The Impact of Obesity on Atrial Fibrillation Review: Prevalence, Pathophysiology, and Challenges in Management
Main Article Content
Abstract
Atrial fibrillation is a growing global health concern due to increasing prevalence and increasing monetary cost on healthcare. Obesity independently contributes to the development of atrial fibrillation through structural, hemodynamic, and electrophysiological changes, necessitating accountability for these changes in atrial fibrillation treatment. With the prevalence of obesity rising as well, and around 18% of atrial fibrillation cases being attributable to obesity, there is a critical need to address obesity in atrial fibrillation. Despite these strong associations, obese patients remain to be underrepresented in atrial fibrillation clinical trials, limiting the applicability of current treatment guidelines to this population.
Treatment of atrial fibrillation in obese patients is altered. Rate control strategies such as using beta-blockers and atrioventricular nodal blockers are less effective due to altered cardiac electrophysiology in obese patients. Rhythm control through cardioversion and catheter ablation also shows reduced efficacy, with higher energy thresholds and increased recurrence rates post-ablation. Increased bleeding risks in obese patients complicate drug pharmacokinetics of anticoagulation treatments. Furthermore, the association between obesity and sleep apnea may further increase risk of developing and worsening atrial fibrillations. Patients with atrial fibrillation and sleep apnea had higher incidences of stroke, pulmonary embolism, and more severe coronary artery disease, which were associated with elevated CHADS2 and CHA2DS2-VASc scores.
Bariatric surgery has shown promise in reducing atrial fibrillation recurrence and improving procedural success. Lifestyle interventions and comprehensive metabolic may also reduce atrial fibrillation burden and improve outcomes in obese patients.
This paper reviews challenges in atrial fibrillation treatment such as rate and rhythm control, anticoagulation, catheter ablation, cardioversion, highlighting the need for tailored therapeutic strategies and further research, particularly on the role of bariatric surgery and lifestyle modifications in atrial fibrillation prevention and treatment in obese populations.
Article Details
How to Cite
KICHLOO, Asim et al.
The Impact of Obesity on Atrial Fibrillation Review: Prevalence, Pathophysiology, and Challenges in Management.
Medical Research Archives, [S.l.], v. 13, n. 3, apr. 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6408>. Date accessed: 06 apr. 2025.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Nattel S, Harada M. Atrial remodeling and atrial fibrillation: recent advances and translational perspectives. J Am Coll Cardiol. 2014;63(22):2335-2345. doi:10.1016/j.jacc.2014.02.555
2. Li C, Zhang J, Hu W, Li S. Atrial fibrosis underlying atrial fibrillation (Review). Int J Mol Med. 2020;47(3):9. doi:10.3892/ijmm.2020.4842
3. Iwasaki Y ki, Nishida K, Kato T, Nattel S. Atrial Fibrillation Pathophysiology: Implications for Management. Circulation. 2011;124(20):2264-2274. doi:10.1161/CIRCULATIONAHA.111.019893
4. Capucci A, Villani GQ, Aschieri D. Risk of Complications of Atrial Fibrillation. Pacing Clin Electrophysiol. 1997;20(10):2684-2691. doi:10.1111/j.1540-8159.1997.tb06117.x
5. Bordignon S, Chiara Corti M, Bilato C. Atrial Fibrillation Associated with Heart Failure, Stroke and Mortality. J Atr Fibrillation. 2012;5(1):467. doi:10.4022/jafib.467
6. Nuttall FQ. Body Mass Index: Obesity, BMI, and Health: A Critical Review. Nutr Today. 2015;50(3):117-128. doi:10.1097/NT.0000000000000092
7. Potter AW, Chin GC, Looney DP, Friedl KE. Defining Overweight and Obesity by Percent Body Fat Instead of Body Mass Index. J Clin Endocrinol Metab. Published online May 15, 2024:dgae341. doi:10.1210/clinem/dgae341
8. Harris E. Study: Waist-to-Hip Ratio Might Predict Mortality Better Than BMI. JAMA. 2023;330(16):1515. doi:10.1001/jama.2023.19205
9. Ross R, Neeland IJ, Yamashita S, et al. Waist circumference as a vital sign in clinical practice: a Consensus Statement from the IAS and ICCR Working Group on Visceral Obesity. Nat Rev Endocrinol. 2020;16(3):177-189. doi:10.1038/s41574-019-0310-7
10. Ansari S, Haboubi H, Haboubi N. Adult obesity complications: challenges and clinical impact. Ther Adv Endocrinol Metab. 2020;11:2042018820934955. doi:10.1177/2042018820934955
11. Vyas V, Lambiase P. Obesity and Atrial Fibrillation: Epidemiology, Pathophysiology and Novel Therapeutic Opportunities. Arrhythmia Electrophysiol Rev. 2019;8(1):28-36. doi:10.15420/aer.2018.76.2
