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The autonomic nerve system plays an important role in atrial fibrillation (AF). Vagal AF refers AF (generally
paroxysmal) arising in contexts of enhanced parasympathetic tone. Heterogeneity of refractoriness and action
potential abbreviation resulting from spatially variable parasympathetic enhancement of the acetylcholine-
dependent K+-current (IKACh) underlie vagal AF. Adrenergic influences may also contribute to the occurrence of
vagal AF. Cholinergic stimulation may enhance ectopic firing from pulmonary vein cardiomyocytes, which
potentially contribute to the occurrence of vagal AF. On the other hand, underlying heart disease modulates
cholinergic regulation of atrial myocytes. Careful history taking in AF patients is important for vagal AF management.
Vagal denervation may play a role in the efficacy of ablation procedures, but the results are conflicting. Specific
IKACh channel blockers may become the treatment of choice in the future.
Key Words: Vagal atrial fibrillation · Acetylcholine · Muscarinic receptor · Pulmonary vein · Vagal
denervation
making, phospholipase A2, phospholipase D and tyrosine pathetic effects on the heart. Cardiac GIRK channels
kinase. 5-7 Some studies also suggest that the cyclic are composed of two homologous proteins: GIRK1
guanosine monophosphate ( cGMP) signaling pathway is and GIRK4 (Kir3.1 and 3.4). 15 In mammals, I KACh is
involved in muscarinic activation.8-10 found in the SAN, atria, AVN and Purkinje fibers. 16
Activation of mAChRs in the heart results in (1) When acetylcholine is applied to atrial myocytes,
hyperpolarization and slowed spontaneous depolariza- heterotrimeric Gi/o-proteins (composed of an a, b
tion in sinoatrial node (SAN), (2) shortened APD and and g subunit) coupled to mAChRs dissociate into
reduced contractile force in atrium and (3) decreased their constituent Gai/o and Gbg dimer subunits. Dis-
conduction velocity in the atrioventricular node (AVN). sociated Gai/o and Gbg subunits are able to modulate
The effects on cardiac electrophysiology are mainly physiological actions by interacting with numerous
through regulation of membrane ion channels and pos- effectors, including protein kinases, phospholipases,
sibly gap junctions. Figure 1 shows an overview of phosphodiesterases and ion channels. Gbg is the pri-
mAChR regulation of cardiac ion channels. mary activator of GIRK channels via a membrane
Regulation of pacemaker current If delimited pathway. 17 In SAN, I KACh results in mem-
ACh decreases I f and shifts its activation to more brane hyperpolarization and slowing of pacemaker
negative potentials, thus slowing pacemaker activity in activity. In atrial myocytes, I KACh causes atrial repo-
SAN.11,12 If is a directly cAMP-sensitive current.13 The larization and is the main current that ACh activates to
ACh-induced decrease in If is mainly via mAChRs and shorten APD, which facilitates reentry and tachy-
Gi/o protein, resulting in inhibition of adenylyl cyclase arrhythmia.
and decreased cAMP production. In addition, there is an Regulation of L-type calcium current ICa.L
alternative pathway by which mAChR activation can in- Muscarinic activation suppresses ICa,L.18,19 This sup-
hibit If via cAMP-independent signaling, but this may be pressive effect could be via inhibition of adenyly cyclase,
of lesser importance.14 thereby decreasing cAMP concentrations, or via cGMP/
Regulation of IKACh PKG-dependent activation of okadaic acid-sensitive
I KACh is an inwardly-rectified K + current carried protein phosphatase.20,21 This decrease in ICa,L may con-
by GIRK (Kir3) channel subunits activated by acetyl- tribute to the APD shortening by cholinergic stimulation.
choline or other muscarinic agonists. I KACh activation Effects on other ion currents
is believed to be the principle mediator of parasym- In guinea pig cardiomyocytes, ACh alone has no ef-
fect on delayed rectifier K+ currents (IK), but the increase
in IK by isoproterenol can be antagonized by ACh via re-
duction of intracellular cAMP.22 INa may be enhanced by
muscarinic stimulation23 whereas Cl- current activated
by b-adrenergic agonists are suppressed by muscarinic
stimulation.24 The physiological roles of these responses
in human hearts are still unclear.
