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The case of diabetes mellitus and atrial fibrillation: Underlining the importance of non-cardiovascular comorbidities

  • Marco Proietti
    Correspondence
    Corresponding author at: Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Via Camaldoli 64, Milan 20138, Italy.
    Affiliations
    Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy

    Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Via Camaldoli 64, Milan 20138, Italy

    Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
    Search for articles by this author
  • Giulio Francesco Romiti
    Affiliations
    Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom

    Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
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  • Stefania Basili
    Affiliations
    Department of Translational and Precision Medicine, Sapienza – University of Rome, Rome, Italy
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Published:June 27, 2022DOI:https://doi.org/10.1016/j.ejim.2022.06.017
The case of diabetes mellitus and atrial fibrillation: Underlining the importance of non-cardiovascular comorbidities
Previous ArticleNot all the eggs and the chickens are the same: The case of uric acid and metabolic syndrome
Next ArticleImpact of diabetes on the management and outcomes in atrial fibrillation: an analysis from the ESC-EHRA EORP-AF Long-Term General Registry
      In the currently changing scenario, in which our patients are progressively older and more likely burdened by concomitant chronic long-term conditions [

      World Health Organization Integrated Health Services. Multimorbidity: technical series on safer primary care.; 2016. https://www.who.int/publications/i/item/9789241511650.

      ], diabetes mellitus (DM) play a prominent role in determining the health state of patients worldwide [
      • Lin X.
      • Xu Y.
      • Pan X.
      • et al.
      Global, regional, and national burden and trend of diabetes in 195 countries and territories: an analysis from 1990 to 2025.
      Sci Rep. 2020; 10: 14790https://doi.org/10.1038/s41598-020-71908-9
      ]. In particular a strict relationship exists between DM and atrial fibrillation (AF), which is one of the most common cardiovascular conditions [
      • Hindricks G.
      • Potpara T.
      • Dagres N.
      • et al.
      2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS).
      Eur Heart J. 2021; 42: 373-498https://doi.org/10.1093/eurheartj/ehaa612
      ]. Indeed, DM is now recognized as one of the most important risk factors leading to the development of AF, with a number of mechanisms involved in determining this relationship [
      • Boriani G.
      • Proietti M.
      Atrial fibrillation prevention: an appraisal of current evidence.
      Heart. 2018; 104: 882-887https://doi.org/10.1136/heartjnl-2017-311546
      ,
      • Wang A.
      • Green J.B.
      • Halperin J.L.
      • Piccini J.P.
      Atrial fibrillation and diabetes mellitus: JACC review topic of the week.
      J Am Coll Cardiol. 2019; 74: 1107-1115https://doi.org/10.1016/j.jacc.2019.07.020
      ]. Indeed, through the relationship between glycaemic fluctuations, oxidative stress and inflammation, the presence of DM promotes incident AF, also with a “dose-response” relationship between the severity and duration of disease [
      • Wang A.
      • Green J.B.
      • Halperin J.L.
      • Piccini J.P.
      Atrial fibrillation and diabetes mellitus: JACC review topic of the week.
      J Am Coll Cardiol. 2019; 74: 1107-1115https://doi.org/10.1016/j.jacc.2019.07.020
      ]. Furthermore, data are consistent in reporting that the management of DM is effective in reducing the risk of AF as much as the disease is controlled [
      • Boriani G.
      • Proietti M.
      Atrial fibrillation prevention: an appraisal of current evidence.
      Heart. 2018; 104: 882-887https://doi.org/10.1136/heartjnl-2017-311546
      ]. Furthermore, beyond being part of the CHA2DS2-VASc score for the evaluation of the baseline thromboembolic risk [
      • Hindricks G.
      • Potpara T.
      • Dagres N.
      • et al.
      2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS).
      Eur Heart J. 2021; 42: 373-498https://doi.org/10.1093/eurheartj/ehaa612
      ], the presence of DM increases overall the risk of all the AF-related adverse outcomes [
      • Boriani G.
      • Vitolo M.
      • Diemberger I.
      • et al.
      Optimizing indices of atrial fibrillation susceptibility and burden to evaluate atrial fibrillation severity, risk and outcomes.
      Cardiovasc Res. 2021; 117: 1-21https://doi.org/10.1093/cvr/cvab147
      ]. Indeed, in the last years, several studies (Table 1) have shown a largely ranging prevalence of DM among AF cohort (between ∼ 20% and 30%), and substantially agreed on the independent increase of risk for all the major AF-associated clinical outcomes (all-cause death, cardiovascular death, major adverse cardiovascular events) in DM patients [
      • Echouffo-Tcheugui J.B.
      • Shrader P.
      • Thomas L.
      • et al.
      Care patterns and outcomes in atrial fibrillation patients with and without diabetes: ORBIT-AF registry.
      J Am Coll Cardiol. 2017; 70: 1325-1335https://doi.org/10.1016/j.jacc.2017.07.755
      ,
      • Patti G.
      • Lucerna M.
      • Cavallari I.
      • et al.
      Insulin-requiring versus noninsulin-requiring diabetes and thromboembolic risk in patients with atrial fibrillation: PREFER in AF.
      J Am Coll Cardiol. 2017; 69: 409-419https://doi.org/10.1016/j.jacc.2016.10.069
      ,
      • Fumagalli S.
      • Said S.A.
      • Laroche C.
      • et al.
      Management and prognosis of atrial fibrillation in diabetic patients: an EORP-AF general pilot registry report.
      Eur Hear J Cardiovasc Pharmacother. 2018; 4: 172-179https://doi.org/10.1093/ehjcvp/pvx037
      ,
      • García-Fernández A.
      • Esteve-Pastor M.A.
      • Roldán-Rabadán I.
      • et al.
      Relationship of adverse events to quality of anticoagulation control in atrial fibrillation patients with diabetes: real-world data from the FANTASIIA registry.
      Ann Med. 2020; 52: 300-309https://doi.org/10.1080/07853890.2020.1778176
      ,
      • Krittayaphong R.
      • Aroonsiriwattana S.
      • Ngamjanyaporn P.
      • Patmuk T.
      • Kaewkumdee P.
      Outcomes of patients with atrial fibrillation with and without diabetes: a propensity score matching of the COOL-AF registry.
      Int J Clin Pract. 2021; 75https://doi.org/10.1111/ijcp.14671
      ].
      Table 1Relationship between diabetes mellitus and outcomes in atrial fibrillation patients.
      Study Year Geographic Location N DM Patients

