Elsevier

Heart Rhythm

Volume 14, Issue 1, January 2017, Pages e3-e40
Heart Rhythm

EHRA/HRS/APHRS/SOLAECE Document-Reviewers 2016
EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: Definition, characterization, and clinical implication

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Introduction and definition of atrial cardiomyopathy

The atria provide an important contribution to cardiac function.1, 2 Besides their impact on ventricular filling, they serve as a volume reservoir, host pacemaker cells and important parts of the cardiac conduction system (e.g. sinus node, AV node), and secrete natriuretic peptides like atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) that regulate fluid homeostasis. Atrial myocardium is affected by many cardiac and non-cardiac conditions3 and is, in some respects, more

Gross morphology

Each atrium has a morphologically characteristic atrial body and appendage (Figure 4). In the body, there is a venous component with the orifices of the systemic or pulmonary veins (PVs) and a vestibular component that surrounds the atrial outlet.20 The interatrial septum (IAS) separates the atrial bodies. The venous component of the left atrium (LA) is located posterosuperiorly and receives the PVs at the four corners, forming a prominent atrial dome. The LA is situated more posteriorly and

Atrial-selective electrophysiological properties

The atria have a number of electrophysiological features that distinguish them from the ventricles and govern their arrhythmia susceptibility.

Action potential/ion-channel properties

Atrial cardiomyocytes have distinct action potential (AP) properties from ventricular cardiomyocytes, resulting in a large part from distinct ion-channel properties and distribution (Figure 6A).36, 37 Atrial background inward-rectifier K+ current (IK1) is smaller than that of ventricular K+ current, resulting in a less negative resting potential and more

Lone atrial fibrillation (atrial fibrillation without concomitant conditions)

‘Lone’ atrial fibrillation (LAF) is diagnosed when no apparent explanation or underlying comorbidity can be identified.65, 66 Over the last few years, new epidemiological associations with AF have emerged and the number of true LAF cases has progressively decreased.67 Like AF associated with comorbidities, LAF occurs more frequently in males than in females with a ratio of 3 to 4:1.68 Recent studies have shown that true cases of LAF can be diagnosed even in subjects older than 60 years, so that

Impact of atrial cardiomyopathies on occurrence of atrial fibrillation and atrial arrhythmia

Controversy about the mechanism of AF has been alive for over 100 years, yet given the continued increase in worldwide burden of AF,233 ongoing investigation will drive improved treatment and prevention. Currently, there are two opposing sides in the debate about re-entrant mechanisms in AF. On one side are those who promote variants of the original idea of Gordon Moe that fibrillation, whether atrial or ventricular, results from the continued random propagation of multiple independent electric

Atrial inflammation and inflammatory biomarkers

Infiltration of neutrophils, macrophages, and lymphocytes accompanies surgical injury or pericarditis, promoting the development of atrial fibrosis, resulting in heterogeneous and slowed conduction, a risk factor for re-entrant arrhythmia.257, 258, 259, 260, 261 This provides a mechanistic link between inflammatory activation and atrial arrhythmogenesis. Anti-inflammatory interventions such as prednisone are effective in preventing neutrophil infiltration in sterile pericarditis and in

Imaging techniques to detect atrial cardiomyopathies mapping and ablation in atrial cardiomyopathies

It is well established that an enlarged LA is associated with adverse cardiovascular outcomes.311, 312, 313, 314, 315, 316 In the absence of MVD, an increase in LA size most commonly reflects increased wall tension as a result of increased LA pressure,317, 318, 319, 320 as well as impairment in LA function secondary to atrial myopathy.321, 322 A clear relationship exists between an enlarged LA and the incidence of atrial fibrillation and stroke,323, 324, 325, 326, 327, 328, 329, 330, 331, 332

Conclusion

Atrial cardiomyopathies as defined in this consensus paper have a significant impact on atrial function and arrhythmogenesis. The EHRAS classification (EHRAS Class I – IV) is a first attempt to characterize atrial pathologies into discrete cohorts. Because disease-related histological changes in atrial tissue are often poorly characterized, not necessarily specific and vary considerably over time their classification is challenging. Further studies are needed to implement and validate the EHRAS

Conflict of interest

A detailed list of disclosures of financial relations is provided as Supplementary material online.

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    Endorsed by EHRA, APHRS, SOLAECE in May 2016, by HRS, AHA, ACC in June 2016. Developed in partnership with the European Heart Rhythm Association (EHRA) [a registered branch of the European Society of Cardiology (ESC)], the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Sociedad Latino Americana de Estimulación Cardĺacay Electrofisiologĺa (SOLAECE), and in collaboration with the American College of Cardiology (ACC), the American Heart Association (AHA).

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