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