Author + information
- Received December 12, 2018
- Revision received May 3, 2019
- Accepted May 5, 2019
- Published online September 23, 2019.
- aFeinberg Cardiovascular and Renal Research Institute, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- bCardiac Electrophysiology, Prairie Heart Institute of Illinois, HSHS St. John's Hospital, Springfield, Illinois
- cCenter for Arrhythmia Research, University of Michigan, Ann Arbor, Michigan
- dCentro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), and CIBERCV, Madrid, Spain
- ↵∗Address for correspondence:
Dr. José Jalife, Center for Arrhythmia Research, University of Michigan, 2800 Plymouth Road, Ann Arbor, Michigan 48109.
• The authors discuss the concept of atrial myopathy; its relationship to aging, electrophysiological remodeling, and autonomic remodeling; the interplay between atrial myopathy, AF, and stroke; and suggest how to identify patients with atrial myopathy and how to incorporate atrial myopathy into decisions about anticoagulation.
• Atrial myopathy seen in animal models of AF and in patients with AF is the result of a combination of factors that lead to electrical and structural remodeling in the atrium. Although AF may lead to the initiation and/or progression of this myopathy, the presence of AF is by no means essential to the development or the maintenance of the atrial myopathic state.
• Methods to identify atrial myopathy include atrial electrograms, tissue biopsy, cardiac imaging, and certain serum biomarkers. A promising modality is 4-dimensional flow cardiac magnetic resonance. The concept of atrial myopathy may help guide oral anticoagulant therapy in selected groups of patients with AF, particularly those with low to intermediate risk of strokes and those who have undergone successful AF ablation. This review highlights the need for prospective randomized trials to test these hypotheses.
This paper discusses the evolving concept of atrial myopathy by presenting how it develops and how it affects the properties of the atria. It also reviews the complex relationships among atrial myopathy, atrial fibrillation (AF), and stroke. Finally, it discusses how to apply the concept of atrial myopathy in the clinical setting—to identify patients with atrial myopathy and to be more selective in anticoagulation in a subset of patients with AF. An apparent lack of a temporal relationship between episodes of paroxysmal AF and stroke in patients with cardiac implantable electronic devices has led investigators to search for additional factors that are responsible for AF-related strokes. Multiple animal models and human studies have revealed a close interplay of atrial myopathy, AF, and stroke via various mechanisms (e.g., aging, inflammation, oxidative stress, and stretch), which, in turn, lead to fibrosis, electrical and autonomic remodeling, and a pro-thrombotic state. The complex interplay among these mechanisms creates a vicious cycle of ever-worsening atrial myopathy and a higher risk of more sustained AF and strokes. By highlighting the importance of atrial myopathy and the risk of strokes independent of AF, this paper reviews the methods to identify patients with atrial myopathy and proposes a way to incorporate the concept of atrial myopathy to guide anticoagulation in patients with AF.
Dr. Arora is an owner of Rhythm Therapeutics, Inc. Dr. Jalife has received a research grant from Medtronic. Dr. Shen has reported that he has no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Basic to Translational Science author instructions page.
- Received December 12, 2018.
- Revision received May 3, 2019.
- Accepted May 5, 2019.
- 2019 The Authors
- Central Illustration
- Atrial Myopathy: The Concept
- Atrial Myopathy and the Aging Heart
- Atrial Myopathy and Electrophysiological Remodeling
- Atrial Myopathy and Autonomic Remodeling
- Atrial Myopathy: Its Interplay between AF and Stroke
- Atrial Myopathy: a Logical Explanation to the Lack of Temporal Relationships Between AF and Stroke
- Atrial Myopathy: Translating the Concept Into Clinical Practice