12. Lang IM, Benza R. Pulmonary hypertension: chapters of innovation and tribulation. Eur Heart J. 2012;33(8):961-968. doi:10.1093/eurheartj/ehs049
13. Gaborit B, Sengenes C, Ancel P, Jacquier A, Dutour A. Role of Epicardial Adipose Tissue in Health and Disease: A Matter of Fat? In: Terjung R, ed. Comprehensive Physiology. 1st ed. Wiley; 2017:1051-1082. doi:10.1002/cphy.c160034
14. Goldman PSN, Ezekowitz MD. Anticoagulation in Atrial Arrhythmias. In: Electrophysiological Disorders of the Heart. Elsevier; 2012:1175-1180. doi:10.1016/B978-1-4377-0285-9.00085-5
15. Alshehri A. Stroke in atrial fibrillation: Review of risk stratification and preventive therapy. J Fam Community Med. 2019;26(2):92. doi:10.4103/jfcm.JFCM_99_18
16. Pistoia F, Sacco S, Tiseo C, Degan D, Ornello R, Carolei A. The Epidemiology of Atrial Fibrillation and Stroke. Cardiol Clin. 2016;34(2):255-268. doi:10.1016/j.ccl.2015.12.002
17. Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837-847. doi:10.1161/CIRCULATIONAHA.113.005119
18. Chooi YC, Ding C, Magkos F. The epidemiology of obesity. Metabolism. 2019;92:6-10. doi:10.1016/j.metabol.2018.09.005
19. Mandviwala T, Khalid U, Deswal A. Obesity and Cardiovascular Disease: a Risk Factor or a Risk Marker? Curr Atheroscler Rep. 2016;18(5):21. doi:10.1007/s11883-016-0575-4
20. Lavie CJ, Pandey A, Lau DH, Alpert MA, Sanders P. Obesity and Atrial Fibrillation Prevalence, Pathogenesis, and Prognosis: Effects of Weight Loss and Exercise. J Am Coll Cardiol. 2017;70(16):2022-2035. doi:10.1016/j.jacc.2017.09.002
21. Huxley RR, Lopez FL, Folsom AR, et al. Absolute and attributable risks of atrial fibrillation in relation to optimal and borderline risk factors: the Atherosclerosis Risk in Communities (ARIC) study. Circulation. 2011;123(14):1501-1508. doi:10.1161/CIRCULATIONAHA.110.009035
22. Nalliah CJ, Sanders P, Kottkamp H, Kalman JM. The role of obesity in atrial fibrillation. Eur Heart J. 2016;37(20):1565-1572. doi:10.1093/eurheartj/ehv486
23. Alpert MA, Omran J, Bostick BP. Effects of Obesity on Cardiovascular Hemodynamics, Cardiac Morphology, and Ventricular Function. Curr Obes Rep. 2016;5(4):424-434. doi:10.1007/s13679-016-0235-6
24. Mahajan R, Lau DH, Brooks AG, et al. Electrophysiological, Electroanatomical, and Structural Remodeling of the Atria as Consequences of Sustained Obesity. J Am Coll Cardiol. 2015;66(1):1-11. doi:10.1016/j.jacc.2015.04.058
25. Karam BS, Chavez-Moreno A, Koh W, Akar JG, Akar FG. Oxidative stress and inflammation as central mediators of atrial fibrillation in obesity and diabetes. Cardiovasc Diabetol. 2017;16(1):120. doi:10.1186/s12933-017-0604-9
26. Wong CX, Ganesan AN, Selvanayagam JB. Epicardial fat and atrial fibrillation: current evidence, potential mechanisms, clinical implications, and future directions. Eur Heart J. 2017;38(17):1294-1302. doi:10.1093/eurheartj/ehw045
27. Pokushalov E, Kozlov B, Romanov A, et al. Long-Term Suppression of Atrial Fibrillation by Botulinum Toxin Injection Into Epicardial Fat Pads in Patients Undergoing Cardiac Surgery: One-Year Follow-Up of a Randomized Pilot Study. Circ Arrhythm Electrophysiol. 2015;8(6):1334-1341. doi:10.1161/CIRCEP.115.003199
28. Wong CX, Sun MT, Odutayo A, et al. Associations of Epicardial, Abdominal, and Overall Adiposity With Atrial Fibrillation. Circ Arrhythm Electrophysiol. 2016;9(12):e004378. doi:10.1161/CIRCEP.116.004378
29. Packer DL, Mark DB, Robb RA, et al. Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) Trial: Study Rationale and Design. Am Heart J. 2018;199:192-199. doi:10.1016/j.ahj.2018.02.015
30. Wilber DJ, Pappone C, Neuzil P, et al. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. JAMA. 2010;303(4):333-340. doi:10.1001/jama.2009.2029
31. Di Biase L, Mohanty P, Mohanty S, et al. Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device: Results From the AATAC Multicenter Randomized Trial. Circulation. 2016;133(17):1637-1644. doi:10.1161/CIRCULATIONAHA.115.019406
32. Asad ZUA, Yousif A, Khan MS, Al-Khatib SM, Stavrakis S. Catheter Ablation Versus Medical Therapy for Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Circ Arrhythm Electrophysiol. 2019;12(9):e007414. doi:10.1161/CIRCEP.119.007414
33. Badheka AO, Rathod A, Kizilbash MA, et al. Influence of obesity on outcomes in atrial fibrillation: yet another obesity paradox. Am J Med. 2010;123(7):646-651. doi:10.1016/j.amjmed.2009.11.026
34. Groves EM, Erande AS, Le C, et al. Comparison of epicardial adipose tissue volume and coronary artery disease severity in asymptomatic adults with versus without diabetes mellitus. Am J Cardiol. 2014;114(5):686-691. doi:10.1016/j.amjcard.2014.05.057
35. Packer M. Disease-treatment interactions in the management of patients with obesity and diabetes who have atrial fibrillation: the potential mediating influence of epicardial adipose tissue. Cardiovasc Diabetol. 2019;18(1):121. doi:10.1186/s12933-019-0927-9