Effects on gap junction
Muscarinic activation can also affect gap junction
function in the heart. Takens-Kwak et al.9 showed that
muscarinic activation in neonatal rat cardiomyocytes re-
duces the intercellular current. Gap junction conductance
in cultured neonatal rat cardiomyocytes is also decreased
Figure 1. Overview of signaling pathways responsible for M2AChR by carbachol in a cGMP-dependent manner.8,10 These re-
regulation of cardiac ion channels. ACh, acetylcholine; M2, muscarinic sults suggest that muscarinic activation inhibits gap
acetylcholine receptor subtype 2; GIRK, G-protein regulated inward-
rectifier K+ channels; IKACh, acetylcholine-sensitive K+ current; If, pace-
junction communication, which could decrease conduc-
maker current; ICa,L, L-type Ca2+ current; PKA, protein kinase A; PKG, tion velocity in atrium, which might facilitate reentry
protein kinase G. and lead to arrhythmia.
Tissue effects of cholinergic stimulation mAChRs and IKACh measured by Western blot and patch
Cholinergic stimulation abbreviates APD and ERP, clamp respectively are higher in LA, RA appendage and
mainly through the activation of I KACh . Experimental LA free wall of dogs than in RA free wall, PVs and
studies also show that vagal stimulation increases the superior vena cava. Administration of amiodarone elimi-
spatial dispersion in atrial refractoriness,25-28 as well as nates the difference in IKACh densities between LA and
in APD. Both absolute APD/ERP shortening and in- RA, but IKACh is still higher in LA and RA appendage.
creased APD/ERP heterogeneity facilitate reentry and They suggested that decreased dispersion of IKACh densi-
tachyarrhythmia. Liu et al.27 showed that vagal stimula- ties may be a potential mechanism for amiodarone
tion increases the variability in atrial refractoriness, as efficacy in AF.
indicated by the standard deviation of ERP at different Mapping studies show that spontaneous premature
atrial sites and of activation frequency during AF. Al- atrial premature depolarizations precede spontaneous AF
though sympathetic stimulation also decreases atrial induced by vagal stimulation.38 The mechanism of thess
ERP, it has no significant effect on these indexes of ERP spontaneous atrial depolarizations that trigger vagal AF
heterogeneity.27 Perhaps because of its lack of effect on was proposed to be local microreentry.32,38,39 Computer
spatial ERP dispersion, sympathetic stimulation was simulation suggests that vagal AF is maintained by sin-
much less effective than vagal stimulation in promoting gle or a small number of reentry sources with fibrillatory
AF. In another animal study in which AF was induced by conduction.32,39 Kneller et al.32 showed that cholinergic
vagal stimulation,29 flecainide doses that terminated AF stimulation stabilizes the primary spiral wave generator
significantly reduced refractoriness heterogeneity during and vagal-mediated refractoriness heterogeneity results
nerve stimulation, to the same range under control con- in wavefront disorganization and breakup. These results
ditions without nerve stimulation. These observations are compatible with experimental mapping studies which
suggest that increased heterogeneity may be a very im- show that vagal stimulation greatly increases the genera-
portant atrial proarrhythmic vagal mechanism. This idea tion of atrial extrasystoles initiating AF.38,40,41 In a study
is compatible with both experimental and computer in which AF was induced by ACh perfusion in isolated
models of AF which indicate that heterogeneity in canine RA preparations,41 activation sequence mapping
refractoriness is an important determinant of AF occur- revealed multifocal atrial premature depolarizations and
rence.30-32 regions of functional block during AF. In another study,
Potential mechanisms for the increased spatial heter- Sharifov et al.38 stimulated vagus nerve in open chest
ogeneity in refractoriness induced by vagal stimulation dogs to induce AF and showed that vagal-mediated focal
includes inhomogeneous nerve innervation33,34 and vary- ectopic atrial premature depolarizations are widely
ing IKACh densities due to heterogeneous distribution of distributed over the atria. The occurrence of atrial tac-
mAChRs and/or GIRK channels over the atria.34-37 La- hyarrhythmia events increased proportionally with stimu-
beling for the high affinity choline transporter, an in- lation intensity. In most cases of sustained AF, a single
dicator of cholinergic nerve fibers, is distributed hetero- leading and stable source of reentry circuit was estab-
geneously over the atria.34 These fibers are abundant in lished after second to third beat or after interaction
the sinus and atrioventricular nodes, interatrial septum, among unstable sources. Both animal and computer si-
and much of the right atrium (RA), but less abundant in mulation models suggest that spiral wave reentry42 under-
the left atrium (LA). Lomax et al.35 also showed that in lies vagal AF.
