AF and HFpEF are vicious twins. Both AF and HFpEF are increasing in prevalence. Patients with AF and HFpEF are heterogeneous and share clinical risk factors, like hypertension, diabetes and obesity. These factors are linked, both to each other and to adverse cardiovascular outcomes. AF is an independent prognostic factor in patients with HFpEF. It is questioned whether it is AF itself that contributes to worse prognosis, or, instead, whether AF is just a bystander being a marker of more severe atrial and ventricular diseases.
There are many unanswered questions about the pathophysiology, risk factors, symptomatology, diagnosis, and prognosis of AF and HFpEF. The diagnosis of HFpEF in AF, however, is challenging because risk factors, symptoms, and natriuretic peptides overlap, and diastolic dysfunction, a hallmark of HFpEF, is difficult to determine in AF. Additionally, treatment is cumbersome. Although it is generally assumed that eliminating AF is associated with improved outcome, so far, however, the trials did not show any benefit of attempts to abolish AF. Recent data, though, demonstrated that in patients with AF and HFpEF a strategy focusing on risk factor management, i.e. optimal therapy of HFpEF, hypertension, diabetes and obesity, instead of antiarrhythmic therapies, was associated with a favourable effect on sinus rhythm maintenance, in addition to risk factor reduction. Therefore, more systematic research is needed to answer these issues and to provide treatments that improve quality of life and reduce adverse outcomes. For that, extensive phenotyping to assess the presence of risk factors using (new) imaging techniques, measures of atrial myopathy, and of diastolic dysfunction, are essential. The central hypothesis of our proposal links AF (progression) with HFpEF (progression), and risk factors. It is our hypothesis that
- the pathophysiology and prognostic significance of AF depends on severity of risk factors;
- atrial myopathy develops in association with and as marker of ventricular myopathy;
- diabetes, hypertension and obesity play a pivotal role as risk factors for atrial and ventricular myopathy; and finally
- personalized risk factor reduction reduces AF progression, atrial myopathy and severity of HFpEF. AF, thus, is just a bystander being a marker of severity of disease.