The Present and Future
JACC State-of-the-Art Review
Prevention of Pathological Atrial Remodeling and Atrial Fibrillation: JACC State-of-the-Art Review

https://doi.org/10.1016/j.jacc.2021.04.012Get rights and content
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Highlights

  • Atrial enlargement occurs physiologically in athletes and during pregnancy and pathologically in patients with various cardiovascular diseases, and it can be challenging to distinguish benign from pathological enlargement.

  • Physiological and pathological atrial enlargement have different functional, structural and molecular profiles.

  • Pathological atrial enlargement is associated with atrial fibrillation, and the capacity for reverse remodeling is limited.

  • Distinguishing the mechanisms responsible for physiological and pathological atrial enlargement could facilitate earlier interventions to prevent and reverse pathological remodeling.

Abstract

Atrial enlargement in response to pathological stimuli (e.g., hypertension, mitral valve disease) and physiological stimuli (exercise, pregnancy) can be comparable in magnitude, but the diseased enlarged atria is associated with complications such as atrial fibrillation (AF), whereas physiological atrial enlargement is not. Pathological atrial enlargement and AF is also observed in a small percentage of athletes undergoing extreme/intense endurance sport and pregnant women with preeclampsia. Differences between physiological and pathological atrial enlargement and underlying mechanisms are poorly understood. This review describes human and animal studies characterizing atrial enlargement under physiological and pathological conditions and highlights key knowledge gaps and clinical challenges, including: 1) the limited ability of atria to reverse remodel; and 2) distinguishing physiological and pathological enlargement via imaging/biomarkers. Finally, this review discusses how targeting distinct molecular mechanisms underlying physiological and pathological atrial enlargement could provide new therapeutic and diagnostic strategies for preventing or reversing atrial enlargement and AF.

Key Words

atrial remodeling
heart disease
exercise
pregnancy
reverse remodeling
treatment

Abbreviations and Acronyms

AF
atrial fibrillation
ANP
atrial natriuretic peptide
CMR
cardiac magnetic resonance imaging
HF
heart failure
LA
left atrium/atrial
LAVi
left atrial volume index
LV
left ventricle/ventricular
RA
right atrium
RAS
renin-angiotensin system

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Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.

Luigi Badano, MD, served as Guest Associate Editor for this paper. Athena Poppas, MD, served as Guest Editor-in-Chief for this paper.

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.

Drs. Chen and Voskoboinik contributed equally to this work.