Atrial fibrillation burden and management in cardiomyopathies: Current evidence and unmet needs

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in patients with cardiomyopathies and its clinical management presents a significant challenge. The prevalence of AF varies among cardiomyopathies, with hypertrophic (HCM) and dilated cardiomyopathy (DCM) associated with higher rates of AF. Presence of AF portends increased risk for thromboembolism, heart failure, and cardiovascular morbidity and mortality in patients with cardiomyopathy. The complex genetic substrate in DCM and non-dilated left ventricular cardiomyopathy (NDLVC) contribute to the heterogeneity of AF burden and its sequelae among cardiomyopathy genotypes, necessitating genotype-tailored approach in AF screening and management. Given the lack of validation of traditional risk scores for AF in cardiomyopathies, current clinical recommendations emphasize the importance of comprehensive risk stratification for AF, monitoring for AF, and early initiation of oral anticoagulation for brief AF episodes in specific cardiomyopathy subtypes such as hypertrophic or amyloid cardiomyopathy. AF management includes antiarrhythmic drugs, interventional therapies such as catheter ablation, mitral valve replacement when necessary, and lifestyle modifications to attenuate AF burden and improve quality of life. This review summarizes the current knowledge on the clinical significance, prognostic implications, and treatment of AF among different cardiomyopathy subtypes. We underscore the paradigm shift in AF management advocating for an individualized, subtype-specific, and genotype-aware approach to AF in cardiomyopathies, which is instrumental in improving prognosis and patient-centric care.