The complex interplay between diabetes mellitus and atrial fibrillation

ABSTRACT

Introduction

A growing body of evidence suggests that diabetes mellitus (DM) is associated with an increased risk of new-onset atrial fibrillation (AF) and contributes to suboptimal arrhythmia control and poor prognosis in patients with AF. The high prevalence of AF among patients with DM is primarily attributed to common risk factors, shared pathophysiological mechanisms, and associated atrial remodeling and autonomic dysfunction.

Areas covered

This comprehensive review covers the current data on the role of DM in the development and prognosis of AF. In addition, we review the impact of anti-DM medications on AF prevention and the role of anticoagulation in patients with coexisting DM and AF.

Expert opinion

DM is independently associated with new-onset AF, and the coexistence of these two conditions contributes to poor outcomes, from reduced quality of life to increased risks of thromboembolic events, heart failure, and mortality. Despite this strong link, the current evidence is insufficient to recommend routine screening for AF in patients with DM. Although some observations exist on preventing AF with anti-DM medications, randomized controlled trials are warranted to explore the proposed benefits of novel anti-DM medicines in reducing the risk of incident AF.

KEYWORDS:

• Diabetes mellitus
• atrial fibrillation
• direct oral anticoagulation agents
• anticoagulation
• antidiabetic medications

Article highlights

• DM is highly prevalent in patients with atrial (AF).

• DM is an independent risk factor for developing new-onset, “silent,” or non-paroxysmal AF.

• Atrial remodeling (structural and electrical) and autonomic dysfunction are proposed pathophysiologic mechanisms involved in the onset of AF attributed to DM.

• DM increases the risk of AF-related complications such as heart failure, stroke, and mortality.

• The efficacy and safety of long-term systemic anticoagulation in patients with DM are similar to those without DM.

• Direct oral anticoagulants are the preferred anticoagulation agents for preventing stroke and systemic embolism in diabetic patients with concomitant AF.

• SGLT2 inhibitors appear to reduce the risk of incident AF in patients with type-2 DM based on a post hoc analysis.

• Current evidence is insufficient to support routine AF screening of all patients with DM. However, AF screening might be reasonable in diabetic patients with poor glycemic control, microvascular complications, or a longer duration of DM.

Declaration of Interest

CJ Lavie has served as a Promotional Speaker and Consultant for AstraZeneca on their SGLT-2 Inhibitors for Heart Failure Applications. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.