36. Mulder BA, Van Veldhuisen DJ, Crijns HJGM, et al. Lenient vs. strict rate control in patients with atrial fibrillation and heart failure: a post-hoc analysis of the RACE II study. Eur J Heart Fail. 2013;15(11):1311-1318. doi:10.1093/eurjhf/hft093
37. Qureshi W, O’Neal WT, Soliman EZ, Al-Mallah MH. Systematic review and meta-analysis of mortality and digoxin use in atrial fibrillation. Cardiol J. 2016;23(3):333-343. doi:10.5603/CJ.a2016.0016
38. Mareev Y, Cleland JGF. Should β-Blockers Be Used in Patients With Heart Failure and Atrial Fibrillation? Clin Ther. 2015;37(10):2215-2224. doi:10.1016/j.clinthera.2015.08.017
39. Ardestani A, Hoffman HJ, Cooper HA. Obesity and outcomes among patients with established atrial fibrillation. Am J Cardiol. 2010;106(3):369-373. doi:10.1016/j.amjcard.2010.03.036
40. Lévy S, Lauribe P, Dolla E, et al. A randomized comparison of external and internal cardioversion of chronic atrial fibrillation. Circulation. 1992;86(5):1415-1420. doi:10.1161/01.cir.86.5.1415
41. Voskoboinik A, Moskovitch J, Plunkett G, et al. Cardioversion of atrial fibrillation in obese patients: Results from the Cardioversion‐BMI randomized controlled trial. J Cardiovasc Electrophysiol. 2019;30(2):155-161. doi:10.1111/jce.13786
42. Barras M, Legg A. Drug dosing in obese adults. Aust Prescr. 2017;40(5):189-193. doi:10.18773/austprescr.2017.053
43. Ornelas-Loredo A, Kany S, Abraham V, et al. Association Between Obesity-Mediated Atrial Fibrillation and Therapy With Sodium Channel Blocker Antiarrhythmic Drugs. JAMA Cardiol. 2020;5(1):57. doi:10.1001/jamacardio.2019.4513
44. McCauley MD, Hong L, Sridhar A, et al. Ion Channel and Structural Remodeling in Obesity-Mediated Atrial Fibrillation. Circ Arrhythm Electrophysiol. 2020;13(8):e008296. doi:10.1161/CIRCEP.120.008296
45. Winkle RA, Mead RH, Engel G, et al. Impact of obesity on atrial fibrillation ablation: Patient characteristics, long-term outcomes, and complications. Heart Rhythm. 2017;14(6):819-827. doi:10.1016/j.hrthm.2017.02.023
46. Shoemaker MB, Muhammad R, Farrell M, et al. Relation of morbid obesity and female gender to risk of procedural complications in patients undergoing atrial fibrillation ablation. Am J Cardiol. 2013;111(3):368-373. doi:10.1016/j.amjcard.2012.10.013
47. Sanghai SR, Sardana M, Hansra B, et al. Indexed Left Atrial Adipose Tissue Area Is Associated With Severity of Atrial Fibrillation and Atrial Fibrillation Recurrence Among Patients Undergoing Catheter Ablation. Front Cardiovasc Med. 2018;5:76. doi:10.3389/fcvm.2018.00076
48. Sepehri Shamloo A, Dagres N, Dinov B, et al. Is epicardial fat tissue associated with atrial fibrillation recurrence after ablation? A systematic review and meta-analysis. Int J Cardiol Heart Vasc. 2019;22:132-138. doi:10.1016/j.ijcha.2019.01.003
49. Donnellan E, Wazni OM, Kanj M, et al. Association between pre-ablation bariatric surgery and atrial fibrillation recurrence in morbidly obese patients undergoing atrial fibrillation ablation. Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol. 2019;21(10):1476-1483. doi:10.1093/europace/euz183
50. Meinel TR, Branca M, De Marchis GM, et al. Prior Anticoagulation in Patients with Ischemic Stroke and Atrial Fibrillation. Ann Neurol. 2021;89(1):42-53. doi:10.1002/ana.25917
51. Moore KT, Kröll D. Influences of Obesity and Bariatric Surgery on the Clinical and Pharmacologic Profile of Rivaroxaban. Am J Med. 2017;130(9):1024-1032. doi:10.1016/j.amjmed.2017.05.011
52. Lubitz SA, Fischer A, Fuster V. Catheter ablation for atrial fibrillation. BMJ. 2008;336(7648):819-826. doi:10.1136/bmj.39513.555150.BE
53. Lioni L, Korantzopoulos P, Letsas KP. Catheter Ablation of Atrial Fibrillation in Overweight and Obese Patients. J Atr Fibrillation. 2011;4(4):1216. doi:10.4022/jafib.454
54. Abed HS, Nelson AJ, Richardson JD, et al. Impact of weight reduction on pericardial adipose tissue and cardiac structure in patients with atrial fibrillation. Am Heart J. 2015;169(5):655-662.e2. doi:10.1016/j.ahj.2015.02.008
55. Glover BM, Hong KL, Dagres N, et al. Impact of body mass index on the outcome of catheter ablation of atrial fibrillation. Heart. 2019;105(3):244-250. doi:10.1136/heartjnl-2018-313490
56. Al Chekakie MO, Akar JG. Epicardial Fat and Atrial Fibrillation: A Review. J Atr Fibrillation. 2012;4(6):483. doi:10.4022/jafib.483
57. Kim AM, Keenan BT, Jackson N, et al. Tongue Fat and its Relationship to Obstructive Sleep Apnea. Sleep. 2014;37(10):1639-1648. doi:10.5665/sleep.4072
58. Shelton KE, Woodson H, Gay S, Suratt PM. Pharyngeal Fat in Obstructive Sleep Apnea. Am Rev Respir Dis. 1993;148(2):462-466. doi:10.1164/ajrccm/148.2.462
