Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia. The scope and impact of atrial fibrillation are wide; it can affect cardiac function, functional status, and quality of life, and it confers a stroke risk. There are sex differences in atrial fibrillation across the scope of the disease process, from epidemiology and causative mechanisms to management and outcomes. The approach to management of atrial fibrillation differs between women and men, and there are sex differences in response to medical therapy and catheter ablation. There are many gaps in our knowledge of the gender differences in atrial fibrillation, and many opportunities for future research.
Keywords: Atrial fibrillation, gender differences, antiarrhythmic drugs, catheter ablation, stroke, future research.
[1]
Kim MH, Johnston SS, Chu BC, Dalal MR, Schulman KL. Estimation of total incremental health care costs in patients with atrial fibrillation in the United States. Circ Cardiovasc Qual Outcomes 2011; 4(3): 313-20.
[2]
Mou L, Norby FL, Chen LY, et al. Lifetime risk of atrial fibrillation by race and socioeconomic status: ARIC Study (Atherosclerosis Risk in Communities). Circ Arrhythm Electrophysiol 2018; 11(7): e006350.
[3]
Schnabel RB, Yin X, Gona P, et al. 50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: A cohort study. Lancet 2015; 386(9989): 154-62.
[4]
Wolbrette D, Naccarelli G, Curtis A, Lehmann M, Kadish A. Gender differences in arrhythmias. Clin Cardiol 2002; 25(2): 49-56.
[5]
Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics-2018 update: A report from the American Heart Association. Circulation 2018; 137(12): e67-e492.
[6]
Benjamin EJ, Levy D, Vaziri SM, D'Agostino RB, Belanger AJ, Wolf PA. Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study. JAMA 1994; 271(11): 840-4.
[7]
Mathew JP, Parks R, Savino JS, et al. Atrial fibrillation following coronary artery bypass graft surgery: Predictors, outcomes, and resource utilization. JAMA 1996; 276(4): 300-6.
[8]
Magnussen C, Niiranen TJ, Ojeda FM, et al. Sex differences and similarities in atrial fibrillation epidemiology, risk factors, and mortality in community cohorts: Results from the BiomarCaRE Consortium (Biomarker for Cardiovascular Risk Assessment in Europe). Circulation 2017; 136(17): 1588-97.
[9]
Duca F, Zotter-Tufaro C, Kammerlander AA, et al. Gender-related differences in heart failure with preserved ejection fraction. Sci Rep 2018; 8(1): 1080.
[10]
Conde-Martel A, Arkuch ME, Formiga F, et al. Gender related differences in clinical profile and outcome of patients with heart failure. Results of the RICA Registry. Rev Clin Esp 2015; 215(7): 363-70.
[11]
Kassim NA, Althouse AD, Qin D, Leef G, Saba S. Gender differences in management and clinical outcomes of atrial fibrillation patients. J Cardiol 2017; 69(1): 195-200.
[12]
Nielsen PB, SkjA,th F, Overvad TF, Larsen TB, Lip GYH. Female sex is a risk modifier rather than a risk factor for stroke in atrial fibrillation: Should we use a CHA2DS2-VA score rather than CHA2DS2-VASc? Circulation 2018; 137(8): 832-40.
[13]
Wong JA, Rexrode KM, Sandhu RK, Conen D, Albert CM. Number of pregnancies and atrial fibrillation risk: The women's health study. Circulation 2017; 135(6): 622-4.
[14]
Craici I, Wagner S, Garovic VD. Preeclampsia and future cardiovascular risk: Formal risk factor or failed stress test? Ther Adv Cardiovasc Dis 2008; 2(4): 249-59.
[15]
Stuart JJ, Tanz LJ, Cook NR, et al. Hypertensive disorders of pregnancy and 10-year cardiovascular risk prediction. J Am Coll Cardiol 2018; 72(11): 1252-63.
[16]
Scantlebury DC, Kattah AG, Weissgerber TL, et al. Impact of a history of hypertension in pregnancy on later diagnosis of atrial fibrillation. J Am Heart Assoc 2018; 7(10): e007584.
[17]
Rautaharju PM, Zhou SH, Wong S, et al. Sex differences in the evolution of the electrocardiographic QT interval with age. Can J Cardiol 1992; 8(7): 690-5.
[18]
Surawicz B, Parikh SR. Differences between ventricular repolarization in men and women: description, mechanism and implications. Ann Noninvasive Electrocardiol 2003; 8(4): 333-40.
