New research will help doctors identify, treat and prevent potentially dangerous irregular heartbeats in patients with hypertrophic cardiomyopathy, a common heart condition in which the heart thickens and strains to pump blood.
These chaotic heart rhythms are known as atrial fibrillation. Atrial fibrillation can be asymptomatic, but it can lead to blood clots, stroke or even heart failure.
The new research, from an international team of doctors and scientists, identifies risk factors for major atrial fibrillation outcomes, such as the need for procedures or hospitalization for more than 24 hours, in patients with hypertrophic cardiomyopathy.
Age was the dominant predictor, the researchers found. But they also identified a list of other predictors, including obesity as measured by body mass index. Obesity was particularly important in younger patients, the researchers conclude.
“The latter finding points out the importance of weight loss and exercise in [hypertrophic cardiomyopathy] patients,” said researcher Dr. Christopher Kramer, the chief of the Division of Cardiovascular Medicine at UVA Health, Virginia’s only designated Center of Excellence by the Hypertrophic Cardiomyopathy Association. “Until only recently, exercise was thought to be contraindicated in HCM. This is no longer the case based on recent studies.”
Atrial fibrillation in hypertrophic cardiomyopathy
Like atrial fibrillation, hypertrophic cardiomyopathy often goes undiagnosed. It is, however, the most common inheritable heart disease, and it is the most common cause of sudden cardiac death in young athletes.
Atrial fibrillation is a common complication among patients with hypertrophic cardiomyopathy. Previous studies have focused on detecting atrial fibrillation, as patients may require blood thinners to prevent stroke. But Kramer and his colleagues wanted to look at atrial fibrillation outcomes to better identify those who need early or tailored interventions.
The researchers examined data from 2,631 patients, identifying 127 major endpoints, such as needing hospitalization or catheter ablation, in 96 of the patients. Key risk factors for reaching an endpoint included age; BMI; size and function of the heart’s left atrium; moderate or severe failure of the heart’s mitral valve to close completely; and history of arrhythmia (irregular heartbeat).
Obesity was a stronger risk factor in younger patients than older ones. The remaining risk factors were greater risk factors for middle-aged and older patients.
The researchers say their findings can be used to create a risk-assessment tool for patients, to identify those at risk and help keep them out of the hospital.
“These findings will help physicians who treat HCM patients, as they can target the risk factors that lead to atrial fibrillation,” Kramer said.
Atrial fibrillation (AF) is the most common arrhythmia and is associated with substantial morbidity and mortality . AF is increasingly considered the consequence of a complex atrial cardiomyopathy due to the combined effects of genetics, risk factors and comorbidities . Current pharmacological and catheter based anti-arrhythmic interventions have limited efficacy and AF-promoting atrial cardiomyopathy is often progressing despite temporally effective rhythm control.
The development and the progression of atrial cardiomyopathy can be partially prevented by the treatment of concomitant conditions and management of risk factors by changes in lifestyle. Physical activity, changes in diet and weight loss have been shown to control sinus rhythm and current AF guidelines  now recommend risk factor modification as an important component of rhythm control strategies in AF patients.
Changes in lifestyle and diet have been related to alterations in gut microbiota . The gut microbiota is a dynamic ecosystem of commensal, symbiotic and pathogenic microorganisms that influence host health by producing bioactive metabolites. The human body consists of about 100 trillion microbial cells [bacteria, viruses, archaea and eukaryotes] and 20 million microbial genes that outnumber by about 10–1000 times the number of human cells and genes, respectively .
In recent years, growing evidence has demonstrated that interventions directed at gut microbiota may play a critical role in many cardiovascular diseases including heart failure, hypertension, and coronary artery disease . Therefore, therapeutic targeting of gut microbiota may contribute to a better AF control by affecting multiple risk factors of AF. One key product of gut microbiota is trimethylamine [TMA] which is produced from dietary choline and carnitine [from meat and dairy products]. TMA N-oxide [TMAO] is a product of TMA oxidization by liver flavin-containing monooxygenase enzyme and the most extensively studied microbial metabolite involved in AF pathogenesis , , , .
In this issue of the journal Nguyen et al.  assessed the levels of TMAO in 56 patients with paroxysmal AF in comparison to 22 patients with persistent [<1 year] AF in whom a rhythm control strategy was preferred. The authors detected a significant correlation between the levels of TMAO and AF progression phenotypes without difference in precursor levels [betaine, choline and L-carnitine]. These findings confirm the previously reported positive correlations between TMAO and AF , , ,  and add additional information about the association between TMAO levels and AF progression.
The study has some limitations that need consideration when interpreting the results. The authors did not include a control group in sinus rhythm. Therefore, the role of increased TMAO levels in AF patients remain unclear and requires further investigation. Also, the study population is very small, which raises serious concerns about the putative predictive value of TMAO for AF.
In addition, given the higher comorbidity burden in persistent compared to paroxysmal AF patients and the multiple lines of evidence that TMAO is associated with increased risk of pre-clinical and clinical coronary artery disease , hypertension  and heart failure , the difference in TMAO level could be a result from the concomitant comorbidities rather than from AF itself. Clearly, randomized clinical trials or larger observational studies with propensity score matching are required to demonstrate and validate the putative effect of TMAO on AF type and AF progression. Overall, despite the many evidence, it is still unclear whether TMAO is a risk factor, a mediator or a bystander in the disease process.
The putative mechanisms of TMAO action potentially promoting AF are incompletely understood. In a canine model local injection of TMAO into four major anterior right ganglionated plexi enhances neural activity via activation of p65 nuclear factor kappa-light-chain-enhancer of activated B cells pathway and increases the expression of c-fos and nerve growth factor. TMAO also prevents the rapid atrial pacing-induced shortening of the atrial effective refractory period, thereby reducing the likelihood of reentry and the vulnerability to AF .
Neonatal rat cardiomyocytes exposed to TMAO show increased mRNA and protein levels of hypertrophy markers such as atrial natriuretic peptide, beta-myosin heavy chain along with more fibrosis via unregulated transforming growth factor β1/Smad3 signaling pathways. Rats treated with intraperitoneal TMAO injection for 1–2 weeks reveal increases in left ventricular wall dimensions along with an enhanced expression of hypertrophy markers, increased cardiomyocyte size and interstitial fibrosis .
Finally, neonatal cardiac fibroblasts exposed to increasing concentrations of TMAO for 24 h show oxidative stress and increases of NOD-, LRR- and pyrin domain-containing protein 3 [NLRP3] inflammasome activity, a caspase-1 platform responsible for the maturation of interleukins-1β [IL-1β] and IL-18 , which has been casually associated with the development and progression of AF , . Thus, TMAO could be an upstream activator of the NLRP3 system, a hypothesis that requires direct verification.
In conclusion, recent research has provided important information on risk factors and the mechanisms contributing to AF, but many unresolved issues and translational challenges remain , . Although there is some preclinical and clinical evidence for a potential role of TMAO in AF pathophysiology, further experimental and clinical work is needed to validate the causal relationship between gut microbiota and its metabolites and AF and to delineate the underlying mechanisms of interaction.
More information: Christopher M. Kramer et al, Predictors of Major Atrial Fibrillation Endpoints in the National Heart, Lung, and Blood Institute HCMR, JACC: Clinical Electrophysiology (2021). DOI: 10.1016/j.jacep.2021.04.004