59. Unnikrishnan D, Jun J, Polotsky V. Inflammation in sleep apnea: an update. Rev Endocr Metab Disord. 2015;16(1):25-34. doi:10.1007/s11154-014-9304-x
60. Haines KL, Nelson LG, Gonzalez R, et al. Objective evidence that bariatric surgery improves obesity-related obstructive sleep apnea. Surgery. 2007;141(3):354-358. doi:10.1016/j.surg.2006.08.012
61. Appleton SL, Vakulin A, Wittert GA, et al. The association of obstructive sleep apnea (obstructive sleep apnea) and nocturnal hypoxemia with the development of abnormal HbA1c in a population cohort of men without diabetes. Diabetes Res Clin Pract. 2016;114:151-159. doi:10.1016/j.diabres.2015.12.007
62. Lip GYH, Frison L, Halperin JL, Lane DA. Identifying patients at high risk for stroke despite anticoagulation: a comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke. 2010;41(12):2731-2738. doi:10.1161/STROKEAHA.110.590257
63. Saliba W, Rennert G. CHA2DS2-VASc score is directly associated with the risk of pulmonary embolism in patients with atrial fibrillation. Am J Med. 2014;127(1):45-52. doi:10.1016/j.amjmed.2013.10.004
64. Szymański FM, Płatek AE, Karpiński G, Koźluk E, Puchalski B, Filipiak KJ. Obstructive sleep apnoea in patients with atrial fibrillation: prevalence, determinants and clinical characteristics of patients in Polish population. Kardiol Pol. 2014;72(8):716-724. doi:10.5603/KP.a2014.0070
65. Birkbak J, Clark AJ, Rod NH. The effect of sleep disordered breathing on the outcome of stroke and transient ischemic attack: a systematic review. J Clin Sleep Med JCSM Off Publ Am Acad Sleep Med. 2014;10(1):103-108. doi:10.5664/jcsm.3376
66. Yazdan-Ashoori P, Baranchuk A. Obstructive sleep apnea may increase the risk of stroke in atrial fibrillation patients: refining the CHADS2 score. Int J Cardiol. 2011;146(2):131-133. doi:10.1016/j.ijcard.2010.10.104
67. Lynch KT, Mehaffey JH, Hawkins RB, Hassinger TE, Hallowell PT, Kirby JL. Bariatric surgery reduces incidence of atrial fibrillation: a propensity score-matched analysis. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2019;15(2):279-285. doi:10.1016/j.soard.2018.11.021
68. Jamaly S, Carlsson L, Peltonen M, Jacobson P, Sjöström L, Karason K. Bariatric Surgery and the Risk of New-Onset Atrial Fibrillation in Swedish Obese Subjects. J Am Coll Cardiol. 2016;68(23):2497-2504. doi:10.1016/j.jacc.2016.09.940
69. Nor Hanipah Z, Punchai S, Karas LA, et al. The Outcome of Bariatric Surgery in Patients Aged 75 years and Older. Obes Surg. 2018;28(6):1498-1503. doi:10.1007/s11695-017-3020-z
70. Shimada YJ, Tsugawa Y, Camargo CA, Brown DFM, Hasegawa K. Effect of Bariatric Surgery on Emergency Department Visits and Hospitalizations for Atrial Fibrillation. Am J Cardiol. 2017;120(6):947-952. doi:10.1016/j.amjcard.2017.06.026
71. Shoemaker MB, Gidfar S, Pipilas DC, et al. Prevalence and predictors of atrial fibrillation among patients undergoing bariatric surgery. Obes Surg. 2014;24(4):611-616. doi:10.1007/s11695-013-1123-8
72. Yuan H, Miranda W, Lopez-Jimenez F, Cha Y. The impact of bariatric surgery on incidence of atrial fibrillation. Heart Rhythm. Published online 2014.
73. Höskuldsdóttir G, Sattar N, Miftaraj M, et al. Potential Effects of Bariatric Surgery on the Incidence of Heart Failure and Atrial Fibrillation in Patients With Type 2 Diabetes Mellitus and Obesity and on Mortality in Patients With Preexisting Heart Failure: A Nationwide, Matched, Observational Cohort Study. J Am Heart Assoc. 2021;10(7):e019323. doi:10.1161/JAHA.120.019323
74. Moussa O, Ardissino M, Eichhorn C, et al. Atrial fibrillation and obesity: Long-term incidence and outcomes after bariatric surgery. Eur J Prev Cardiol. 2021;28(9):e22-e24. doi:10.1177/2047487320904515
75. Yuan H, Medina-Inojosa JR, Lopez-Jimenez F, et al. The Long-Term Impact of Bariatric Surgery on Development of Atrial Fibrillation and Cardiovascular Events in Obese Patients: An Historical Cohort Study. Front Cardiovasc Med. 2021;8:647118. doi:10.3389/fcvm.2021.647118
76. Abed HS, Wittert GA, Leong DP, et al. Effect of Weight Reduction and Cardiometabolic Risk Factor Management on Symptom Burden and Severity in Patients With Atrial Fibrillation: A Randomized Clinical Trial. JAMA. 2013;310(19):2050. doi:10.1001/jama.2013.280521
77. Tsai AG, Williamson DF, Glick HA. Direct medical cost of overweight and obesity in the USA: a quantitative systematic review. Obes Rev Off J Int Assoc Study Obes. 2011;12(1):50-61. doi:10.1111/j.1467-789X.2009.00708.x
78. Dor A, Ferguson C, Langwith C, Tan E. A heavy burden: The individual costs of being overweight and obese in the United States. Dep Health Policy Sch Public Health Health Serv George Wash Univ. Published online 2010.
