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https://doi.org/10.15836/ccar2019.174

Pretilost i fibrilacija atrija

Juraj Jug ; Medicinski fakultet Sveučilišta u Zagrebu, Zagreb, Hrvatska
Mirna Čilić ; Medicinski fakultet Sveučilišta u Zagrebu, Zagreb, Hrvatska
Martina Lovrić Benčić   ORCID icon orcid.org/0000-0001-8446-6120 ; Medicinski fakultet Sveučilišta u Zagrebu, Zagreb, Hrvatska; Medicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
Martina Matovinović ; Medicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
Ingrid Prkačin ; Medicinski fakultet Sveučilišta u Zagrebu, Zagreb, Hrvatska 2Medicinski fakultet;

Puni tekst: hrvatski, XML (62 KB) str. 174-179 preuzimanja: 154* citiraj
APA 6th Edition
Jug, J., Čilić, M., Lovrić Benčić, M., Matovinović, M. i Prkačin, I. (2019). Pretilost i fibrilacija atrija. Cardiologia Croatica, 14 (7-8), 174-179. https://doi.org/10.15836/ccar2019.174
MLA 8th Edition
Jug, Juraj, et al. "Pretilost i fibrilacija atrija." Cardiologia Croatica, vol. 14, br. 7-8, 2019, str. 174-179. https://doi.org/10.15836/ccar2019.174. Citirano 01.12.2021.
Chicago 17th Edition
Jug, Juraj, Mirna Čilić, Martina Lovrić Benčić, Martina Matovinović i Ingrid Prkačin. "Pretilost i fibrilacija atrija." Cardiologia Croatica 14, br. 7-8 (2019): 174-179. https://doi.org/10.15836/ccar2019.174
Harvard
Jug, J., et al. (2019). 'Pretilost i fibrilacija atrija', Cardiologia Croatica, 14(7-8), str. 174-179. https://doi.org/10.15836/ccar2019.174
Vancouver
Jug J, Čilić M, Lovrić Benčić M, Matovinović M, Prkačin I. Pretilost i fibrilacija atrija. Cardiologia Croatica [Internet]. 2019 [pristupljeno 01.12.2021.];14(7-8):174-179. https://doi.org/10.15836/ccar2019.174
IEEE
J. Jug, M. Čilić, M. Lovrić Benčić, M. Matovinović i I. Prkačin, "Pretilost i fibrilacija atrija", Cardiologia Croatica, vol.14, br. 7-8, str. 174-179, 2019. [Online]. https://doi.org/10.15836/ccar2019.174
Puni tekst: engleski, XML (62 KB) str. 174-179 preuzimanja: 87* citiraj
APA 6th Edition
Jug, J., Čilić, M., Lovrić Benčić, M., Matovinović, M. i Prkačin, I. (2019). Obesity and atrial fibrillation. Cardiologia Croatica, 14 (7-8), 174-179. https://doi.org/10.15836/ccar2019.174
MLA 8th Edition
Jug, Juraj, et al. "Obesity and atrial fibrillation." Cardiologia Croatica, vol. 14, br. 7-8, 2019, str. 174-179. https://doi.org/10.15836/ccar2019.174. Citirano 01.12.2021.
Chicago 17th Edition
Jug, Juraj, Mirna Čilić, Martina Lovrić Benčić, Martina Matovinović i Ingrid Prkačin. "Obesity and atrial fibrillation." Cardiologia Croatica 14, br. 7-8 (2019): 174-179. https://doi.org/10.15836/ccar2019.174
Harvard
Jug, J., et al. (2019). 'Obesity and atrial fibrillation', Cardiologia Croatica, 14(7-8), str. 174-179. https://doi.org/10.15836/ccar2019.174
Vancouver
Jug J, Čilić M, Lovrić Benčić M, Matovinović M, Prkačin I. Obesity and atrial fibrillation. Cardiologia Croatica [Internet]. 2019 [pristupljeno 01.12.2021.];14(7-8):174-179. https://doi.org/10.15836/ccar2019.174
IEEE
J. Jug, M. Čilić, M. Lovrić Benčić, M. Matovinović i I. Prkačin, "Obesity and atrial fibrillation", Cardiologia Croatica, vol.14, br. 7-8, str. 174-179, 2019. [Online]. https://doi.org/10.15836/ccar2019.174

