To the Editor:
We read with great interest the recently published manuscript by van Kleef et al.
[1]
Based on the evaluation of atrial fibrillation (AF), hepatic steatosis and liver stiffness by 12-lead electrocardiogram (ECG), abdominal ultrasound and transient elastography, respectively, the authors concluded that liver stiffness but not non-alcoholic fatty liver disease (NAFLD) was significantly associated with atrial fibrillation. Having read the manuscript, we wanted to raise the following points:First, AF was diagnosed based on a 10-second 12-lead ECG performed at regular visits in the present study. Although the ECG was assessed by the modular ECG analysis system and validated by 2 research physicians, the accuracy of the prevalent rate of AF has to be reconsidered. From a recent comprehensive evaluation of AF, the sensitivity of AF diagnosis by a 10-second ECG was less than 5%.
[2]
Using a 7-day Holter ECG to diagnose AF might yield around 50% sensitivity for detecting AF. According to guideline recommendations,[3]
we suggest that the diagnosis of AF might be based on screening tools such as mobile/wearable devices, a single-lead ECG tracing of ≥30 seconds, long-term Holter and 1–2-week continuous ECG patches to prevent from the underestimation of AF prevalence. Furthermore, the prevalence of AF in those aged 65-69 years old was 3∼4.6% in the previous study.- Hindricks G.
- Potpara T.
- Dagres N.
- Arbelo E.
- Bax J.J.
- Blomström-Lundqvist C.
- et al.
2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.
Eur Heart J. 2021; 42: 373-498
[4]
With the average age around 69.5-year-old, the prevalence of AF was reported at around 7% in this study which seems to be higher than the previous data. Not to mention that this prevalence may possibly be underestimated, as mentioned earlier. The high prevalence rate of AF in the Rotterdam Study deserves further study and clarification.Second, comorbidities such as obesity, thyroid disorder, valvular heart disease (mitral valve stenosis especially) and chronic obstructive pulmonary disease are well known to be the risk factors of AF,
[5]
which were not evaluated to clarify the relationship between liver disease and prevalent AF in the present study. It is a particular pity that the association between the available BMI data and AF was not studied.Third, the authors assessed liver stiffness by transient elastography in the present study. It would be interesting to know the results of evaluating steatosis by controlled attenuation parameter (CAP). Recently published EASL Clinical Practice Guidelines
[6]
stated that there was insufficient evidence to recommend CAP as a first-line technique. Nevertheless, despite there being no consensual cut-offs, CAP values above 275 dB/m have high sensitivities and positive predictive value (>90%) for the identification of NAFLD. The addition of CAP data would solve several issues, enabling the: i) effective validation of the diagnosis of NAFLD by abdominal ultrasound; ii) assessment of the association between steatosis and AF; iii) assessment of the association between AF and non-alcoholic steatohepatitis (NASH) by the FAST (FibroScan-AST [aspartate aminotransferase]) score which has been reported to provide an efficient way to identify patients at risk of progressive NASH.[7]
We believe that it will further add to the body of evidence regarding the association between AF and NAFLD/NASH.- Newsome P.N.
- Sasso M.
- Deeks J.J.
- Paredes A.
- Boursier J.
- Chan W.K.
- et al.
FibroScan-AST (FAST) score for the non-invasive identification of patients with non-alcoholic steatohepatitis with significant activity and fibrosis: a prospective derivation and global validation study.
Lancet Gastroenterol Hepatol. 2020; 5: 362-373
Financial support
The authors received no financial support to produce this manuscript.
Authors' contributions
Chia-Yen Dai and Wei-Chung Tsai conceived of the presented idea. Chia-Yen Dai and Wei-Chung Tsai wrote the manuscript in consultation with Ming-Lung Yu. All authors discussed the results and contributed to the final manuscript.
Conflicts of interest
CY Dai: Consultant of Gilead, Abbvie; Speaker of Gilead, Abbvie and Merck. ML Yu: Research support (grant) from Gilead and Abbott; Consultant of Gilead, Abbvie and Merck; Speaker of Gilead, Abbvie and Merck.
Please refer to the accompanying ICMJE disclosure forms for further details.
Supplementary data
The following are the supplementary data to this article:
- Multimedia component 1
References
- Liver stiffness, but not fattyliver disease, is associated with atrial fibrillation: the Rotterdam study.J Hepatol. 2022; 77: 931-938
- Comprehensive evaluation of rhythm monitoring strategies in screening for atrial fibrillation: snsights from aatients at risk monitored long term with an implantable loop recorder.Circulation. 2020; 141: 1510-1522
- 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.Eur Heart J. 2021; 42: 373-498
- Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications.Arch Intern Med. 1995; 155: 469-473
- The clinical profile and pathophysiology of atrial fibrillation: relationships among clinical features, epidemiology, and mechanisms.Circ Res. 2014; 114: 1453-1468
- EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis - 2021 update.J Hepatol. 2021; 75: 659-689
- FibroScan-AST (FAST) score for the non-invasive identification of patients with non-alcoholic steatohepatitis with significant activity and fibrosis: a prospective derivation and global validation study.Lancet Gastroenterol Hepatol. 2020; 5: 362-373
Article info
Publication history
Published online: July 07, 2022
Accepted:
June 30,
2022
Received:
June 25,
2022
Identification
Copyright
© 2022 Published by Elsevier B.V. on behalf of European Association for the Study of the Liver.