79. Wang YC, McPherson K, Marsh T, Gortmaker SL, Brown M. Health and economic burden of the projected obesity trends in the USA and the UK. The Lancet. 2011;378(9793):815-825. doi:10.1016/S0140-6736(11)60814-3
80. Seidell JC. Societal and personal costs of obesity. Exp Clin Endocrinol Diabetes Off J Ger Soc Endocrinol Ger Diabetes Assoc. 1998;106 Suppl 2:7-9. doi:10.1055/s-0029-1212029
81. Johnsen SP, Dalby LW, Täckström T, Olsen J, Fraschke A. Cost of illness of atrial fibrillation: a nationwide study of societal impact. BMC Health Serv Res. 2017;17(1):714. doi:10.1186/s12913-017-2652-y
82. Wolowacz SE, Samuel M, Brennan VK, Jasso-Mosqueda JG, Van Gelder IC. The cost of illness of atrial fibrillation: a systematic review of the recent literature. Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol. 2011;13(10):1375-1385. doi:10.1093/europace/eur194
2. Li C, Zhang J, Hu W, Li S. Atrial fibrosis underlying atrial fibrillation (Review). Int J Mol Med. 2020;47(3):9. doi:10.3892/ijmm.2020.4842
3. Iwasaki Y ki, Nishida K, Kato T, Nattel S. Atrial Fibrillation Pathophysiology: Implications for Management. Circulation. 2011;124(20):2264-2274. doi:10.1161/CIRCULATIONAHA.111.019893
4. Capucci A, Villani GQ, Aschieri D. Risk of Complications of Atrial Fibrillation. Pacing Clin Electrophysiol. 1997;20(10):2684-2691. doi:10.1111/j.1540-8159.1997.tb06117.x
5. Bordignon S, Chiara Corti M, Bilato C. Atrial Fibrillation Associated with Heart Failure, Stroke and Mortality. J Atr Fibrillation. 2012;5(1):467. doi:10.4022/jafib.467
6. Nuttall FQ. Body Mass Index: Obesity, BMI, and Health: A Critical Review. Nutr Today. 2015;50(3):117-128. doi:10.1097/NT.0000000000000092
7. Potter AW, Chin GC, Looney DP, Friedl KE. Defining Overweight and Obesity by Percent Body Fat Instead of Body Mass Index. J Clin Endocrinol Metab. Published online May 15, 2024:dgae341. doi:10.1210/clinem/dgae341
8. Harris E. Study: Waist-to-Hip Ratio Might Predict Mortality Better Than BMI. JAMA. 2023;330(16):1515. doi:10.1001/jama.2023.19205
9. Ross R, Neeland IJ, Yamashita S, et al. Waist circumference as a vital sign in clinical practice: a Consensus Statement from the IAS and ICCR Working Group on Visceral Obesity. Nat Rev Endocrinol. 2020;16(3):177-189. doi:10.1038/s41574-019-0310-7
10. Ansari S, Haboubi H, Haboubi N. Adult obesity complications: challenges and clinical impact. Ther Adv Endocrinol Metab. 2020;11:2042018820934955. doi:10.1177/2042018820934955
11. Vyas V, Lambiase P. Obesity and Atrial Fibrillation: Epidemiology, Pathophysiology and Novel Therapeutic Opportunities. Arrhythmia Electrophysiol Rev. 2019;8(1):28-36. doi:10.15420/aer.2018.76.2
12. Lang IM, Benza R. Pulmonary hypertension: chapters of innovation and tribulation. Eur Heart J. 2012;33(8):961-968. doi:10.1093/eurheartj/ehs049
13. Gaborit B, Sengenes C, Ancel P, Jacquier A, Dutour A. Role of Epicardial Adipose Tissue in Health and Disease: A Matter of Fat? In: Terjung R, ed. Comprehensive Physiology. 1st ed. Wiley; 2017:1051-1082. doi:10.1002/cphy.c160034
14. Goldman PSN, Ezekowitz MD. Anticoagulation in Atrial Arrhythmias. In: Electrophysiological Disorders of the Heart. Elsevier; 2012:1175-1180. doi:10.1016/B978-1-4377-0285-9.00085-5
15. Alshehri A. Stroke in atrial fibrillation: Review of risk stratification and preventive therapy. J Fam Community Med. 2019;26(2):92. doi:10.4103/jfcm.JFCM_99_18
16. Pistoia F, Sacco S, Tiseo C, Degan D, Ornello R, Carolei A. The Epidemiology of Atrial Fibrillation and Stroke. Cardiol Clin. 2016;34(2):255-268. doi:10.1016/j.ccl.2015.12.002
17. Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837-847. doi:10.1161/CIRCULATIONAHA.113.005119
18. Chooi YC, Ding C, Magkos F. The epidemiology of obesity. Metabolism. 2019;92:6-10. doi:10.1016/j.metabol.2018.09.005
19. Mandviwala T, Khalid U, Deswal A. Obesity and Cardiovascular Disease: a Risk Factor or a Risk Marker? Curr Atheroscler Rep. 2016;18(5):21. doi:10.1007/s11883-016-0575-4
20. Lavie CJ, Pandey A, Lau DH, Alpert MA, Sanders P. Obesity and Atrial Fibrillation Prevalence, Pathogenesis, and Prognosis: Effects of Weight Loss and Exercise. J Am Coll Cardiol. 2017;70(16):2022-2035. doi:10.1016/j.jacc.2017.09.002
21. Huxley RR, Lopez FL, Folsom AR, et al. Absolute and attributable risks of atrial fibrillation in relation to optimal and borderline risk factors: the Atherosclerosis Risk in Communities (ARIC) study. Circulation. 2011;123(14):1501-1508. doi:10.1161/CIRCULATIONAHA.110.009035
