To the Editor: We read with interest the recently published article by Zethelius and colleagues in Diabetologia, which studied characteristics of type 2 diabetes patients contributing to atrial fibrillation (AF) risk in a very large observational cohort [1]. The modifiable risk factor, albuminuria, was found to be strongly associated with AF in type 2 diabetes. Zethelius et al claim that microalbuminuria and macroalbuminuria, as risk factors for AF in diabetes, have not been described previously in the literature; this is incorrect, in our opinion.
AF is the most common sustained cardiac arrhythmia. Diabetes contributes to an increased risk for AF, which has been estimated to be from 26 to over 100% higher in patients with diabetes than in non-diabetic people [2]. The mechanisms underlying this association remain largely unknown. Interestingly, prolonged P-wave duration on the ECG, considered to be an intermediate indicator of the accumulation of insults that ultimately leads to AF, has also been reported to be increased in patients with diabetes, even in those without ischaemia, hypertension or left ventricular hypertrophy [3].
Reduced kidney function and the presence of albuminuria were found to be predictive of AF in Atherosclerosis Risk in Communities (ARIC) study participants [4]. Microalbuminuria has also been linked to AF in a population of more than 20,000 hypertensive patients [5]. In the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) study, which included more than 11,000 patients with type 2 diabetes, Du et al showed that patients with AF had higher levels of blood pressure and albuminuria [6]. Finally, studying 2,671 type 2 diabetes patients originating from the SURDIAGENE (Survie, Diabete de type 2 et Genetique) and DIAB2NEPHROGENE (Diabete de type 2, Nephropathie et Genetique) cohorts, our group showed that albuminuria was strongly linked to prevalent AF and prolonged P-wave duration [7].
The association in type 2 diabetes between impaired renal function and/or albuminuria on the one hand and AF on the other is actually already well described, and urinary albumin should be tested as an indicator of atrial tissue damage in future studies, potentially leading to interventions such as more stringent monitoring of diabetic patients with renal damage. This could allow patients at risk from AF to be more easily identified and lead to a better assessment of stroke risk in these patients.
Abbreviations
- AF:
-
Atrial fibrillation
References
Zethelius B, Gudbjörnsdottir S, Eliasson B, Eeg-Olofsson K, Svensson AM, Cederholm J (2015) Risk factors for atrial fibrillation in type 2 diabetes: report from the Swedish National Diabetes Register (NDR). Diabetologia 58:2259–2268
Nichols GA, Reinier K, Chugh SS (2009) Independent contribution of diabetes to increased prevalence and incidence of atrial fibrillation. Diabetes Care 32:1851–1856
Magnani JW, Williamson MA, Ellinor PT, Monahan KM, Benjamin EJ (2009) P wave indices: current status and future directions in epidemiology, clinical, and research applications. Circ Arrhythm Electrophysiol 2:72–79
Alonso A, Lopez FL, Matsushita K et al (2011) Chronic kidney disease is associated with the incidence of atrial fibrillation: the Atherosclerosis Risk in Communities (ARIC) study. Circulation 123:2946–2953
Böhm M, Thoenes M, Neuberger HR et al (2009) Atrial fibrillation and heart rate independently correlate to microalbuminuria in hypertensive patients. Eur Heart J 30:1364–1371
Du X, Ninomiya T, de Galan B et al (2009) Risks of cardiovascular events and effects of routine blood pressure lowering among patients with type 2 diabetes and atrial fibrillation: results of the ADVANCE study. Eur Heart J 30:1128–1135
Montaigne D, Bailloeuil O, Hulin-Delmotte C et al (2012) DIAB2NEPHROGENE and SURDIAGENE study groups. Renal complications correlate with electrical atrial vulnerability hallmarks in type 2 diabetic patients. Int J Cardiol 159:63–66
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The SURDIAGENE and DIAB2NEPHROGENE cohorts were supported by grants from the French Ministry of Health (PHRC-Poitiers 2004; PHRC-IR 2008), Association Française des Diabétiques (AFD; Research Grant 2003) and Groupement pour l’Etude des Maladies Métaboliques et Systémiques (GEMMS Poitiers, France).
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Montaigne, D., Coisne, A., Sosner, P. et al. Electrical atrial vulnerability and renal complications in type 2 diabetes. Diabetologia 59, 861–862 (2016). https://doi.org/10.1007/s00125-015-3840-0
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DOI: https://doi.org/10.1007/s00125-015-3840-0