[19]
Allessie M, Ausma J, Schotten U. Electrical, contractile and structural remodeling during atrial fibrillation. Cardiovasc Res 2002; 54(2): 230-46.
[20]
Tse HF, Oral H, Pelosi F, Knight BP, Strickberger SA, Morady F. Effect of gender on atrial electrophysiologic changes induced by rapid atrial pacing and elevation of atrial pressure. J Cardiovasc Electrophysiol 2001; 12(9): 986-9.
[21]
Li Z, Wang Z, Yin Z, et al. Gender differences in fibrosis remodeling in patients with long-standing persistent atrial fibrillation. Oncotarget 2017; 8(32): 53714-29.
[22]
Cochet H, Mouries A, Nivet H, et al. Age, atrial fibrillation, and structural heart disease are the main determinants of left atrial fibrosis detected by delayed-enhanced magnetic resonance imaging in a general cardiology population. J Cardiovasc Electrophysiol 2015; 26(5): 484-92.
[23]
Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002; 347(23): 1825-33.
[24]
Marrouche NF, Brachmann J, Andresen D, et al. Catheter ablation for atrial fibrillation with heart failure. N Engl J Med 2018; 378(5): 417-27.
[25]
Prabhu S, Taylor AJ, Costello BT, et al. Catheter ablation versus medical rate control in atrial fibrillation and systolic dysfunction: The CAMERA-MRI study. J Am Coll Cardiol 2017; 70(16): 1949-61.
[26]
Piccini JP, Simon DN, Steinberg BA, et al. Differences in clinical and functional outcomes of atrial fibrillation in women and men: Two-year results from the ORBIT-AF registry. JAMA Cardiol 2016; 1(3): 282-91.
[27]
Dagres N, Nieuwlaat R, Vardas PE, et al. Gender-related differences in presentation, treatment, and outcome of patients with atrial fibrillation in Europe: A report from the Euro Heart Survey on Atrial Fibrillation. J Am Coll Cardiol 2007; 49(5): 572-7.
[28]
Schnabel RB, Pecen L, Ojeda FM, et al. Gender differences in clinical presentation and 1-year outcomes in atrial fibrillation. Heart 2017; 103(13): 1024-30.
[29]
Lee JM, Kim TH, Cha MJ, et al. Gender-related differences in management of nonvalvular atrial fibrillation in an Asian population. Korean Circ J 2018; 48(6): 519-28.
[30]
Rienstra M, Van Veldhuisen DJ, Hagens VE, et al. Gender-related differences in rhythm control treatment in persistent atrial fibrillation: Data of the Rate Control Versus Electrical Cardioversion (RACE) study. J Am Coll Cardiol 2005; 46(7): 1298-306.
[31]
Somberg JC, Preston RA, Ranade V, Cvetanovic I, Molnar J. Gender differences in cardiac repolarization following intravenous sotalol administration. J Cardiovasc Pharmacol Ther 2012; 17(1): 86-92.
[32]
Weeke P, Delaney J, Mosley JD, et al. QT variability during initial exposure to sotalol: Experience based on a large electronic medical record. Europace 2013; 15(12): 1791-7.
[33]
Lehmann MH, Hardy S, Archibald D. quart B, MacNeil DJ. Sex difference in risk of torsade de pointes with d,l-sotalol. Circulation 1996; 94(10): 2535-41.
[34]
Torp-Pedersen C, Møller M, Bloch-Thomsen PE, et al. Dofetilide in patients with congestive heart failure and left ventricular dysfunction. Danish Investigations of Arrhythmia and Mortality on Dofetilide Study Group. N Engl J Med 1999; 341(12): 857-65.
[35]
Steinberg JS, Shah Y, Szepietowska B. pharmacologic conversion during dofetilide treatment for persistent atrial fibrillation. Pacing Clin Electrophysiol 2017; 40(6): 667-71.
[36]
Pokorney SD, Yen DC, Campbell KB, et al. Dofetilide dose reductions and discontinuations in women compared with men. Heart Rhythm 2018; 15(4): 478-84.
[37]
Hassan Virk HU, Qureshi WT, Makkar N, et al. Short- and long-term clinical predictors of pharmacological cardioversion of persistent atrial fibrillation by dofetilide: A retrospective cohort study of 160 patients. Clin Cardiol 2017; 40(7): 474-9.
