Growing evidence suggests periodontitis as a possible modifiable risk factor for atrial fibrillation (Afib), though left unanswered is the question of whether improving oral health can help clinical outcomes.
A histologic association between inflammatory gum disease and atrial fibrosis was confirmed in a small prospective study showing that people exhibiting signs of periodontitis -- bleeding on probing, periodontal probing depth 4 mm or deeper, and greater periodontal inflamed surface area (PISA) -- tended to have atrial fibrosis based on their resected left atrial appendages (LAAs).
PISA was significantly associated with atrial fibrosis after multivariable adjustment.
With fibrotic replacement of atrial myocardium known to contribute to the development of Afib, these findings add to the evidence for a link between oral and systemic disease, according to Yukiko Nakano, MD, PhD, of Hiroshima University in Japan, and colleagues.
"This study provides basic evidence that periodontitis can aggravates [sic] atrial fibrosis and thus leads to the onset and persistence of Afib," they stated in JACC: Clinical Electrophysiology. "Further prospective clinical studies are warranted to clarify whether periodontal intervention alone can inhibit atrial fibrosis and improve Afib outcome." The findings are slated for inclusion at the 2022 American Heart Association annual meeting.
"Studies are now warranted to show that treatment of chronic periodontitis is atrial protective," agreed Andreas Goette, MD, of St. Vincenz Hospital in Paderborn, Germany, in an accompanying editorial.
There are decades of research linking oral infections with conditions such as diabetes mellitus, atherosclerosis, cardiovascular and cerebrovascular diseases, and rheumatoid arthritis. What Nakano and colleagues have done is "add a small piece in the puzzle to understand the role of chronic inflammation in the development of atrial fibrosis, Afib, and stroke," Goette commented.
"Importantly, about 50% of the middle-aged population is affected by different stages of periodontitis. Thus, it is of potential clinical importance to assess if chronic oral inflammatory processes may contribute to the development of atrial pathologies," Goette said.
The prospective study included 76 people with Afib (mean age 71.1, 63% men) scheduled to undergo LAA excision during cardiac surgery. All underwent an oral examination in the 3 days before surgery and the degree of fibrosis in each LAA was quantified by Azan-Mallory staining.
Degree of atrial fibrosis correlated with the patient's Afib duration, Nakano's group reported.
Atrial fibrosis was significantly more common in patients with nonparoxysmal Afib than in patients with paroxysmal Afib. Likewise, PISA was significantly greater in patients with nonparoxysmal Afib.
Patients with a LAA thrombus had significantly higher PISA than did those without.
"It is tempting to speculate that the increasing incidence of Afib in the world is at least to some extent related to oral infections, which could be an easy therapeutic target for primary prevention of Afib and stroke in the overall population," Goette said.
However, the study was limited by its small sample size. Additionally, the observational design precluded any causal finding between inflammatory gum disease and atrial fibrosis; based on the data, it's possible that periodontitis reflects poor self-care by the patient, according to the authors.
Also unclear are the molecular mechanisms that would link periodontitis and atrial fibrosis, Goette noted.
"Furthermore, it is unclear whether the release of inflammatory markers around infected teeth and oral tissue into the systemic circulation directly causes atrial changes or if the immune response induced by periodontitis causes via activation several secondary factors activation of fibroblast," he wrote.
Disclosures
The study was funded by Japan Society for the Promotion of Science grants.
Nakano and co-authors disclosed no relationships with industry.
The editorial was supported by a European Union grant. Goette disclosed relationships with Abbott, AstraZeneca, Bayer Health Care, Berlin Chemie, Biotronik, Boehringer Ingelheim, BMS/Pfizer, Boston Scientific, Daiichi Sankyo, Medtronic, Omeicos, and Sanofi.
Primary Source
JACC: Clinical Electrophysiology
Secondary Source
JACC: Clinical Electrophysiology
Source Reference: Goette A "Is periodontist a modifiable risk factor for atrial fibrillation substrate?" JACC Clin Electrophysiol 2022; DOI: 10.1016/j.jacep.2022.09.013.
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