      N (%)      		 Results
      ORBIT-AF
      • Echouffo-Tcheugui J.B.
      • Shrader P.
      • Thomas L.
      • et al.
      Care patterns and outcomes in atrial fibrillation patients with and without diabetes: ORBIT-AF registry.
      J Am Coll Cardiol. 2017; 70: 1325-1335https://doi.org/10.1016/j.jacc.2017.07.755
      		 2017 US 9749 2874 (29.5) DM increases the risk of all the outcomes examined, as all-cause death (aHR 1.63, 95% CI 1.04–2.56 in patients <70 years and aHR 1.25, 95% CI 1.09–1.44 in patients ≥70 years) and CV death (aHR 2.20, 95% CI 1.22–3.98 in patients <70 years and aHR 1.24, 95% CI 1.02–1.51 in patients ≥70 years)
      PREFER-AF
      • Patti G.
      • Lucerna M.
      • Cavallari I.
      • et al.
      Insulin-requiring versus noninsulin-requiring diabetes and thromboembolic risk in patients with atrial fibrillation: PREFER in AF.
      J Am Coll Cardiol. 2017; 69: 409-419https://doi.org/10.1016/j.jacc.2016.10.069
      		 2017 Europe 5717 1288 (22.5) Insulin-requiring DM increases the risk of IS/SE both compared to non-insulin-requiring DM and no-diabetes
      EORP-AF Pilot
      • Fumagalli S.
      • Said S.A.
      • Laroche C.
      • et al.
      Management and prognosis of atrial fibrillation in diabetic patients: an EORP-AF general pilot registry report.
      Eur Hear J Cardiovasc Pharmacother. 2018; 4: 172-179https://doi.org/10.1093/ehjcvp/pvx037
      		 2018 Europe 3101 638 (20.6) DM independently increases the risk of all-cause death in full multivariate analysis (aHR 1.86, 95% CI 1.31–2.62)
      FANTASIIA
      • García-Fernández A.
      • Esteve-Pastor M.A.
      • Roldán-Rabadán I.
      • et al.
      Relationship of adverse events to quality of anticoagulation control in atrial fibrillation patients with diabetes: real-world data from the FANTASIIA registry.
      Ann Med. 2020; 52: 300-309https://doi.org/10.1080/07853890.2020.1778176
      		 2020 Spain 1956 574 (29.3) DM increases risk of MACEs (aHR 2.03, 95% CI 1.47–2.80), CV death (aHR 2.40, 95% CI 1.62–3.56), all-cause death (aHR 1.58, 95% CI 1.20–2.07)
      COOL-AF
      • Krittayaphong R.
      • Aroonsiriwattana S.
      • Ngamjanyaporn P.
      • Patmuk T.
      • Kaewkumdee P.
      Outcomes of patients with atrial fibrillation with and without diabetes: a propensity score matching of the COOL-AF registry.
      Int J Clin Pract. 2021; 75https://doi.org/10.1111/ijcp.14671
      		 2021 Thailand 3402 923 (27.1) Presence of DM Increases Risk of Outcomes in PM Analysis: IS/TIA aHR 1.67, 95% CI 1.02–2.73; MB aHR 1.65, 95% CI 1.13–2.40; HF aHR 1.87, 95% CI 1.34–2.59
      Legend: aHR= adjusted Hazard Ratio; CI= Confidence Interval; CV= Cardiovascular; DM= Diabetes Mellitus; HF= Heart Failure; IS= Ischemic Stroke; MACE= Major Adverse Cardiovascular Events; MB= Major Bleeding; PM= Propensity Matched; SE= Systemic Embolism; TIA= Transient Ischemic Attack.
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      References

