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Arginine in older patients with persistent atrial fibrillation: A link to endothelial dysfunction?

  • Stefano Fumagalli
    Correspondence
    Corresponding author.
    Affiliations
    Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Largo Brambilla, 3 – 5013, Florence, Italy
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  • Giulia Ricciardi
    Affiliations
    Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Largo Brambilla, 3 – 5013, Florence, Italy
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  • Claudia Di Serio
    Affiliations
    Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Largo Brambilla, 3 – 5013, Florence, Italy
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  • Giancarlo La Marca
    Affiliations
    Department of Experimental and Clinical Biomedical Sciences ‘Mario Serio’, Newborn Screening, Clinical Chemistry and Pharmacology Lab, Meyer Children's Hospital and University of Florence, Florence, Italy
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  • Niccolò Marchionni
    Affiliations
    Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Largo Brambilla, 3 – 5013, Florence, Italy
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Published:October 27, 2022DOI:https://doi.org/10.1016/j.ejim.2022.10.017
      Dear Editor, atrial fibrillation (AF) is the most frequent sustained arrhythmia observed in clinical practice. Still now, thromboembolic stroke is the most relevant acute clinical complication of AF. Indeed, the incidence of such an event significantly grows with age, reaching 8.9% at five-years in those older than 85 years. Moreover, AF can be observed in 24% of patients presenting an embolic stroke of undetermined source (ESUS) when using a monitoring technique with an appropriate recording length [
      • Tsao C.W.
      • Aday A.W.
      • Almarzooq Z.I.
      • Alonso A.
      • Beaton A.Z.
      • Bittencourt M.S.
      • et al.
      Heart disease and stroke statistics-2022 update: a report from the American Heart Association.
      ]. Current evidence supports the hypothesis that in many cases AF is directly responsible of a thromboembolic event. However, a temporal disconnection between the presence of the arrhythmia and stroke development can often be noticed. Thus, present findings suggest that AF is at the same time a cause and a “bystander” of such a dramatic complication, with the arrhythmia representing a marker of underling thrombogenic atrial conditions, ultimately responsible of a thrombo-embolic event [
      • Freedman B.
      • Kamel H.
      • Van Gelder I.C.
      • Schnabel R.B.
      Atrial fibrillation: villain or bystander in vascular brain injury.
      ]. On this basis, the concept of atrial myopathy was introduced in clinical practice. The condition appears to be characterized by atrial enlargement, alterations of coagulation, electrical remodeling, myocyte dysfunction, fibrosis and hemodynamic disturbances [
      • Schnabel R.B.
      • Haeusler K.G.
      • Healey J.S.
      • Freedman B.
      • Boriani G.
      • Brachmann J.
      • et al.
      Searching for atrial fibrillation poststroke: a white paper of the AF-SCREEN International Collaboration.
      ]. Endothelial dysfunction has been also advocated as another plausible component of atrial myopathy [
      • Schnabel R.B.
      • Haeusler K.G.
      • Healey J.S.
      • Freedman B.
      • Boriani G.
      • Brachmann J.
      • et al.
      Searching for atrial fibrillation poststroke: a white paper of the AF-SCREEN International Collaboration.
      ], and changes in the Virchow's triad - alterations in vascular endothelium, blood flow, and hypercoagulability - could contribute to explain an enhanced thrombogenesis [
      • Freedman B.
      • Kamel H.
      • Van Gelder I.C.
      • Schnabel R.B.
      Atrial fibrillation: villain or bystander in vascular brain injury.
      ,
      • Boriani G.
      • Vitolo M.
      • Diemberger I.
      • Proietti M.
      • Valenti A.C.
      • Malavasi V.L.
      • et al.
      Optimizing indices of atrial fibrillation susceptibility and burden to evaluate atrial fibrillation severity, risk and outcomes.
      ]. Accordingly, aim of this study was to evaluate the existence of endothelial dysfunction in older patients with persistent forms of AF, particularly exposed to the most severe complications of the arrhythmia [
      • Boriani G.
      • Vitolo M.
      • Diemberger I.
      • Proietti M.
      • Valenti A.C.
      • Malavasi V.L.
      • et al.
      Optimizing indices of atrial fibrillation susceptibility and burden to evaluate atrial fibrillation severity, risk and outcomes.
      ]. Hence, we conducted this pilot study analyzing the concentration of an amino acid - marker of endothelial function - arginine, from which nitric oxide (NO) is produced through the activity of NO synthase [
      • Gambardella J.
      • Khondkar W.
      • Morelli M.B.
      • Wang X.
      • Santulli G.
      • Trimarco V.
      Arginine and Endothelial Function.
      ].

      Keywords

      Abbreviations:

      AF (atrial fibrillation), ESUS (embolic stroke of undetermined source), GDS (Geriatric Depression Scale), MMSE (Mini-Mental State Examination), NO (nitric oxide), SPPB (Short-Physical Performance Battery)
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