Structural and Functional Arterial Properties: Comparison
Please note this is a comparison between Version 2 by Peter Tang and Version 1 by Dave Veerasingam.

Atrial fibrillation (AF), the most common cardiac arrhythmia, is associated with adverse cardiovascular (CV) outcomes. Vascular aging (VA), which is defined as the progressive deterioration of arterial function and structure over a lifetime, is an independent predictor of both AF development and CV events. A timing identification and treatment of early VA has therefore the potential to reduce the risk of AF incidence and related CV events. 

  • vascular aging
  • atrial fibrillation
  • arteriosclerosis
  • cardiovascular disease

1. Introduction

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is associated with a high burden of cardiovascular (CV) morbidity and mortality, mainly related to an increased risk of cardioembolic stroke and heart failure [1]. The global cumulative mortality attributed to AF was 0.51% in 2017, reflecting an 81% relative increase over the past two decades [1]. The prevalence of AF is currently increasing and is expected to rise in the coming years across all age groups and regions [2]. This is primarily attributed to the growing burden of comorbidities, socioeconomic deprivation and AF risk factors such as hypertension, obesity, diabetes and ischemic heart disease [3].
From a pathophysiological point of view, AF is defined as a supraventricular tachyarrhythmia marked by uncoordinated atrial electrical activation, leading to ineffective atrial contraction and causing an irregular heart rhythm. From a clinical perspective, AF is classified as paroxysmal (PAF, episodes lasting less than one week), persistent (continuously sustained beyond 7 days, including episodes terminated by cardioversion) or permanent (stable AF rhythm with no further attempts to restore/maintain sinus rhythm) [4]; long-standing persistent AF (continuously sustained for an extended period, typically lasting beyond 12 months); valvular/non-valvular AF (valvular AF indicates the presence of moderate/severe mitral stenosis or a mechanical prosthetic heart valve(s)). The classification of lone AF, referring to AF without any other cardiorespiratory diseases or risk factors, is now dismissed.
Notably, asymptomatic AF poses a challenge to clinicians, potentially causing delays in establishing preventive strategies [5]. It is estimated that one out of ten ischemic strokes is related to a previously unknown history of AF [6]. This could be prevented by implementing digital systems and mobile health technologies for AF screening and detection, especially in individuals at risk [7].
The term vascular aging (VA) is commonly used to describe the deterioration of both structural and functional components of the arterial tree, although a universally acknowledged definition is still lacking [8].

2. Structural Arterial Properties: The Arterial Stiffness

At a structural level, the process of VA is identified with the progressive stiffening of the arterial tree, namely arterial stiffness (AS). This process mainly occurs at the level of large elastic arteries such as the aorta and the carotid arteries, where a mechanical remodeling of the arterial wall is observed [9]. The most commonly used method for the non-invasive estimation of arterial stiffness is the measure of the pulse wave velocity (PWV), which represents the velocity of the pressure waves generated from the systolic contraction along a defined arterial segment. Most commonly, the carotid–femoral PWV (cfPWV) is used as a marker of aortic stiffness. CfPWV has been associated with adverse clinical outcomes in several population settings [10], and predicts CV outcome better than chronological aging [11,12][11][12]. Several other methods used for arterial stiffness estimation are summarized in Table 1.
Table 1.
Description of vascular aging biomarkers.

3. Functional Arterial Properties: The Endothelial Dysfunction

At a functional level, the hallmark of VA is the impairment of endothelial function, which is the result of a decrease in nitric oxide synthase (eNOS) expression in endothelial cells and that, in turn, promotes the development of a prothrombotic state [13] and atherosclerosis [9]. This process, namely the endothelial dysfunction (ED), is hastened by oxidative stress and occurs in response to both physiological aging and systemic inflammation [14,15][14][15]. Flow-mediated dilation (FMD), usually assessed at the brachial artery, has been established as a reliable and reproducible technique for assessment of ED [16[16][17],17], and has been independently associated with vascular disease and adverse CV events [18].
The exposure to CV risk factors, including smoking, obesity, hypertension, diabetes and hypercholesterolemia, promotes the development of both early VA and AF. Therefore, measurement of VA biomarkers such as PWV and brachial FMD in people with AF, or at risk for it, has a strong rationale and large expected impact on clinical practice to better characterize the individual CV risk and to provide targeted interventions.


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