22. Nalliah CJ, Sanders P, Kottkamp H, Kalman JM. The role of obesity in atrial fibrillation. Eur Heart J. 2016;37(20):1565-1572. doi:10.1093/eurheartj/ehv486
23. Alpert MA, Omran J, Bostick BP. Effects of Obesity on Cardiovascular Hemodynamics, Cardiac Morphology, and Ventricular Function. Curr Obes Rep. 2016;5(4):424-434. doi:10.1007/s13679-016-0235-6
24. Mahajan R, Lau DH, Brooks AG, et al. Electrophysiological, Electroanatomical, and Structural Remodeling of the Atria as Consequences of Sustained Obesity. J Am Coll Cardiol. 2015;66(1):1-11. doi:10.1016/j.jacc.2015.04.058
25. Karam BS, Chavez-Moreno A, Koh W, Akar JG, Akar FG. Oxidative stress and inflammation as central mediators of atrial fibrillation in obesity and diabetes. Cardiovasc Diabetol. 2017;16(1):120. doi:10.1186/s12933-017-0604-9
26. Wong CX, Ganesan AN, Selvanayagam JB. Epicardial fat and atrial fibrillation: current evidence, potential mechanisms, clinical implications, and future directions. Eur Heart J. 2017;38(17):1294-1302. doi:10.1093/eurheartj/ehw045
27. Pokushalov E, Kozlov B, Romanov A, et al. Long-Term Suppression of Atrial Fibrillation by Botulinum Toxin Injection Into Epicardial Fat Pads in Patients Undergoing Cardiac Surgery: One-Year Follow-Up of a Randomized Pilot Study. Circ Arrhythm Electrophysiol. 2015;8(6):1334-1341. doi:10.1161/CIRCEP.115.003199
28. Wong CX, Sun MT, Odutayo A, et al. Associations of Epicardial, Abdominal, and Overall Adiposity With Atrial Fibrillation. Circ Arrhythm Electrophysiol. 2016;9(12):e004378. doi:10.1161/CIRCEP.116.004378
29. Packer DL, Mark DB, Robb RA, et al. Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) Trial: Study Rationale and Design. Am Heart J. 2018;199:192-199. doi:10.1016/j.ahj.2018.02.015
30. Wilber DJ, Pappone C, Neuzil P, et al. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. JAMA. 2010;303(4):333-340. doi:10.1001/jama.2009.2029
31. Di Biase L, Mohanty P, Mohanty S, et al. Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device: Results From the AATAC Multicenter Randomized Trial. Circulation. 2016;133(17):1637-1644. doi:10.1161/CIRCULATIONAHA.115.019406
32. Asad ZUA, Yousif A, Khan MS, Al-Khatib SM, Stavrakis S. Catheter Ablation Versus Medical Therapy for Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Circ Arrhythm Electrophysiol. 2019;12(9):e007414. doi:10.1161/CIRCEP.119.007414
33. Badheka AO, Rathod A, Kizilbash MA, et al. Influence of obesity on outcomes in atrial fibrillation: yet another obesity paradox. Am J Med. 2010;123(7):646-651. doi:10.1016/j.amjmed.2009.11.026
34. Groves EM, Erande AS, Le C, et al. Comparison of epicardial adipose tissue volume and coronary artery disease severity in asymptomatic adults with versus without diabetes mellitus. Am J Cardiol. 2014;114(5):686-691. doi:10.1016/j.amjcard.2014.05.057
35. Packer M. Disease-treatment interactions in the management of patients with obesity and diabetes who have atrial fibrillation: the potential mediating influence of epicardial adipose tissue. Cardiovasc Diabetol. 2019;18(1):121. doi:10.1186/s12933-019-0927-9
36. Mulder BA, Van Veldhuisen DJ, Crijns HJGM, et al. Lenient vs. strict rate control in patients with atrial fibrillation and heart failure: a post-hoc analysis of the RACE II study. Eur J Heart Fail. 2013;15(11):1311-1318. doi:10.1093/eurjhf/hft093
37. Qureshi W, O’Neal WT, Soliman EZ, Al-Mallah MH. Systematic review and meta-analysis of mortality and digoxin use in atrial fibrillation. Cardiol J. 2016;23(3):333-343. doi:10.5603/CJ.a2016.0016
38. Mareev Y, Cleland JGF. Should β-Blockers Be Used in Patients With Heart Failure and Atrial Fibrillation? Clin Ther. 2015;37(10):2215-2224. doi:10.1016/j.clinthera.2015.08.017
39. Ardestani A, Hoffman HJ, Cooper HA. Obesity and outcomes among patients with established atrial fibrillation. Am J Cardiol. 2010;106(3):369-373. doi:10.1016/j.amjcard.2010.03.036
40. Lévy S, Lauribe P, Dolla E, et al. A randomized comparison of external and internal cardioversion of chronic atrial fibrillation. Circulation. 1992;86(5):1415-1420. doi:10.1161/01.cir.86.5.1415
41. Voskoboinik A, Moskovitch J, Plunkett G, et al. Cardioversion of atrial fibrillation in obese patients: Results from the Cardioversion‐BMI randomized controlled trial. J Cardiovasc Electrophysiol. 2019;30(2):155-161. doi:10.1111/jce.13786
42. Barras M, Legg A. Drug dosing in obese adults. Aust Prescr. 2017;40(5):189-193. doi:10.18773/austprescr.2017.053
