Obesity, Exercise, Obstructive Sleep Apnea, and Modifiable Atherosclerotic Cardiovascular Disease Risk Factors in Atrial Fibrillation.

Classically, the 3 pillars of atrial fibrillation (AF) management have included anticoagulation for prevention of thromboembolism, rhythm control, and rate control. In both prevention and management of AF, a growing body of evidence supports an increased role for comprehensive cardiac risk factor modification (RFM), herein defined as management of traditional modifiable cardiac risk factors, weight loss, and exercise. In this narrative review, we summarize the evidence demonstrating the importance of each facet of RFM in AF prevention and therapy. Additionally, we review emerging data on the importance of weight loss and cardiovascular exercise in prevention and management of AF.

[1]  G. Lip,et al.  Inflammation in atrial fibrillation. , 2012, Journal of the American College of Cardiology.

[2]  Catherine R. Rahilly-Tierney,et al.  Regular Physical Activity and Risk of Atrial Fibrillation: A Systematic Review and Meta-analysis , 2013, Circulation. Arrhythmia and electrophysiology.

[3]  Christopher X. Wong,et al.  Obesity and the Risk of Incident, Post-Operative, and Post-Ablation Atrial Fibrillation: A Meta-Analysis of 626,603 Individuals in 51 Studies. , 2015, JACC. Clinical electrophysiology.

[4]  H. Hense,et al.  The aging process of the heart: obesity is the main risk factor for left atrial enlargement during aging the MONICA/KORA (monitoring of trends and determinations in cardiovascular disease/cooperative research in the region of Augsburg) study. , 2009, Journal of the American College of Cardiology.

[5]  C. Murray,et al.  Worldwide Epidemiology of Atrial Fibrillation: A Global Burden of Disease 2010 Study , 2014, Circulation.

[6]  H. Kottkamp Human atrial fibrillation substrate: towards a specific fibrotic atrial cardiomyopathy. , 2013, European heart journal.

[7]  N. Lundbom,et al.  Epicardial fat, cardiac dimensions, and low-grade inflammation in young adult monozygotic twins discordant for obesity. , 2012, The American journal of cardiology.

[8]  A. Folsom,et al.  Smoking and incidence of atrial fibrillation: results from the Atherosclerosis Risk in Communities (ARIC) study. , 2011, Heart Rhythm.

[9]  J. McMurray,et al.  Population prevalence, incidence, and predictors of atrial fibrillation in the Renfrew/Paisley study , 2001, Heart.

[10]  B. Gersh,et al.  Obstructive Sleep Apnea and the Recurrence of Atrial Fibrillation , 2003, Circulation.

[11]  F. Greenway,et al.  Obesity Increases the Production of Proinflammatory Mediators from Adipose Tissue T Cells and Compromises TCR Repertoire Diversity: Implications for Systemic Inflammation and Insulin Resistance , 2010, The Journal of Immunology.

[12]  Y. Ohashi,et al.  Alcohol consumption and risk of atrial fibrillation: a meta-analysis. , 2011, Journal of the American College of Cardiology.

[13]  P. Kowey,et al.  Efficacy and safety of prescription omega-3 fatty acids for the prevention of recurrent symptomatic atrial fibrillation: a randomized controlled trial. , 2010, JAMA.

[14]  T. Assimes,et al.  Obesity, Physical Activity, and Their Interaction in Incident Atrial Fibrillation in Postmenopausal Women , 2014, Journal of the American Heart Association.

[15]  S. Kaul,et al.  Prevention of atrial fibrillation with omega-3 fatty acids: a meta-analysis of randomised clinical trials , 2011, Heart.

[16]  T. Chao,et al.  Atrial substrate properties and outcome of catheter ablation in patients with paroxysmal atrial fibrillation associated with diabetes mellitus or impaired fasting glucose. , 2010, The American journal of cardiology.

[17]  D. Goff,et al.  Impact of intensive glycemic control on the incidence of atrial fibrillation and associated cardiovascular outcomes in patients with type 2 diabetes mellitus (from the Action to Control Cardiovascular Risk in Diabetes Study). , 2014, The American journal of cardiology.

[18]  G Van Nooten,et al.  Variations of autonomic tone preceding onset of atrial fibrillation after coronary artery bypass grafting. , 1998, The American journal of cardiology.

[19]  V. Somers,et al.  Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation. , 2007, Journal of the American College of Cardiology.

[20]  R. Mahajan,et al.  Impact of CARDIOrespiratory FITness on Arrhythmia Recurrence in Obese Individuals With Atrial Fibrillation: The CARDIO-FIT Study. , 2015, Journal of the American College of Cardiology.

