分析或证据质量非常低。我们还排除了非英文文章。当同一主题有多篇文章发表时，我们会选择包含最完整数据的文章。我们优先考虑可以在该领域提供最佳证据的所有论文。因此，本综述文章基于 104 篇参考文献。
尽管多年来人们对 AACM 和射血分数降低的心力衰竭（HFrEF）的病理生理学进行了详细研究，但心房心律失常与射血分数保留的心力衰竭（HFpEF）之间的因果关系一直是研究的热点。HFpEF 与 AA 密切相关，AA 一直被认为是重要的危险因素。在本次综述中，我们描述了心房颤动和心力衰竭之间的病理生理学联系。此外，我们阐述和讨论了 AF 和 HFpEF 的临床前和临床预测因素，以及可用治疗药物的相应靶点。最后，我们概述了有发生 AF 和 HFpEF 风险的患者表型（中心插图）。
在本次综述中，我们强调了这两种临床情况（AF 和 HFpEF）是“统一体”，因此应被视为一种单一疾病，它可以在同一患者表型中表现出来，但在不同时间表现。此外，鉴于我们目前治疗这些患者的治疗策略有限，最好在疾病的初始阶段进行早期诊断，甚至在出现 HF 的迹象和症状之前进行干预。这只有通过更加关注有潜在危险因素的患者，并通过正确的诊断方法进行有针对性的筛查才能实现。旨在通过降低体重指数、威胁潜在危险因素、降低平均心率和减少交感神经系统激活来改善这些患者的免疫代谢特征的系统方法是降低这种疾病临床影响的关键策略。
