Atrial cardiomyopathy

Atrial cardiomyopathy

The term atrial cardiomyopathy was used initially in 1972 to describe familial atrial cardiomyopathy with heart block and later atrial standstill [1]. In 1997, the concept of tachycardia induced atrial cardiomyopathy in atrial fibrillation was suggested. Electrophysiological and anatomic remodeling of the atria were considered part of atrial cardiomyopathy which led to maintenance of atrial fibrillation (AF) [2].

Fibrotic atrial cardiomyopathy was proposed as specific disease or syndrome supplying substrates for atrial fibrillation, atrial tachycardia, dual nodal disease and thromboembolic complications in 2012 [3]. The author cited the concept of ‘AF begets AF’ which was considered to be the result of tachycardia induced atrial remodeling. It was also suggested that the so called ‘lone AF’ may have an undetected chronic substrate.

Atrial fibrosis correlates with persistence and burden of atrial fibrillation. Gadolinium enhanced magnetic resonance imaging may be used to detect and quantify atrial fibrotic substrate, though with some limitations. Presence of an atrial substrate has also been invoked by the fact that popular scores incompletely account for thromboembolic risk. It is also known that stroke can occur in patient with AF even after sinus rhythm is restored [4].

A multi-society expert consensus statement on atrial cardiomyopathy was published in 2016 [5]. A review in 2017 asked whether atrial cardiomyopathy is a useful notion in cardiac disease management or just a passing fad. They noted the paucity of citations on Medline, just 39 at that time, suggesting limited use of the term [6]. As on date, a PubMed search on “atrial cardiomyopathy” has just 181 results. Still, there is an article in 2021 describing atrial cardiomyopathy as an emerging cause for Embolic Stroke of Undetermined Source (ESUS) [7].

The 2020 ESC/EACTS guidelines caution us that withholding oral anticoagulants after left atrial appendage occlusion is likely to result in undertreating the overall risk of stroke related to atrial cardiomyopathy [8]. The guidelines also mentioned the role of drugs which affect the atrial remodeling process in prevention of new onset atrial fibrillation, acting as non-conventional anti arrhythmic drugs, termed as upstream therapy. The drug groups included as upstream therapy were angiotensin converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, beta blockers and statins. But the evidence is not convincing in most cases.

The risk factors in the scoring systems used to assess thromboembolic risk in atrial fibrillation are also causes for atrial disease or cardiomyopathy. It is possible that the presence and type of atrial cardiomyopathy is an independent predictor of stroke in patients with atrial fibrillation [6].

References

1. Nagle RE, Smith B, Williams DO. Familial atrial cardiomyopathy with heart block. Br Heart J. 1972 Feb;34(2):205. PMID: 5007810.
2. Zipes DP. Atrial fibrillation. A tachycardia-induced atrial cardiomyopathy. Circulation. 1997 Feb 4;95(3):562-4. doi: 10.1161/01.cir.95.3.562. PMID: 9024138.
3. Kottkamp H. Fibrotic atrial cardiomyopathy: a specific disease/syndrome supplying substrates for atrial fibrillation, atrial tachycardia, sinus node disease, AV node disease, and thromboembolic complications. J Cardiovasc Electrophysiol. 2012 Jul;23(7):797-9. doi: 10.1111/j.1540-8167.2012.02341.x. Epub 2012 May 3. PMID: 22554187.
4. Hirsh BJ, Copeland-Halperin RS, Halperin JL. Fibrotic atrial cardiomyopathy, atrial fibrillation, and thromboembolism: mechanistic links and clinical inferences. J Am Coll Cardiol. 2015 May 26;65(20):2239-51. doi: 10.1016/j.jacc.2015.03.557. PMID: 25998669.
5. Goette A, Kalman JM, Aguinaga L, Akar J, Cabrera JA, Chen SA, Chugh SS, Corradi D, D’Avila A, Dobrev D, Fenelon G, Gonzalez M, Hatem SN, Helm R, Hindricks G, Ho SY, Hoit B, Jalife J, Kim YH, Lip GY, Ma CS, Marcus GM, Murray K, Nogami A, Sanders P, Uribe W, Van Wagoner DR, Nattel S; Document Reviewers:. EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication. Europace. 2016 Oct;18(10):1455-1490. doi: 10.1093/europace/euw161. Epub 2016 Jul 8. PMID: 27402624; PMCID: PMC6392440.
6. Guichard JB, Nattel S. Atrial Cardiomyopathy: A Useful Notion in Cardiac Disease Management or a Passing Fad? J Am Coll Cardiol. 2017 Aug 8;70(6):756-765. doi: 10.1016/j.jacc.2017.06.033. PMID: 28774383.
7. Ning Y, Tse G, Luo G, Li G. Atrial Cardiomyopathy: An Emerging Cause of the Embolic Stroke of Undetermined Source. Front Cardiovasc Med. 2021 Aug 9;8:674612. doi: 10.3389/fcvm.2021.674612. PMID: 34434973; PMCID: PMC8382140.
8. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. doi: 10.1093/eurheartj/ehaa612. Erratum in: Eur Heart J. 2021 Feb 1;42(5):507. Erratum in: Eur Heart J. 2021 Feb 1;42(5):546-547. Erratum in: Eur Heart J. 2021 Oct 21;42(40):4194. PMID: 32860505.