      1. World Health Organization Integrated Health Services. Multimorbidity: technical series on safer primary care.; 2016. https://www.who.int/publications/i/item/9789241511650.

        View in Article
        • Lin X.
        • Xu Y.
        • Pan X.
        • et al.
        Global, regional, and national burden and trend of diabetes in 195 countries and territories: an analysis from 1990 to 2025.
        Sci Rep. 2020; 10: 14790https://doi.org/10.1038/s41598-020-71908-9
        View in Article
        • Hindricks G.
        • Potpara T.
        • Dagres N.
        • et al.
        2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS).
        Eur Heart J. 2021; 42: 373-498https://doi.org/10.1093/eurheartj/ehaa612
        View in Article
        • Boriani G.
        • Proietti M.
        Atrial fibrillation prevention: an appraisal of current evidence.
        Heart. 2018; 104: 882-887https://doi.org/10.1136/heartjnl-2017-311546
        View in Article
        • Wang A.
        • Green J.B.
        • Halperin J.L.
        • Piccini J.P.
        Atrial fibrillation and diabetes mellitus: JACC review topic of the week.
        J Am Coll Cardiol. 2019; 74: 1107-1115https://doi.org/10.1016/j.jacc.2019.07.020
        View in Article
        • Boriani G.
        • Vitolo M.
        • Diemberger I.
        • et al.
        Optimizing indices of atrial fibrillation susceptibility and burden to evaluate atrial fibrillation severity, risk and outcomes.
        Cardiovasc Res. 2021; 117: 1-21https://doi.org/10.1093/cvr/cvab147
        View in Article
        • Echouffo-Tcheugui J.B.
        • Shrader P.
        • Thomas L.
        • et al.
        Care patterns and outcomes in atrial fibrillation patients with and without diabetes: ORBIT-AF registry.
        J Am Coll Cardiol. 2017; 70: 1325-1335https://doi.org/10.1016/j.jacc.2017.07.755
        View in Article
        • Patti G.
        • Lucerna M.
        • Cavallari I.
        • et al.
        Insulin-requiring versus noninsulin-requiring diabetes and thromboembolic risk in patients with atrial fibrillation: PREFER in AF.
        J Am Coll Cardiol. 2017; 69: 409-419https://doi.org/10.1016/j.jacc.2016.10.069
        View in Article
        • Fumagalli S.
        • Said S.A.
        • Laroche C.
        • et al.
        Management and prognosis of atrial fibrillation in diabetic patients: an EORP-AF general pilot registry report.
        Eur Hear J Cardiovasc Pharmacother. 2018; 4: 172-179https://doi.org/10.1093/ehjcvp/pvx037
        View in Article
        • García-Fernández A.
        • Esteve-Pastor M.A.
        • Roldán-Rabadán I.
        • et al.
        Relationship of adverse events to quality of anticoagulation control in atrial fibrillation patients with diabetes: real-world data from the FANTASIIA registry.
        Ann Med. 2020; 52: 300-309https://doi.org/10.1080/07853890.2020.1778176
        View in Article
        • Krittayaphong R.
        • Aroonsiriwattana S.
        • Ngamjanyaporn P.
        • Patmuk T.
        • Kaewkumdee P.
        Outcomes of patients with atrial fibrillation with and without diabetes: a propensity score matching of the COOL-AF registry.
        Int J Clin Pract. 2021; 75https://doi.org/10.1111/ijcp.14671
        View in Article
        • Ding W.Y.
        • Kotalczyk A.
        • Boriani G.
        • et al.
        Impact of diabetes on the management and outcomes in atrial fibrillation: an analysis from the ESC-EHRA EORP-AF long-term general registry.
        Eur J Intern Med. 2022; 103: 41-49
        View in Article
        • Boriani G.
        • Proietti M.
        • Laroche C.
        • et al.
        Contemporary stroke prevention strategies in 11 096 European patients with atrial fibrillation: a report from the EURObservational Research Programme on atrial fibrillation (EORP-AF) long-term general registry.
        Europace. 2018; 20: 747-757https://doi.org/10.1093/europace/eux301
        View in Article
        • Boriani G.
        • Proietti M.
        • Laroche C.
        • et al.
