Atrial fibrillation and sympatho–vagal imbalance: from the choice of the antiarrhythmic treatment to patients with syncope and ganglionated plexi ablation

Abstract

For several years, the autonomic nervous system has played a central role in the pathophysiological mechanism of atrial fibrillation (AF), so much so that it has been considered one of the cornerstones of Coumel’s triangle. The clinical and therapeutic management of AF secondary to sympatho–vagal imbalance represents one of the most important examples of how precision medicine should be applied. Increasing knowledge of this kind of arrhythmias has made it possible to select specific antiarrhythmic drugs and to diversify their use according to vagal or adrenergic AF forms. Ablative strategies, such as cardioneuroablation and non-direct cardiac neuromodulation methods (such as renal denervation and peripheral vagal stimulation), have gradually emerged. In the possibly near future, there will be a development of new acquisitions regarding new pharmacological therapeutic strategies and gene therapy. Finally, finding an AF in patients experiencing syncopal episodes opens a whole chapter regarding interesting, but also complex, diagnostic and therapeutic strategies, ranging from neurally mediated forms to convulsive seizure that could also increase the risk of sudden death.

Incidental and anticipated arrhythmic diagnoses in patients with an implantable cardiac monitor

“…Similarly, Pecha et al 16 highlighted how the ILR allows the detection and treatment of clinically asymptomatic bradyarrhythmias in this setting of patients. Also, our incidental finding of atrial fibrillation in patients implanted for syncope may provide insights into the underlying cause of unexplained loss of consciousness as previously investigated 17–20 . In our study, clinical interventions following ICM findings were performed in approximately one in four patients within a relatively short timeframe.…”

“…Also, our incidental finding of atrial fibrillation in patients implanted for syncope may provide insights into the underlying cause of unexplained loss of consciousness as previously investigated. [17][18][19][20] In our study, clinical interventions following ICM findings were performed in approximately one in four patients within a relatively short timeframe. It is noteworthy that the study involved the period of the COVID-19 pandemic that led to a deferral of nonurgent interventions and a reduction in elective CIED implantations in several arrhythmia centers.…”

Circulating neuropeptide Y as a biomarker in postoperative atrial fibrillation cases administered off-pump coronary bypass Graft surgery

“…Mechanistically, NPY-Y2 receptors found on vagal neurons regulate sympatho-vagal cross-talk [ 37 ]. Vagal AF, often occurring without structural heart disease, tends to be maintained by shortening the atrial effective refractory period [ 38 , 39 ]. Furthermore, the present study found that increased HF was associated with POAF, implying high NPY levels may stimulate vagal neurons, which contributes to POAF maintenance.…”