Rad u XML formatu

Sažetak
Pretilost se kao zdravstveni poremećaj povezuje s brojnim kroničnim bolestima. Rezultati većine istraživanja pokazuju pozitivnu povezanost patofizioloških procesa u osoba prekomjerne tjelesne mase s nastankom fibrilacije atrija (FA), njezinih komplikacija te uspješnosti liječenja. Povećano volumno opterećenje srca pri pretilosti te prekomjerno nakupljanje epikardijalnoga masnoga tkiva smatraju se glavnim uzrocima za nastanak FA-a. Osim toga, neka druga stanja poput opstruktivne apneje u spavanju mogu utjecati na ishode liječenja i učestalost pojavnosti FA-a. Ipak, postoje istraživanja koja daju oprečne rezultate. Rezultati istraživanja provedenog na Klinici za bolesti srca i
krvnih žila Kliničkog bolničkog centra Zagreb pokazali su da strukturni plan gubitka tjelesne mase smanjuje kardiometabolički rizik, a samim time i inzulinsku rezistenciju, te upalne procese u tijelu za koje se vjeruje da su bitan čimbenik nastanka FA-a. Vjerujemo kako bi se promjenom životnih navika, prije svega povećanjem tjelesne aktivnosti i smanjenjem sjedilačkog načina života, u bolesnika s povišenom tjelesnom masom moglo postići i smanjenje incidencije FA-a.

Ključne riječi
pretilost; fibrilacija atrija; aritmije

Hrčak ID: 226610

URI
https://hrcak.srce.hr/226610

▼ Article Information



Introduction

As the main preventable risk factor for the development of chronic non-infectious diseases and death, obesity is a growing public health issue in the modern world. The prevalence of obesity has nearly doubled between 1975 and 2016. In Croatia, 57.4% persons older than 18 have a body-mass index (BMI) higher than 25 kg/m2, of which 38.7% are overweight and 18.7% obese. When stratified according to sex, obesity is present in 20.8% men and 16.8% women. (1) Studies have shown that increase in mean BMI from 1.31 kg/m2 in women and 1.41 kg/m2 in men reduces the expected lifespan by one year. (2)

The association and influence between obesity and the development of atrial fibrillation (AF) has become clearer after the publication of a metanalysis according to which every round-number increase in BMI increased the risk of AF by 3.5-5.3%. (3) Obesity (defined as BMI >30 kg/m2) together with arterial hypertension (defined as increased arterial pressure values >139/89 mmHg), excessive consumption of alcohol, diabetes, smoking, and hyperlipidemia causes deterioration of the diastolic function of the heart and leads to inflammation and fatty tissue deposits in the pericardium. (4, 5)

The influence of obesity on AF can be evaluated through several other variables:

  1. Blood volume. Increased blood volume in obese persons creates a load on the heart and leads to hypertrophy and ultimately to dilatation. Left atrial (LA) enlargement as a consequence of volume overload is a well-known etiological factor for the development of AF. (6) Many studies have shown that obesity is an independent predictor for the development of ventricular diastolic disfunction, which is also a risk factor for the development of AF. (7) Abed et al. performed a randomized case-control study (8) demonstrating that participants who underwent strictly controlled physical activity and diet control experienced a reduction in body weight and improvement in diastolic heart function and reduced AF symptoms. Transthoracic echocardiography also showed improved heart structure, a reduction in LA volume and septum and inner myocardial wall thickness. Participants in the control group were orally advised on changes to diet and physical activity, but their results were not significant.

  2. Pericardial fatty tissue. The Framingham Heart Study together with another cohort study (Third Generation Cohorts) that included 2317 participants demonstrated an association between AF prevalence with pericardial fatty tissue volume as measured by CT. (9) This study indicates the important of the localization of fatty tissue, whereas its total volume in the body is less important. Pericardial fatty tissue is thus more strongly associated with AF prevalence than fatty tissue in the chest or abdomen. Epicardial fatty tissue is in direct contact with the myocardium, with which is shares microcirculation, and is metabolically active. (10) A study published in 2010 by Chekakiea et al. (11) showed that every increase in pericardial fatty tissue of 10 mL increases the chance of AF development by 13%. Wong et al. also presented the same results, with the conclusion that increase in pericardial fatty tissue also increases the chances of recurrent AF after catheter ablation. (12) Although the influence of the fatty tissue in the pericardium as a whole was studied, it is believed that periatrial fatty tissue might be a more important predictor for the development of AF. (13) This was confirmed in a study by Gierd, which noted a stronger correlation of inflammatory factors and pericardial fatty tissue thickness. (14)