[38]
Hosseini SM, Rozen G, Saleh A, et al. Catheter ablation for cardiac arrhythmias: Utilization and in-hospital complications, 2000 to 2013. JACC Clin Electrophysiol 2017; 3(11): 1240-8.
[39]
Elayi CS, Darrat Y, Suffredini JM, et al. Sex differences in complications of catheter ablation for atrial fibrillation: Results on 85,977 patients. J Interv Card Electrophysiol 2018. [Epub ahead of print].
[40]
Bollmann A, Ueberham L, Schuler E, et al. Cardiac tamponade in catheter ablation of atrial fibrillation: German-wide analysis of 21 141 procedures in the Helios atrial fibrillation ablation registry (SAFER). Europace 2018. [Epub ahead of print].
[41]
Hoyt H, Bhonsale A, Chilukuri K, et al. Complications arising from catheter ablation of atrial fibrillation: Temporal trends and predictors. Heart Rhythm 2011; 8(12): 1869-74.
[42]
Spragg DD, Dalal D, Cheema A, et al. Complications of catheter ablation for atrial fibrillation: Incidence and predictors. J Cardiovasc Electrophysiol 2008; 19(6): 627-31.
[43]
Inoue K, Murakawa Y, Nogami A, et al. Clinical and procedural predictors of early complications of ablation for atrial fibrillation: Analysis of the national registry data. Heart Rhythm 2014; 11(12): 2247-53.
[44]
Baman TS, Jongnarangsin K, Chugh A, et al. Prevalence and predictors of complications of radiofrequency catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2011; 22(6): 626-31.
[45]
Guhl EN, Siddoway D, Adelstein E, et al. Incidence and predictors of complications during cryoballoon pulmonary vein isolation for atrial fibrillation. J Am Heart Assoc 2016; 5(7): e003724.
[46]
Yang E, Ipek EG, Balouch M, et al. Factors impacting complication rates for catheter ablation of atrial fibrillation from 2003 to 2015. Europace 2017; 19(2): 241-9.
[47]
Huang G, Parikh PB, Malhotra A, Gruberg L, Kort S. Relation of body mass index and gender to left atrial size and atrial fibrillation. Am J Cardiol 2017; 120(2): 218-22.
[48]
Aldhoon B, Wichterle D, Peichl P, Čihák R, Kautzner J. Complications of catheter ablation for atrial fibrillation in a high-volume centre with the use of intracardiac echocardiography. Europace 2013; 15(1): 24-32.
[49]
Sharma PS, Padala SK, Gunda S, Koneru JN, Ellenbogen KA. Vascular complications during catheter ablation of cardiac arrhythmias: A comparison between vascular ultrasound guided access and conventional vascular access. J Cardiovasc Electrophysiol 2016; 27(10): 1160-6.
[50]
Trivedi C, Mohanty S, Gianni C, et al. Abstract 16665: Real-time ultrasound guidance for venous access reduces vascular complications in women aged 75 years or older undergoing catheter ablation for atrial fibrillation under uninterrupted anticoagulation. Circulation 2018; 136: A16665.
[51]
Kuck KH, Brugada J, Fürnkranz A, et al. Impact of female sex on clinical outcomes in the FIRE AND ICE trial of catheter ablation for atrial fibrillation. Circ Arrhythm Electrophysiol 2018; 11(5): e006204.
[52]
Forleo GB, Tondo C, De Luca L, et al. Gender-related differences in catheter ablation of atrial fibrillation. Europace 2007; 9(8): 613-20.
[53]
Yu HT, Yang PS, Kim TH, et al. Poor rhythm outcome of catheter ablation for early-onset atrial fibrillation in women- Mechanistic insight. Circ J 2018; 82(9): 2259-68.
[54]
Kaiser DW, Fan J, Schmitt S, et al. Gender differences in clinical outcomes after catheter ablation of atrial fibrillation. JACC Clin Electrophysiol 2016; 2(6): 703-10.
[55]
Patel D, Mohanty P, Di Biase L, et al. Outcomes and complications of catheter ablation for atrial fibrillation in females. Heart Rhythm 2010; 7(2): 167-72.
[56]
Jacobs V, May HT, Bair TL, et al. The impact of risk score (CHADS2 versus CHA2DS2-VASc) on long-term outcomes after atrial fibrillation ablation. Heart Rhythm 2015; 12(4): 681-6.
