Stanley Nattel, MD

Montreal Heart Institute

Atrial Cardiomyopathy, a new concept.

How does it help?

History of atrial cardiomyopathy

First recorded use of term “cardiomyopathy”:

History of atrial cardiomyopathy

First recorded use of term “cardiomyopathy”:

First recorded use of term “atrial cardiomyopathy”:

History of atrial cardiomyopathy

First recorded use of term “cardiomyopathy”:

First recorded use of term “atrial cardiomyopathy”:

First recorded use of term “atrial cardiomyopathy” in combination with atrial fibrillation:

Ventricular cardiomyopathy

Atrial cardiomyopathy consensus document 2016: Participating Members

European Heart Rhythm Association (EHRA)

Professor Andreas Goette Germany

Professor Jose Angel Cabrera Spain

Professor Domenico Corradi Italy

Professor Dobromir Dobrev Germany

Professor Stephane Hatem France

Professor Gregory Lip UK

Professor Gerhard Hindricks Germany

Professor Siew Yen Ho UK

Heart Rhythm Society (HRS)

Professor Stanley Nattel Canada

Asso. Professor David Van Wagoner USA

Professor Sumeet Chugh USA

Professor Mario Gonzalez USA

Doctor Robert Helm USA

Professor Katherine Murray USA

Doctor Greg Marcus USA

Asso.Professor Joseph Akar USA

Professor José Jalife USA

Professor Brian Hoit USA

Asia Pacific Heart Rhythm Society (APHRS)

Professor Jonathan Kalman Australia

Professor Prashanthan Sanders Australia

Professor Young Hoon Kim Korea

Doctor Shih-Ann Chen Taiwan

Doctor Chang-Sheng Ma China

Doctor Akihiko Nogami Japan

Sociedad Latino Americana de Estimulación Cardíaca y Electrofisiología (SOLAECE)

Doctor Luis Aguinaga Argentina

Professor Guilherme Fenelon Brazil

Doctor William Uribe Colombia

Doctor Andre d’Avila Brazil

Consensus document 2016

Published simultaneously in Europace, Heart Rhythm and Journal of Arrhythmia

Cardiac disease Risk factors

Systemic conditions Gene variants

Autonomic imbalance

Fibroblasts

Basic mechanisms leading to atrial

cardiomyopathy

AF

Angiotensin-dependent Angiotensin-independent

Cardiac disease Risk factors

Systemic conditions Gene variants

Autonomic imbalance

AF

Ion channel abnormities

Ca2+ handling abnormities

Fibrosis

Myofibroblasts

Collagen production

and secretion

AF

AF

Atrial Cardiomyopathy-

Useful concept or just another term to be forgotten?

To be of value, the term should add something to our practical

understanding and clinical management of AF cases: Evidence of value?

We predict stroke risk and decide on

anticoagulation not based on AF

characteristics, but based on factors

associated with atrial cardiomyopathy.

Atrial Cardiomyopathy- Stroke Risk Time of stroke

AF episodes

Martin DT et al, EHJ 2015

No clear relationship between timing of AF and stroke

6 months pre-stroke

No AF episodes pre-stroke

Could AF-associated stroke risk be a function of associated

atrial cardiomyopathy and not AF itself?

Nattel S et al, EHJ 2015

Atrial Cardiomyopathy-

Role in progression of AF

AF progression is largely a function of associated atrial cardiomyopathy

Collagen

Fibroblasts

Cardiomyocytes Primarily Cardiomyocyte-dependent (Class I) - lone AF

- genetic diseases

- diabetes mellitus .

Primarily Fibroblast-dependent (Class II)

- aging

- cigarette smoking

Mixed Cardiomyocyte-Fibroblast-dependent (Class III)

- CHF

- valvular diseases

Primarily Non-Collagen Deposits (Class IV)

- isolated atrial amyloidosis

- granulomatosis

- inflammatory Infiltrates

- glycosphingolipids

Non-Collagen

interstitial deposits

Classification of Atrial Cardiomyopathies

(EHRA-HRS-APHRS-SOLEACE…..EHRAS Class I-IV)

Limitations of EHRAS Classification of

Atrial Cardiomyopathies

2. Requirement for

histology

1. Assignment

overlap

3. Lack of clear

classification-based

action points

Considerations in Classification of

Atrial Cardiomyopathies

Classification indices should be readily obtained with noninvasive approaches

Classification should provide prognostic information

Classification should provide information that is useful for therapeutic decision making

Potential elements of a clinically relevant classification

of atrial cardiomyopathies

Atrial electrical dysfunction, AF

Atrial mechanical dysfunction

Procoagulant state

Atrial fibrosis

ATRIAL CARDIOMYOPATHY

Gene variants Risk factors Ventricular dysfunction Infiltrative disorders

Drug toxicity Valvular heart disease Endocrine abnormalities

1) Causal factors

c) LGE-MRI (fibrosis)

b) ECG indices

(PR; AF rate, amplitude)

a) Echo indices (LA size, contractility)

d) Biomarkers (VWF, coagulation markers)

Cardiac dysfunction

Stroke

Impaired QOL Testing for validity:

Quantifiable outcomes

2) Objective+

quantifiable

classification

measures

Therapeutic decision making

Conclusions

Atrial cardiomyopathy is an evolving concept

Conclusions

Atrial cardiomyopathy is an evolving concept

There is evidence that consideration of atrial cardiomyopathy may add value to patient management

Conclusions

Atrial cardiomyopathy is an evolving concept

There is evidence that consideration of atrial cardiomyopathy may add value to patient management

A histological classification has been suggested, but it has many limitations

Conclusions

Atrial cardiomyopathy is an evolving concept

There is evidence that consideration of atrial cardiomyopathy may add value to patient management

A histological classification has been suggested, but it has many limitations

It may be possible to develop a more clinically relevant classification by considering etiological factors and indices of electrical, mechanical and structural remodeling

Thank you!..Grazie!