  3. Obstructive sleep apnea syndrome. The mechanism of the association between AF and obstructive sleep apnea has still not been elucidated, but two possible theories have been established that could explain this phenomenon. The first focuses on distension of the atrium and pulmonary arteries due to apnea, which causes drastic changes in transmural pressure and consequent atrial dilatation. (15) The second theory connects the development of AF with vagus nerve activation due to negative tracheal pressure in apnea. (16) Sleep apnea severity can be the cause of AF resistance to antiarrhythmic therapy. (17)

Development of AF has been observed in inflammatory states such as pericarditis and myocarditis as well as after these states as a consequence of various cardiosurgical procedures. (18) Obesity is, as an inflammatory state, also a possible trigger for AF development. Many studies have focused on establishing the association between adiponectin and leptin and development of AF, and animal models have shown that leptin has a role in the scarring of the atrium and consequent development of AF. (19) Adiponectin was considered a protective factor in inflammation caused by excess fatty tissue deposits. However, current studies show that increased levels of adiponectin sometimes have a protective role. (20)

Although many studies have examined the influence of body mass on AF prognosis, the results are still controversial, so every study is important in order to contribute to better understanding of this increasingly common issue in the modern lifestyle.

Patients and Methods

This study was conducted in the Day Hospital of the Endocrinology Department at the Zagreb University Hospital Centre (UHC) between 2013 and 2016 to examine the effect of weight loss on cardiovascular risk factors and structural and functional remodeling of the heart. We included 85 obese participants (56 women and 29 men) with an average age of 58 (range 36-71). The control group comprised 40 patients of similar age and sex who only received advice for losing weight but were not regularly monitored, while 45 patients underwent an intensive program for losing body weight known as the Clinical Five-day Weight Loss Program at the Zagreb UHC Day Hospital. Differences between sexes were not compared.

The Clinical Five-day Weight Loss Program comprised professionally structured and guided lifestyle changes, changes in diet, increase in physical activity, and regulation of sleep duration and quality. All patients were clinically monitored through the polyclinic over a period of 12 months in three-month intervals, and received recommendations to improve their lifestyle (e.g. reduction in meals, dietary reduction in kcal) and to increase awareness of dietary habits (food with a lower glycemic index, adequate hydration with 1600 mL of water, increased physical activity with individual advisement more frequent than every 3 months, and the option for early phone consultations). At the start and during the monitoring, as well as at the end of the 12-month period, we performed an analysis of cardiovascular risk factors, echocardiography, ergometry, 24-hour Holter monitoring, and 24-hour continuous arterial pressure monitoring (CAPM). CRP levels, insulin and glycemia levels, and the HOMA index (determining insulin resistance; fasting serum insulin (μU/mL) × fasting plasma glucose (mmol/L) / 22.5) were measured in all patients at the start of the study and after monitoring. (21)

We excluded patients with chronic kidney disease, diabetes type 2, diabetes type 1, infection, or any acute condition.

Patients signed a written informed consent form, and the study was conducted in adherence with ethical principles.

All results were analysed with the t-test for small binary samples who served as their own controls.

Results

The results of the study showed a statistically significant improvement of left and right atrial volume, a reduction in ventricular mass, reduction in systolic pressure, and improved ergometry results. Insulin resistance measured with the HOMA index was also significantly reduced, with a significant drop in CRP.

Holter ECG showed a significant reduction in AF episodes and supraventricular extrasystoles (SVES). Ejection fraction changed somewhat less significantly after 12 months of weight loss. The number of SVES in the guided group was almost three times lower in comparison with the baseline values, whereas there were no significant changes in the control group. The average number of AF paroxysms (longer than 30 seconds) evidenced in Holter ECG was 3 times lower compared with baseline values, but there were also statistically significantly less paroxysms in the control group as well. All the above results are shown in Table 1.

TABLE 1 Results of weight loss and its impact on cardiometabolic profile.
StartAfter 12 monthsp value
Control group (n=40)Guided group (n=45)Control groupGuided group
Weight (kg)100±11100±1297±1588±12<0.01
BMI (kg/m2)36±836.8±935.5±832.7±4<0.01
Left atrium volume (mL)109±25105±19110.7±2196.6±9<0.01
Right atrium volume (mL)97±1999±996±1785±13<0.01
Ventricular mass (g)138±38139±26136±34121±20<0.01
Systolic pressure (mmHg)147±21149±16138±17132±12<0.01
Ejection fraction (%)61.5±2.860±3.461.8±2.363±3.1<0.05
MET7.3±1.37.1±1.47.0±1.08.4±1.0<0.01
HOMA8.5±412±57±39±2NS
CRP2.8±0.93.0±1.92.2±1.11.3±0.9<0.01
PAC number349±89407.5±77330.5±60162.5±48<0.01
Number of AF paroxysms64±1275±1841±825±7<0.01
BMI = body mass index, MET = equivalent 3.5mL/min/kg of body mass, CRP = C-reactive protein, PAC = premature atrial contractions, AF = atrial fibrillation with duration longer than 30 seconds, NS = not significant.

