Abstract
The increased cardiovascular risk in patients with type 2 diabetes mellitus (DM) is further augmented by the presence of atrial fibrillation (AF). Therefore, the treatment strategy should be directed at improving the metabolic situation – e.g. avoiding marked fluctuations of blood glucose levels – and eliminating AF. Some of the life-style modifications recommended for patients with type 2 DM – such as weight reduction, engagement in regular physical activity, and cessation of tobacco use – can decrease the susceptibility to AF. The first-line pharmacological therapy of type 2 DM is metformin which also decreases the susceptibility to AF by improving insulin sensitivity. The most effective add-on therapy, especially in diabetes with atrial fibrillation, are sodium-glucose cotransporter 2 (SGLT2) inhibitors, dapagliflozin and empagliflozin. These drugs have been shown to reduce hospitalization for heart failure, cardiovascular mortality and the risk of incident atrial fibrillation. A promising new agent is the non-steroidal mineralocorticoid receptor antagonist finerenone. It reduced cardiovascular death, and the risks of hospitalization and new-onset AF. Since the risk of stroke and thromboembolism is especially high in DM with AF, nearly all affected patients need anticoagulation. Direct oral anticoagulants are more effective and safer than vitamin K antagonists. Atrial fibrillation occurs in type 2 DM despite optimal treatment of metabolic and clinical risk factors. In the past, antiarrhythmic drug treatment was used with limited success. In contrast to antiarrhythmic drug therapy, catheter ablation is an effective and safe treatment modality for the restoration of sinus rhythm. Since the long-term arrhythmia-free survival after catheter ablation is lower among patients with type 2 DM, individual ablation strategies are required in some of these patients. In summary, DM patients with AF require optimal treatment of metabolic risk factors, concomitant diseases, and specific strategies to prevent AF.