[57]
Rostock T, Salukhe TV, Steven D, et al. Long-term single- and multiple-procedure outcome and predictors of success after catheter ablation for persistent atrial fibrillation. Heart Rhythm 2011; 8(9): 1391-7.
[58]
Hayashi K, An Y, Nagashima M, et al. Importance of nonpulmonary vein foci in catheter ablation for paroxysmal atrial fibrillation. Heart Rhythm 2015; 12(9): 1918-24.
[59]
Takigawa M, Takahashi A, Kuwahara T, et al. Impact of non-pulmonary vein foci on the outcome of the second session of catheter ablation for paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2015; 26(7): 739-46.
[60]
Kamel H, Okin PM, Elkind MS, Iadecola C. Atrial fibrillation and mechanisms of stroke: Time for a new model. Stroke 2016; 47(3): 895-900.
[61]
Amin A. Oral anticoagulation to reduce risk of stroke in patients with atrial fibrillation: Current and future therapies. Clin Interv Aging 2013; 8: 75-84.
[62]
Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361(12): 1139-51.
[63]
Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011; 365(10): 883-91.
[64]
Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011; 365(11): 981-92.
[65]
Thompson LE, Maddox TM, Lei L, et al. Sex differences in the use of oral anticoagulants for atrial fibrillation: A Report From the National Cardiovascular Data Registry (NCDRA(r)) PINNACLE Registry. J Am Heart Assoc 2017; 6(7): e005801.
[66]
Poli D, Antonucci E, Grifoni E, Abbate R, Gensini GF, Prisco D. Gender differences in stroke risk of atrial fibrillation patients on oral anticoagulant treatment. Thromb Haemost 2009; 101(5): 938-42.
[67]
Pancholy SB, Sharma PS, Pancholy DS, Patel TM, Callans DJ, Marchlinski FE. Meta-analysis of gender differences in residual stroke risk and major bleeding in patients with nonvalvular atrial fibrillation treated with oral anticoagulants. Am J Cardiol 2014; 113(3): 485-90.
[68]
Pokorney SD, Simon DN, Thomas L, et al. Patients' time in therapeutic range on warfarin among US patients with atrial fibrillation: Results from ORBIT-AF registry. Am Heart J 2015; 170(1): 141-8. 148 e1
[69]
Sullivan RM, Zhang J, Zamba G, Lip GY, Olshansky B. Relation of gender-specific risk of ischemic stroke in patients with atrial fibrillation to differences in warfarin anticoagulation control (from AFFIRM). Am J Cardiol 2012; 110(12): 1799-802.
[70]
Schmidt B, Betts TR, Sievert H, et al. Incidence of pericardial effusion after left atrial appendage closure: The impact of underlying heart rhythm-Data from the EWOLUTION study. J Cardiovasc Electrophysiol 2018; 29(7): 973-8.
[71]
Holmes DR Jr, Kar S, Price MJ, et al. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: The PREVAIL trial. J Am Coll Cardiol 2014; 64(1): 1-12.
[72]
Reddy VY, Doshi SK, Kar S, et al. 5-year outcomes after left atrial appendage closure: From the PREVAIL and PROTECT AF trials. J Am Coll Cardiol 2017; 70(24): 2964-75.
[73]
Kaneko H, Neuss M, Weissenborn J, Butter C. Predictors of thrombus formation after percutaneous left atrial appendage closure using the WATCHMAN device. Heart Vessels 2017; 32(9): 1137-43.
[74]
Dorian P, Jung W, Newman D, et al. The impairment of health-related quality of life in patients with intermittent atrial fibrillation: Implications for the assessment of investigational therapy. J Am Coll Cardiol 2000; 36(4): 1303-9.
[75]
Hagens VE, Ranchor AV, Van Sonderen E, et al. Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. Results from the Rate Control Versus Electrical Cardioversion (RACE) study. J Am Coll Cardiol 2004; 43(2): 241-7.
[76]
Dorian P, Paquette M, Newman D, et al. Quality of life improves with treatment in the Canadian trial of atrial fibrillation. Am Heart J 2002; 143(6): 984-90.
[77]
Paquette M, Roy D, Talajic M, et al. Role of gender and personality on quality-of-life impairment in intermittent atrial fibrillation. Am J Cardiol 2000; 86(7): 764-8.
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