        Association between antithrombotic treatment and outcomes at 1-year follow-up in patients with atrial fibrillation: the EORP-AF General Long-Term Registry.
        Europace. 2019; 21: 1013-1022https://doi.org/10.1093/europace/euz032
        View in Article
        • Bano A.
        • Rodondi N.
        • Beer J.H.
        • et al.
        Association of diabetes with atrial fibrillation phenotype and cardiac and neurological comorbidities: insights from the SWISS-AF study.
        J Am Heart Assoc. 2021; 10https://doi.org/10.1161/JAHA.121.021800
        View in Article
        • Dai H.
        • Zhang Q.
        • Much A.A.
        • et al.
        Global, regional, and national prevalence, incidence, mortality, and risk factors for atrial fibrillation, 1990–2017: results from the Global burden of disease study 2017.
        Eur Hear J Qual Care Clin Outcomes. 2020; (Published online July 31)https://doi.org/10.1093/ehjqcco/qcaa061
        View in Article
        • Singh S.M.
        • Abdel-Qadir H.
        • Pang A.
        • et al.
        Population trends in all-cause mortality and cause specific-death with incident atrial fibrillation.
        J Am Heart Assoc. 2020; 9e016810https://doi.org/10.1161/JAHA.120.016810
        View in Article
        • Proietti M.
        • Marzona I.
        • Vannini T.
        • et al.
        Long-term relationship between atrial fibrillation, multimorbidity and oral anticoagulant drug use.
        Mayo Clin Proc. 2019; 94: 2427-2436https://doi.org/10.1016/j.mayocp.2019.06.012
        View in Article
        • Proietti M.
        • Laroche C.
        • Nieuwlaat R.
        • et al.
        Increased burden of comorbidities and risk of cardiovascular death in atrial fibrillation patients in Europe over ten years: a comparison between EORP-AF pilot and EHS-AF registries.
        Eur J Intern Med. 2018; 55: 28-34https://doi.org/10.1016/j.ejim.2018.05.016
        View in Article
        • Proietti M.
        • Esteve-Pastor M.A.
        • Rivera-Caravaca J.M.
        • et al.
        Relationship between multimorbidity and outcomes in atrial fibrillation.
        Exp Gerontol. 2021; 153111482https://doi.org/10.1016/j.exger.2021.111482
        View in Article
        • Lip G.Y.H.
        The ABC pathway: an integrated approach to improve AF management.
        Nat Rev Cardiol. 2017; 14: 627-628https://doi.org/10.1038/nrcardio.2017.153
        View in Article
        • Romiti G.F.
        • Pastori D.
        • Rivera-Caravaca J.M.
        • et al.
        Adherence to the “Atrial Fibrillation Better Care” Pathway in patients with atrial fibrillation: impact on clinical outcomes-a systematic review and meta-analysis of 285,000 patients.
        Thromb Haemost. 2022; 122: 406-414https://doi.org/10.1055/a-1515-9630
        View in Article
        • Proietti M.
        • Vitolo M.
        • Harrison S.L.
        • et al.
        Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry.
        BMC Med. 2021; 19: 256https://doi.org/10.1186/s12916-021-02120-3
        View in Article
        • Proietti M.
        • Romiti G.F.
        • Olshansky B.
        • Lane D.A.
        • Lip G.Y.H.
        Comprehensive management with the ABC (Atrial Fibrillation Better Care) pathway in clinically complex patients with atrial fibrillation: a post hoc ancillary analysis from the AFFIRM trial.
        J Am Heart Assoc. 2020; 9e014932https://doi.org/10.1161/JAHA.119.014932
        View in Article
        • Proietti M.
        • Vitolo M.
        • Lip G.Y.H.
        Integrated care and outcomes in patients with atrial fibrillation and comorbidities.
        Eur J Clin Invest. 2021; (Published online February 2Accepted, In Press)https://doi.org/10.1111/eci.13498
        View in Article

      Article info

      Publication history

      Published online: June 27, 2022
      Accepted: June 24, 2022
      Received: June 18, 2022

      Identification

      DOI: https://doi.org/10.1016/j.ejim.2022.06.017

      Copyright

      © 2022 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

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