43. Ornelas-Loredo A, Kany S, Abraham V, et al. Association Between Obesity-Mediated Atrial Fibrillation and Therapy With Sodium Channel Blocker Antiarrhythmic Drugs. JAMA Cardiol. 2020;5(1):57. doi:10.1001/jamacardio.2019.4513
44. McCauley MD, Hong L, Sridhar A, et al. Ion Channel and Structural Remodeling in Obesity-Mediated Atrial Fibrillation. Circ Arrhythm Electrophysiol. 2020;13(8):e008296. doi:10.1161/CIRCEP.120.008296
45. Winkle RA, Mead RH, Engel G, et al. Impact of obesity on atrial fibrillation ablation: Patient characteristics, long-term outcomes, and complications. Heart Rhythm. 2017;14(6):819-827. doi:10.1016/j.hrthm.2017.02.023
46. Shoemaker MB, Muhammad R, Farrell M, et al. Relation of morbid obesity and female gender to risk of procedural complications in patients undergoing atrial fibrillation ablation. Am J Cardiol. 2013;111(3):368-373. doi:10.1016/j.amjcard.2012.10.013
47. Sanghai SR, Sardana M, Hansra B, et al. Indexed Left Atrial Adipose Tissue Area Is Associated With Severity of Atrial Fibrillation and Atrial Fibrillation Recurrence Among Patients Undergoing Catheter Ablation. Front Cardiovasc Med. 2018;5:76. doi:10.3389/fcvm.2018.00076
48. Sepehri Shamloo A, Dagres N, Dinov B, et al. Is epicardial fat tissue associated with atrial fibrillation recurrence after ablation? A systematic review and meta-analysis. Int J Cardiol Heart Vasc. 2019;22:132-138. doi:10.1016/j.ijcha.2019.01.003
49. Donnellan E, Wazni OM, Kanj M, et al. Association between pre-ablation bariatric surgery and atrial fibrillation recurrence in morbidly obese patients undergoing atrial fibrillation ablation. Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol. 2019;21(10):1476-1483. doi:10.1093/europace/euz183
50. Meinel TR, Branca M, De Marchis GM, et al. Prior Anticoagulation in Patients with Ischemic Stroke and Atrial Fibrillation. Ann Neurol. 2021;89(1):42-53. doi:10.1002/ana.25917
51. Moore KT, Kröll D. Influences of Obesity and Bariatric Surgery on the Clinical and Pharmacologic Profile of Rivaroxaban. Am J Med. 2017;130(9):1024-1032. doi:10.1016/j.amjmed.2017.05.011
52. Lubitz SA, Fischer A, Fuster V. Catheter ablation for atrial fibrillation. BMJ. 2008;336(7648):819-826. doi:10.1136/bmj.39513.555150.BE
53. Lioni L, Korantzopoulos P, Letsas KP. Catheter Ablation of Atrial Fibrillation in Overweight and Obese Patients. J Atr Fibrillation. 2011;4(4):1216. doi:10.4022/jafib.454
54. Abed HS, Nelson AJ, Richardson JD, et al. Impact of weight reduction on pericardial adipose tissue and cardiac structure in patients with atrial fibrillation. Am Heart J. 2015;169(5):655-662.e2. doi:10.1016/j.ahj.2015.02.008
55. Glover BM, Hong KL, Dagres N, et al. Impact of body mass index on the outcome of catheter ablation of atrial fibrillation. Heart. 2019;105(3):244-250. doi:10.1136/heartjnl-2018-313490
56. Al Chekakie MO, Akar JG. Epicardial Fat and Atrial Fibrillation: A Review. J Atr Fibrillation. 2012;4(6):483. doi:10.4022/jafib.483
57. Kim AM, Keenan BT, Jackson N, et al. Tongue Fat and its Relationship to Obstructive Sleep Apnea. Sleep. 2014;37(10):1639-1648. doi:10.5665/sleep.4072
58. Shelton KE, Woodson H, Gay S, Suratt PM. Pharyngeal Fat in Obstructive Sleep Apnea. Am Rev Respir Dis. 1993;148(2):462-466. doi:10.1164/ajrccm/148.2.462
59. Unnikrishnan D, Jun J, Polotsky V. Inflammation in sleep apnea: an update. Rev Endocr Metab Disord. 2015;16(1):25-34. doi:10.1007/s11154-014-9304-x
60. Haines KL, Nelson LG, Gonzalez R, et al. Objective evidence that bariatric surgery improves obesity-related obstructive sleep apnea. Surgery. 2007;141(3):354-358. doi:10.1016/j.surg.2006.08.012
61. Appleton SL, Vakulin A, Wittert GA, et al. The association of obstructive sleep apnea (obstructive sleep apnea) and nocturnal hypoxemia with the development of abnormal HbA1c in a population cohort of men without diabetes. Diabetes Res Clin Pract. 2016;114:151-159. doi:10.1016/j.diabres.2015.12.007
62. Lip GYH, Frison L, Halperin JL, Lane DA. Identifying patients at high risk for stroke despite anticoagulation: a comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke. 2010;41(12):2731-2738. doi:10.1161/STROKEAHA.110.590257
63. Saliba W, Rennert G. CHA2DS2-VASc score is directly associated with the risk of pulmonary embolism in patients with atrial fibrillation. Am J Med. 2014;127(1):45-52. doi:10.1016/j.amjmed.2013.10.004