[21]  M. Nieminen,et al.  Angiotensin II receptor blockade reduces new-onset atrial fibrillation and subsequent stroke compared to atenolol: the Losartan Intervention For End Point Reduction in Hypertension (LIFE) study. , 2005, Journal of the American College of Cardiology.

[22]  D. Levy,et al.  Influence of blood pressure on left atrial size. The Framingham Heart Study. , 1995, Hypertension.

[23]  S. Keteyian,et al.  Cardiorespiratory Fitness and Risk of Incident Atrial Fibrillation: Results From the Henry Ford Exercise Testing (FIT) Project , 2015, Circulation.

[24]  B. Davis,et al.  Atrial fibrillation at baseline and during follow-up in ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). , 2009, Journal of the American College of Cardiology.

[25]  Marek Belohlavek,et al.  Comparison of cardiac structural and functional changes in obese otherwise healthy adults with versus without obstructive sleep apnea. , 2007, The American journal of cardiology.

[26]  D. Leong,et al.  Impact of weight reduction on pericardial adipose tissue and cardiac structure in patients with atrial fibrillation. , 2015, American heart journal.

[27]  J. Manson,et al.  The long- and short-term impact of elevated body mass index on the risk of new atrial fibrillation the WHS (women's health study). , 2010, Journal of the American College of Cardiology.

[28]  Dhaval Shah,et al.  Treatment of obstructive sleep apnea reduces the risk of atrial fibrillation recurrence after catheter ablation. , 2012, Journal of the American College of Cardiology.

[29]  G. Wassmer,et al.  Statins for prevention of atrial fibrillation after cardiac surgery: a systematic literature review. , 2009, The Journal of thoracic and cardiovascular surgery.

[30]  K. Filion,et al.  Meta-analysis of cohort and case-control studies of type 2 diabetes mellitus and risk of atrial fibrillation. , 2011, The American journal of cardiology.

[31]  Prashanthan Sanders,et al.  Pericardial fat is associated with atrial fibrillation severity and ablation outcome. , 2011, Journal of the American College of Cardiology.

[32]  J. Brugada,et al.  Sport practice and the risk of lone atrial fibrillation: a case-control study. , 2006, International journal of cardiology.

[33]  J. D. Ward,et al.  Autonomic neuropathy is associated with increased cardiovascular risk factors: the EURODIAB IDDM Complications Study , 2002, Diabetic medicine : a journal of the British Diabetic Association.

[34]  H. May,et al.  Clinical predictors of risk for atrial fibrillation: implications for diagnosis and monitoring. , 2014, Mayo Clinic proceedings.

[35]  D. Levy,et al.  Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study. , 1994, JAMA.

[36]  J. Brugada,et al.  Long-lasting sport practice and lone atrial fibrillation. , 2002, European heart journal.

[37]  Yuan Zhang,et al.  Obesity results in progressive atrial structural and electrical remodeling: implications for atrial fibrillation. , 2013, Heart rhythm.

[38]  J. Olgin,et al.  Racial differences in atrial fibrillation prevalence and left atrial size. , 2010, The American journal of medicine.

[39]  M. Ezekowitz,et al.  2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. , 2014, Circulation.

[40]  David D. McManus,et al.  Simple Risk Model Predicts Incidence of Atrial Fibrillation in a Racially and Geographically Diverse Population: the CHARGE‐AF Consortium , 2013, Journal of the American Heart Association.

[41]  A. Sharrett,et al.  Blood Lipid Levels, Lipid-Lowering Medications, and the Incidence of Atrial Fibrillation: The Atherosclerosis Risk in Communities Study , 2012, Circulation. Arrhythmia and electrophysiology.

[42]  Curt D. Furberg,et al.  Physical Activity and Incidence of Atrial Fibrillation in Older Adults: The Cardiovascular Health Study , 2008, Circulation.

[43]  Fernando Costa,et al.  Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Ph , 2003, Circulation.

[44]  M. Lamberts,et al.  Obesity is a risk factor for atrial fibrillation among fertile young women: a nationwide cohort study. , 2013, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[45]  Thomas Lumley,et al.  Diabetes Mellitus, Glycemic Control, and Risk of Atrial Fibrillation , 2010, Journal of General Internal Medicine.

[46]  J. Brophy,et al.  Fish oil for the reduction of atrial fibrillation recurrence, inflammation, and oxidative stress. , 2014, Journal of the American College of Cardiology.

[47]  Moyses Szklo,et al.  Blood Lipids and the Incidence of Atrial Fibrillation: The Multi‐Ethnic Study of Atherosclerosis and the Framingham Heart Study , 2014, Journal of the American Heart Association.

[48]  L H Kuller,et al.  Incidence of and risk factors for atrial fibrillation in older adults. , 1997, Circulation.