mouse atria IKACh current density is significantly higher IKACh is essential in the generation of vagal AF. In
in SA node myocytes than either RA or LA myocytes Kneller’s32 study the authors suggested that IKACh is a de-
and I KACh is significantly larger in RA than in LA terminant of frequency and stability during vagal AF.
myocytes. In sheep, Sarmast et al 37 showed a greater Kovoor et al.43 studied an IKACh-deficient (GIRK4 knock-
abundance of GIRK1/4 mRNA level and IKACh densities out) mouse model and found that AF can’t be induced in
in LA than in RA, which may account for more ACh- knockout mice lacking IKACh, indicating that activation
induced rotors observed by optical mapping in LA than of IKACh is required for cholinergic AF. AF was induced
in RA. Huang et al. 36 showed that the densities of in the presence of carbachol by burst pacing in 10/14
wild type mice, and lasted for a mean of 5.7 ± 11 min, initiating and maintaining AF.47 Radiofrequency catheter
but AF could not be induced in the absence of carbachol. ablation in and around PVs is most effective in curing
In knockout mice, atrial arrhythmia could not be induced AF among patients without structural heart disease. In
with or without the use of carbachol. dogs PVs have been shown to exert rapid firing of
Interactions between cholinergic and adrenergic ectopic foci and triggered AF-mediated by triggered ac-
stimulation tivity or abnormal automaticity,48 although this has not
Both cholinergic and adrenergic stimulation can been a universl finding.49
promote the occurrence of AF, although adrenergic sti- Since both vagal AF and PV-related AF often occur
mulation is much less effective than cholinergic stimula- in patients without structural heart disease,1 it is natural
tion.27,44 Interaction between adrenergic and cholinergic to investigate the role of cholinergic effects on PVs
tone may play an important role in initiating and perpet- arrhythmogenesis. Recent studies showed that the auto-
uating AF:44,45 simultaneous adrenergic stimulation has nomic nervous system plays important role in initiating
been shown to facilitate the induction of ACh-mediated PV firing and paroxysmal AF.50-55 Schauerte et al.50 per-
AF.45 Sharifov et al.44 showed that catecholamine can in- formed high-frequency electrical stimulation in the PVs
duce AF (about 20% of the time) in open chest dogs, and in dogs, leading to local ERP shortening and occurrence
atropine completely prevents catecholamine-mediated of AF. The response to high-frequency electrical stimu-
AF, indicating an important role of cholinergic tone in lation was completely abolished by atropine, but only
these AF episodes. ACh induced AF in all dogs and blunted by b-adrenergic blockers. Scherlag et al.54 showed
b-adrenergic blockade didn’t prevent ACh-induced AF, in an open chest canine model that when the autonomic
but increased the threshold ACh concentration for AF in- ganglion located at the base of the PVs was stimulated,
duction. Catecholamine administration decreased the producing a response of reduction in heart rate, fewer
threshold of ACh concentration for AF induction and in- atrial premature depolarizations were required to induce
creased AF duration. These results suggest that both AF than in control conditions without ganglionic stimu-
cholinergic and adrenergic stimulation can contribute to lation. The authors suggested that autonomic ganglion
AF induction during the activation of both systems, and stimulation, which led to vagal responses in this experi-
cholinergic stimulation plays a more potent role in AF ment, facilitates the conversion of PV firing into AF.