64. Szymański FM, Płatek AE, Karpiński G, Koźluk E, Puchalski B, Filipiak KJ. Obstructive sleep apnoea in patients with atrial fibrillation: prevalence, determinants and clinical characteristics of patients in Polish population. Kardiol Pol. 2014;72(8):716-724. doi:10.5603/KP.a2014.0070
65. Birkbak J, Clark AJ, Rod NH. The effect of sleep disordered breathing on the outcome of stroke and transient ischemic attack: a systematic review. J Clin Sleep Med JCSM Off Publ Am Acad Sleep Med. 2014;10(1):103-108. doi:10.5664/jcsm.3376
66. Yazdan-Ashoori P, Baranchuk A. Obstructive sleep apnea may increase the risk of stroke in atrial fibrillation patients: refining the CHADS2 score. Int J Cardiol. 2011;146(2):131-133. doi:10.1016/j.ijcard.2010.10.104
67. Lynch KT, Mehaffey JH, Hawkins RB, Hassinger TE, Hallowell PT, Kirby JL. Bariatric surgery reduces incidence of atrial fibrillation: a propensity score-matched analysis. Surg Obes Relat Dis Off J Am Soc Bariatr Surg. 2019;15(2):279-285. doi:10.1016/j.soard.2018.11.021
68. Jamaly S, Carlsson L, Peltonen M, Jacobson P, Sjöström L, Karason K. Bariatric Surgery and the Risk of New-Onset Atrial Fibrillation in Swedish Obese Subjects. J Am Coll Cardiol. 2016;68(23):2497-2504. doi:10.1016/j.jacc.2016.09.940
69. Nor Hanipah Z, Punchai S, Karas LA, et al. The Outcome of Bariatric Surgery in Patients Aged 75 years and Older. Obes Surg. 2018;28(6):1498-1503. doi:10.1007/s11695-017-3020-z
70. Shimada YJ, Tsugawa Y, Camargo CA, Brown DFM, Hasegawa K. Effect of Bariatric Surgery on Emergency Department Visits and Hospitalizations for Atrial Fibrillation. Am J Cardiol. 2017;120(6):947-952. doi:10.1016/j.amjcard.2017.06.026
71. Shoemaker MB, Gidfar S, Pipilas DC, et al. Prevalence and predictors of atrial fibrillation among patients undergoing bariatric surgery. Obes Surg. 2014;24(4):611-616. doi:10.1007/s11695-013-1123-8
72. Yuan H, Miranda W, Lopez-Jimenez F, Cha Y. The impact of bariatric surgery on incidence of atrial fibrillation. Heart Rhythm. Published online 2014.
73. Höskuldsdóttir G, Sattar N, Miftaraj M, et al. Potential Effects of Bariatric Surgery on the Incidence of Heart Failure and Atrial Fibrillation in Patients With Type 2 Diabetes Mellitus and Obesity and on Mortality in Patients With Preexisting Heart Failure: A Nationwide, Matched, Observational Cohort Study. J Am Heart Assoc. 2021;10(7):e019323. doi:10.1161/JAHA.120.019323
74. Moussa O, Ardissino M, Eichhorn C, et al. Atrial fibrillation and obesity: Long-term incidence and outcomes after bariatric surgery. Eur J Prev Cardiol. 2021;28(9):e22-e24. doi:10.1177/2047487320904515
75. Yuan H, Medina-Inojosa JR, Lopez-Jimenez F, et al. The Long-Term Impact of Bariatric Surgery on Development of Atrial Fibrillation and Cardiovascular Events in Obese Patients: An Historical Cohort Study. Front Cardiovasc Med. 2021;8:647118. doi:10.3389/fcvm.2021.647118
76. Abed HS, Wittert GA, Leong DP, et al. Effect of Weight Reduction and Cardiometabolic Risk Factor Management on Symptom Burden and Severity in Patients With Atrial Fibrillation: A Randomized Clinical Trial. JAMA. 2013;310(19):2050. doi:10.1001/jama.2013.280521
77. Tsai AG, Williamson DF, Glick HA. Direct medical cost of overweight and obesity in the USA: a quantitative systematic review. Obes Rev Off J Int Assoc Study Obes. 2011;12(1):50-61. doi:10.1111/j.1467-789X.2009.00708.x
78. Dor A, Ferguson C, Langwith C, Tan E. A heavy burden: The individual costs of being overweight and obese in the United States. Dep Health Policy Sch Public Health Health Serv George Wash Univ. Published online 2010.
79. Wang YC, McPherson K, Marsh T, Gortmaker SL, Brown M. Health and economic burden of the projected obesity trends in the USA and the UK. The Lancet. 2011;378(9793):815-825. doi:10.1016/S0140-6736(11)60814-3
80. Seidell JC. Societal and personal costs of obesity. Exp Clin Endocrinol Diabetes Off J Ger Soc Endocrinol Ger Diabetes Assoc. 1998;106 Suppl 2:7-9. doi:10.1055/s-0029-1212029
81. Johnsen SP, Dalby LW, Täckström T, Olsen J, Fraschke A. Cost of illness of atrial fibrillation: a nationwide study of societal impact. BMC Health Serv Res. 2017;17(1):714. doi:10.1186/s12913-017-2652-y
82. Wolowacz SE, Samuel M, Brennan VK, Jasso-Mosqueda JG, Van Gelder IC. The cost of illness of atrial fibrillation: a systematic review of the recent literature. Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol. 2011;13(10):1375-1385. doi:10.1093/europace/eur194