Atrial Fibrillation and COPD: shared pathways and implications for cardiovascular health

Episode 2 of webinar series "Hypertension and Atrial Fibrillation: a risky couple even more when the family expands".

Summary:

Chronic obstructive pulmonary disease (COPD) is present in up to 23% of patients with atrial fibrillation (AF), a prevalence double as in the general population. Also COPD patients have a 20-30% increased risk of AF, which further increases along with decrease in pulmonary function, frequent exacerbations and left atrial dilatation.

Pathophysiologic mechanisms of the arrhythmogenic mechanisms in COPD patients are diverse. Both intrinsic factors of the disease itself (i.e. systemic inflammation, oxidative stress) as well as changes in physiology (i.e. hypercapnia, hypoxia, autonomic dysfunction, pulmonary hypertension) could explain this increased arrhythmogenicity. In addition, concomitant comorbidities like systemic arterial hypertension, obesity, obstructive sleep apnoea and coronary artery disease may contribute critically to the structural and electrical atrial substrate (remodeling). These comorbidities should be therefore promptly recognized and properly treated. Also, in patients where these comorbidities coexist, the differential diagnosis of dyspnea symptoms could be cumbersome and patients should be systematically screened for COPD or for (diastolic) heart failure including ECG, lab test (for natriuretic peptides) and echocardiogram. The importance of increased atrial ectopic activity for future development of AF was also demonstrated and ECG monitoring is therefore performed also for this purpose.

Finally, management and treatment of COPD patients with AF is particularly challenging, both for rhythm and rate control. Observational data suggest that COPD promotes AF progression, increases AF recurrence after cardioversion, and reduces the efficacy of catheter-based antiarrhythmic therapy. Also, beta-blockers are less frequently prescribed in COPD patients because of potential side effects related to bronchoconstriction.

Overall, the diagnosis and treatment of COPD in AF patients is of crucial clinical importance and necessitates a close interdisciplinary collaboration and a structured follow-up. Treatment of the underlying conditions and risk factors should also be pursued. This implies also continuous patient education: it is crucial that patients understand how lifestyle management can contribute to improving clinical outcomes.