Discussion

In 2010, 12.6 million women and 20.9 million men were suffering from AF across the world. (22) It is estimated that by 2030 the EU will have 14 to 17 million patients with AF, i.e. that 120 000 to 250 000 new patients are diagnosed every year. As the population ages, prevalence and costs associated with AF are constantly increasing, and research that can contribute to insights into preventive measures for this issue is more than necessary.

Today, risk factors for AF are usually increased BMI, advanced age, and arterial hypertension. The underlying cause is a process of atherosclerosis progression that is exacerbated by elevated levels of adipocytes, leptin, interleukin (IL)-6, and MCP-1 that are secreted by adipocytes as well as tumor necrosis factor (TNFα) and MCP-1 secreted from inflammation-stimulated macrophages, with lipid deposition in fatty tissue, followed by muscles, liver, epicardium, and other organs. (23) Such accumulation exacerbates the inhibition of the insulin signal pathway by phosphorylation of the insulin receptor substrate in place of serine (due to elevated TNFα levels) instead of tyrosine. (23) Fatty tissue is an additional source of angiotensin, which is usually produced in the liver, and adipocytes also have an angiotensin receptor (AR-1) on their membrane which increases systemic arterial pressure. (24) Binding IL-6 to hepatocytes causes increased secretion of C-reactive protein (CRP), whose role in atherogenesis is considered in the light of possible causes of myocardial infarction, stroke, and peripheral artery disease. (25)

The lowered plasma CRP levels in participants together with the reduction in the number of AF paroxysms and LA volume support theories that point to the influence of CRP on the development and treatment of AF.

Girerd et al. demonstrated that elevated CRP along with increased waist circumference contribute to elevated risk for the development of postoperative AF after heart bypass surgery. (4) Research on animal models corroborates these facts. (26) In addition to total weight loss, a study by Pathak et al. also considered the fluctuations in body weight, i.e. the speed of weight loss between measurements. Participants who lost >10% of body weight had six times higher chances of not developing arrhythmias compared with those who lost <3% of body weight. On the other hand, participants with a >5% body mass fluctuation had a much higher risk for the development of recurrent AF than those with a <2% fluctuation. Therefore, AF development is facilitated by high body mass as well as large fluctuations in body mass loss. (27)

The present study showed a significant reduction in heart volume and arterial pressure as well as a reduction in arrhythmogenicity and supraventricular extrasystole episodes in the group with supervised guided weight loss, which can also be attributed to structural and electric remodeling of the heart caused by obesity. The group of patients left to pursue their own weight loss plans had poorer results than the professionally guided group. Left ventricular ejection fraction did not change significantly in either group, which could be explained by the short follow-up period.

The progression of paroxysmal to permanent AF is also associated with body mass. Tsang et al. examined 3248 participants with paroxysmal AF and found that 557 participants developed permanent AF over a period of 5 years. After excluding other risk factors such as age and sex, body weight was found to be an independent predictor in the development of permanent AF. (28)

The HOMA index is one of the markers for insulin resistance, which was very high in the present study compared with other studies, at 8.5-12.0. For example, in persons without diabetes the HOMA index is 1.85 in man and 2.07 in middle-aged women of 50 years of age. (29)

This study demonstrated that a structured approach to lifestyle changes to reduce obesity leads to significant recovery in the cardiometabolic profile. After one year of follow-up, all measured parameters were significantly reduced, except for the HOMA index.

Limitations of the study include the fact that patients were not separately analysed based on the presence or absence of sleep apnea as well as the short monitoring period for structural changes on echocardiographic examination. Additionally, no comparison was made between the male and female sexes. We plan to continue the study by following the patients over a longer period of time and to attempt to correct these limitations.

Conclusion

A structured and monitored weight loss plan reduces cardiometabolic risk within one year, and consequently also reduces insulin resistance and inflammatory processes in the body that contribute to the development of AF. We observed a significant reduction in heart volume and arterial pressure, as well as reduced frequency of AF and the number of supraventricular extrasystoles. In obese patients, we believe that gradual body mass reduction of at least 10% should be insisted upon, with the adoption of an individualized approach to every patient.

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