than adrenergic stimulation in this model. In a human study, Zimmermann et al.55 showed that
In a human study, Bettoni et al.46 showed that the in patients with focal ectopic firing from the PVs, epi-
occurrence of paroxysmal AF greatly depends on fluctua- sodes of AF were associated with variations in autonomic
tions in autonomic tone. Using heart rate variability tone, with a significant shift toward vagal predominance
(HRV) analysis method, they showed an increase in before AF onset. Takahashi et al. 53 further showed in
high-frequency components (which suggest increased humans that vagal excitation was associated with shorten-
cholinergic tone) as well as a progressive increase in ing of fibrillatory cycle length in the PVs and facilitated
low-frequency components (which suggest increased AF. These studies suggest that the PVs are susceptible to
adrenergic tone) at least 20 min before AF. The low/high enhanced vagal tone in triggering AF.
frequency ratio showed a linear increase until 10 min be- Triggered activity has been proposed to be the mech-
fore AF onset, followed by a sharp decrease immediately anism of PV arrhythmogenesis resulting from enhanced
before AF. They also showed no difference in HRV parasympathetic tone. Patterson et al.51,56 provided data
between patients with and without underlying heart dis- suggesting that enhanced sodium-calcium exchange ac-
ease. These findings suggest that both components of the tivity initiated by the calcium transient is responsible for
autonomic system are involved in the initiation of parox- focal firing from the PVs during field stimulation. With
ysmal AF, with an initial increase in adrenergic tone the application of ACh, abbreviated APs and early
followed by a shift to vagal predominance. afterdepolarizations (EADs) were induced in superfused
Cholinergic effects on PV myocyte arrhythmo- canine PV preparations. With co-application of ACh and
genesis norepinephrine, tachycardia-pause triggered rapid firing
Pulmonary veins (PVs) are known to be important in within the PV sleeve. The authors proposed that in the
stop in the morning or with exercise (Table 1). Vagal AF et al.77 showed that among patients with PSVT, higher
usually occurs in young patients with ages between 30 baroreflex sensitivity (BRS), which implies higher vagal
and 50, more frequently in men and without structural reactivity, and greater atrial ERP dispersion during
heart disease. The ECG commonly shows flutter al- episodes of PSVT are seen in patients with PSVT associ-
ternating with fibrillation. In contrast, adrenergic AF ated with paroxysmal AF. This observation suggests that
usually occurs in the presence of structural heart disease. higher vagal reflex tone contributes to the genesis of par-
Holter monitoring may show sinus bradycardia before oxysmal AF in patients with PSVT.
the onset of AF and a slow ventricular response during However, evidence regarding the pathophysiological
AF.1,69 However, manifestations of vagal and adrenergic mechanisms underlying vagal AF is not consistent. van
AF may coexist in the same patient, and the clinical pat- den Berg et al.69 showed that vagal AF is not caused by
tern may change over time. increased vagal reactivity. They grouped vagal AF and
Characterization and quantification of autonomic non-vagal AF among paroxysmal AF patients by clinical
changes and evaluation of vagal AF in humans are diffi- criteria. They showed that either a battery of autonomic
cult to refine. Analysis of heart rate variability (HRV) is tests (with use of the Finapress system) or BRS is not
a noninvasive and useful method to evaluate the balance significantly different between vagal AF and non-vagal
between sympathetic and parasympathetic tone.3,70 An AF patients. Furthermore, vagal reactivity among parox-
increase of low-frequency/high-frequency (LF/HF) ratio ysmal AF patients was below the normal range.78 The
means an enhancement of sympathetic tone whereas a authors suggested that either increased susceptibility of
decreased ratio means an enhancement of parasympa- the heart to vagal influences or increased vagal tone
thetic tone. However, this approach is over-simplified could potentially play important roles in vagal AF. More
and may not always accurately reflect autonomic func- studies are needed.
