Recent updates in the management of atrial fibrillation in patients with cardiac amyloidosis

Left atrial myopathy in cardiac amyloidosis leads to structural, functional, and electrophysiologic changes in the left atrial myocardium that create substrate for atrial fibrillation. As a result, the incidence and prevalence of atrial fibrillation in patients with cardiac amyloid exceeds that of other cardiomyopathies. Management of atrial fibrillation in patients with cardiac amyloidosis is particularly challenging given poor hemodynamic tolerance to rate control, limited safety profile of antiarrhythmic drugs, and modest long-term effectiveness of rhythm control strategies. Data on outcomes after cardioversion and catheter ablation are based on retrospective observational studies with small sample size, making it difficult to understand the impact of rhythm control in cardiovascular outcomes of these patients. Moreover, patients with cardiac amyloidosis have a higher risk of thromboembolism than that of other populations with atrial fibrillation, along with a higher risk of bleeding due to alteration in coagulation pathways and fragility of vasculature infiltrated by amyloid fibrils. Decision-making on stroke prevention strategies therefore demands a careful and individualized risk assessment for each patient. In this review, we explore the intricacies of the association between atrial fibrillation and cardiac amyloidosis, including epidemiology, mechanisms of atrial arrhythmia, management considerations, as well gaps in research and future directions.