[49]  F A Mathewson,et al.  The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba Follow-Up Study. , 1995, The American journal of medicine.

[50]  Mark E. Anderson,et al.  Progress toward the prevention and treatment of atrial fibrillation: A summary of the Heart Rhythm Society Research Forum on the Treatment and Prevention of Atrial Fibrillation, Washington, DC, December 9-10, 2013. , 2015, Heart rhythm.

[51]  L. Fauchier,et al.  Antiarrhythmic effect of statin therapy and atrial fibrillation a meta-analysis of randomized controlled trials. , 2008, Journal of the American College of Cardiology.

[52]  R. Bai,et al.  HbA1c levels as predictors of ablation outcome in type 2 diabetes mellitus and paroxysmal atrial fibrillation , 2015, Herz.

[53]  K. Flegal,et al.  Prevalence of childhood and adult obesity in the United States, 2011-2012. , 2014, JAMA.

[54]  Yenn-Jiang Lin,et al.  Heart failure epicardial fat increases atrial arrhythmogenesis. , 2013, International journal of cardiology.

[55]  Paul J. Wang,et al.  Risk factors for atrial fibrillation and their population burden in postmenopausal women: the Women's Health Initiative Observational Study , 2013, Heart.

[56]  D. Singer,et al.  Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. , 2013, The American journal of cardiology.

[57]  Christopher X. Wong,et al.  Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort: A Long-Term Follow-Up Study (LEGACY). , 2015, Journal of the American College of Cardiology.

[58]  Rajiv Mahajan,et al.  Electrophysiological, Electroanatomical, and Structural Remodeling of the Atria as Consequences of Sustained Obesity. , 2015, Journal of the American College of Cardiology.

[59]  R. Mahajan,et al.  Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: the ARREST-AF cohort study. , 2014, Journal of the American College of Cardiology.

[60]  S. Johnston,et al.  Estimation of Total Incremental Health Care Costs in Patients With Atrial Fibrillation in the United States , 2011, Circulation. Cardiovascular quality and outcomes.

[61]  J. Ector,et al.  Obesity is a major determinant of radiation dose in patients undergoing pulmonary vein isolation for atrial fibrillation. , 2007, Journal of the American College of Cardiology.

[62]  E. Kazerooni,et al.  Increased epicardial fat is independently associated with the presence and chronicity of atrial fibrillation and radiofrequency ablation outcome , 2015, European Radiology.

[63]  K. Liestøl,et al.  Upper Normal Blood Pressures Predict Incident Atrial Fibrillation in Healthy Middle-Aged Men: A 35-Year Follow-Up Study , 2012, Hypertension.

[64]  Nish Chaturvedi,et al.  Vascular risk factors and diabetic neuropathy. , 2005, The New England journal of medicine.

[65]  Sunil K. Agarwal,et al.  Absolute and Attributable Risks of Atrial Fibrillation in Relation to Optimal and Borderline Risk Factors: The Atherosclerosis Risk in Communities (ARIC) Study , 2011, Circulation.

[66]  F. Abboud,et al.  Sympathetic neural mechanisms in obstructive sleep apnea. , 1995, The Journal of clinical investigation.

[67]  Gregory Y H Lip,et al.  Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. , 2010, Chest.

[68]  E. Benjamin,et al.  Body fat, body fat distribution, lean body mass and atrial fibrillation and flutter. A Danish cohort study , 2014, Obesity.

[69]  W. Abhayaratna,et al.  Effect of weight reduction and cardiometabolic risk factor management on symptom burden and severity in patients with atrial fibrillation: a randomized clinical trial. , 2013, JAMA.

[70]  John K Triedman,et al.  A multicenter experience with novel implantable cardioverter defibrillator configurations in the pediatric and congenital heart disease population. , 2005, Journal of cardiovascular electrophysiology.

[71]  D. Levy,et al.  Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. , 1998, Circulation.

[72]  H. Müderrisoğlu,et al.  Arrhythmogenic Evidence for Epicardial Adipose Tissue: Heart Rate Variability and Turbulence are Influenced by Epicardial Fat Thickness , 2015, Pacing and clinical electrophysiology : PACE.

[73]  S. Anderson,et al.  Physical activity and incidence of atrial fibrillation: a systematic review and meta-analysis. , 2014, International journal of cardiology.

[74]  J. Kalifa,et al.  Safety and efficacy of catheter ablation of atrial fibrillation in patients with diabetes mellitus—single center experience , 2007, Journal of Interventional Cardiac Electrophysiology.

[75]  Paul A Friedman,et al.  Association of Atrial Fibrillation and Obstructive Sleep Apnea , 2004, Circulation.