tion. Some studies have shown that paroxysmal AF
occurring during sleep are preceded by an increase in Therapeutic Implications
high-frequency components, suggesting increased vagal Pharmacological treatment
activity preceding AF.71-73 However, one group showed Management of AF should be directed according to
data suggesting that sympathetic tone is increased before the condition and the underlying disease.45 Studies ava-
AF onset during sleep.74 Another group showed that both ilable so far indicate that no clear advantage exists be-
LF and HF components are increased before AF onset, tween rhythm control and rate control in AF.79,80 Only
with no change in LF/HF ratio.75 These findings may be anecdotal data are available regarding the pharmacologi-
due to the presence of autonomic fluctuation before the cal rhythm control of vagal AF.1,81,82 van den Berg et al.
onset of paroxysmal AF.46 Different patient groups may reported a case of typical vagal AF, presenting episodes
have contributed to discrepancies. Concurrent enhance- predominantly at rest, during sleep, and after physical
ment of sympathetic tone may play a role in some cases activity.81 Medication with digoxin, verapamil, sotalol,
of vagal AF. and flecainide was ineffective. The patient was treated
Paroxysmal AF tends to co-exist in patients with successfully with disopyramide, which has anticholi-
paroxysmal supraventricular tachycardia (PSVT).76 Chen nergic properties. HRV analysis showed a decrease in
high-frequency components after successful treatment. prevention in both animal models and in patients during
Digoxin or b-blockers are generally not beneficial and cardiac surgery. Chiou et al.87,88 showed that most vagal
can even be detrimental to vagal AF, although they are fibers travel through a fat pad located between aortic
commonly used in AF with structural heart disease. root and superior vena cava, then project onto two fat
Class I antiarrhythmic drugs with vagolytic effects are pads over the heart: one at the junction between inferior
theoretically effective in treating vagal AF. Propafenone vena cava and LA, the other at the junction of right PV
is not very effective because of its b-blocking properties. and RA. They showed that radiofrequency catheter ab-
Coumel2,82 recommended flecainide, quinidine, and di- lation of these fat pads eliminates HRV and BRS. Some
sopyramide in treating vagal AF (in decreasing order, studies suggest that it may not be necessary to ablate all
respectively). three pads to suppress AF induced by vagal stimula-
PV isolation and/or vagal denervation tion. 28,89 However, the results of partial vagal dener-
PVs are well-known to provide a focal origin of AF vation are conflicting. One study showed that ventral
in many patients, and PV ablation is effective in curing cardiac denervation reduces the occurrence of AF after
paroxysmal AF.47 Oral et al.58 showed that PV isolation coronary artery bypass grafting, 90 but another group
is less effective in patients with vagal AF than patients showed that a similar strategy to prevent post-cardiac
with adrenergic or mixed form. Razavi et al.83 showed surgical AF is ineffective.91 Cummings et al.92 showed
that ablation around the PV-LA junction decreases the that removal of a fat pad located between the pulmo-
degree of atrial ERP shortening and vulnerability to AF nary artery and aorta during cardiac surgery prevented
induced by vagal stimulation. Their results suggested sinus bradycardia induced by vagal nerve stimulation,
that the ganglion plexus around PV-LA junction contrib- suggesting the presence of vagal fibers. Paradoxically,
uted to cholinergic innervation in the atria and ablating removal of this fat pad increased the incidence of post-
this region of ganglion plexi can effectively diminish the operative AF. Hirose et al.93 showed that partial vagal
atrial response to vagal stimulation. PVs isolation plus denervation facilitates rather than preventing vagally-
vagal denervation can be effective in treating vagal AF.84 mediated AF. The likely explanation is that partial
Pappone et al.84 showed that in patients with paroxysmal vagal denervation worsens autonomic imbalance, as
AF, after circumferential PV ablation, adjunctive vagal well as parasympathetic inhomogeneities. Nerve regen-
denervation significantly reduced the recurrence of AF eration may attenuate the long-term effects of vagal
at a 12-month follow-up (99% versus 85% in patients denervation. Oh et al.94 showed l that epicardial radio-
without adjunctive vagal denervatioin). Ablating around frequency ablation over fat pads in dogs effectively
the entrance of PVs achieved vagal denervation at areas reduces the inducibility of vagally-mediated AF, but 4
corresponding to areas at which slowing of sinus rhythm weeks later the effect is lost.
or slowing of ventricular response during AF was ob- Selective GIRK channel antagonists
tained during radiofrequency ablation. Scherlag et al.85 Cardiac-selective specific GIRK channel antagonists
also reported the effects of PV isolation plus ganglion could be useful in the treatment of AF. In GIRK4-
plexus ablation in AF patients. The ganglionic plexi knockout mice,43 vagal AF is prevented without favoring
were also identified around the entrance of PVs. Prior to ventricular arrhythmias or affecting AVN function.
PVs isolation, ganglion plexus ablation alone abolished Therefore, GIRK blockers are potentially therapeutic
focal firing from PVs in 95% of cases. These findings without adverse effects on ventricular arrhythmia or con-
are compatible with experimental studies showing that duction. However, the sinus rate might be accelerated by
enhanced parasympathetic tone facilitates focal firing GIRK antagonists. In a canine study, Hashimoto et al.95
from PVs and that vagal denervation abolishes this ef- showed that tertiapin-Q, a specific GIRK channel antag-
fect. Recently, Tan et al.86 showed that adrenergic and onist, prolongs atrial ERP and terminates AF induced by
cholinergic nerves are at highest densities within 5 mm vagal stimulation, without affecting ventricular repo-
of the PV-LA junction and that both are situated close to larization. Cha et al. 66 showed that a GIRK channel
each other and can even be intermixed. antagonist is effective in an atrial tachyrdia-induced AF
Vagal denervation alone has been evaluated for AF model.
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迷走神經性心房顫動
葉勇信 1,2,4 Kristina Lemola1,2 Stanley Nattel1,2,3
Department of Medicine and Research Center, Montreal Heart Institute, Quebec, Canada1
Department of Medicine, University of Montreal, Quebec, Canada2
Department of Pharmacology McGill University, Quebec, Canada3
基隆市 長庚紀念醫院 心臟內科4
自主神經系統在於引起心房顫動扮演重要的角色,迷走神經性心房顫動係指副交感神經興
奮所引起的心房顫動。其作用機轉主要是經由活化乙醯膽鹼鉀離子通道 (IKACh),在心房造
成不均勻地不反應期與動作電位縮短,形成再進入迴路 (reentry) 因而誘發心房顫動。交
感神經興奮會使迷走神經性心房顫動更容易發生。副交感神經興奮會使肺靜脈異常放電更
容易發生,因此肺靜脈異常放電也可能是引起迷走神經性心房顫動的重要原因。心臟本身
疾病會改變迷走神經對於心房細胞的正常作用,可能也是引起心房顫動的原因。臨床的診
斷仍主要有賴於詳細病史詢問,去迷走神經 (vagal denervation) 是否能治療迷走神經性心
房顫動仍有爭議,特異性乙醯膽鹼鉀離子通道阻斷劑未來可能是治療方式的選擇之一。
關鍵詞:迷走神經性心房顫動、乙醯膽鹼、蕈毒鹼接受器、肺靜脈、去迷走神經化。
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