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8. Arrhythmias: atrial fibrillation, ventricular arrhythmias, and sudden cardiac death and diabetes

Diabetes may increase the risk of cardiac arrhythmias via several factors including: associated CV risk factors (e.g. hypertension), CVD (i.e. CAD, prior MI, HF, or stroke), and diabetes-associated factors such as glucose control or diabetic neuropathy.157,569–572 The risk of cardiac arrhythmias or sudden cardiac death (SCD) in patients with diabetes is most often related to the presence and severity of underlying CVD, but diabetes-related factors may induce arrhythmias independently of CV comorbidities.157,573–577 The risk of conduction disturbances and need for pacemaker therapy may also be higher in patients with T2DM than in controls, although the general management for these issues should not differ from that for other patients.578,579

8.1 Atrial fibrillation and diabetes

8.1.1. Epidemiology of atrial fibrillation and its association with diabetes Patients with T1DM or T2DM may exhibit atrial electrical and structural remodelling associated with increased vulnerability for AF.580–583 Many epidemiological studies have reported an association of diabetes (mainly T2DM) with incident AF.584,585 Recent, large analyses confirmed that T1DM was also independently associated with a higher incidence of AF.586–588 Diabetes duration has also been associated with AF; each year with diabetes conferred a 3% increase in the risk of AF.589 A meta-analysis of 11 studies with 108 703 AF cases in 1 686 097 patients showed a 40% greater risk of AF in the presence of diabetes. The effect was attenuated but still significant after adjusting for other risk factors (RR 1.24; 95% CI, 1.06–1.44).590 Although men have higher absolute rates for incidence of AF, the relative rates of incident AF associated with diabetes are higher in women than in men for both T1DM and T2DM.586–588 Diabetes and AF frequently co-exist, and when this occurs, there is a substantially higher risk of all-cause death, CV death, stroke, kidney disease, and HF, regardless of diabetes type.541,577,591–596 Risk factors commonly associated with diabetes and AF (and not fully dissociable, e.g. hypertension and obesity) are also likely to worsen prognosis. In several observational studies, the age-adjusted association of diabetes with incident AF was no longer significant after multiple adjustments for hypertension, CV comorbidity, BMI, or obesity, thus suggesting that strategies for preventing AF in patients with diabetes should focus on controlling diabetes-associated comorbidities (especially weight, sleep apnoea, and BP).597–600

Intensive glucose lowering (target HbA1c <6.0%) has been associated with similar incident AF rates than a less-stringent approach (HbA1c <8.0%).601 The rate of new-onset AF may, however, be affected by diabetes therapy.577 The impact of anti-hyperglycaemic agents on the risk of AF is still debated. It has been suggested that metformin and pioglitazone may reduce the risk of AF.602 SGLT2 inhibitors, compared with placebo, were associated with more new-onset AF cases in EMPA-REG OUTCOME (empagliflozin vs. placebo), but fewer incident AF cases in CANVAS (canagliflozin vs. placebo) and DECLARE-TIMI 58 (dapagliflozin vs. placebo).71,151,153,603 In the EMPA-REG OUTCOME trial, empagliflozin, compared with placebo, reduced CV death or HF hospitalization consistently in patients with diabetes with or without AF (Pint = 0.56).604 It has recently been reported that finerenone may reduce new-onset AF in patients with T2DM and CKD.605 This is consistent with results obtained with other MRAs in HF.508,606 In the ADVANCE study, patients with diabetes and AF (∼8%) had higher risks of all-cause death, CV death, major cerebrovascular events, and HF compared with patients with diabetes without AF. Lowering BP resulted in similar RR reduction in all-cause and CV death but, due to their higher risk of these events, the absolute benefits from BP control was much greater in patients with AF.607 In the VALUE (Valsartan Antihypertensive Long-term Use Evaluation) trial, hypertensive patients with new-onset diabetes had higher rates of new-onset AF compared with patients without diabetes, and were at a higher risk of HF.608 Hence, AF in patients with diabetes should be viewed as a marker of adverse outcome, which should prompt aggressive management of all concomitant risk factors.609

8.1.2 Screening and managing atrial fibrillation in

patients with diabetes Detecting AF in patients with diabetes has clinical consequences because the risk of stroke is markedly higher in these patients. In the absence of other comorbidities, the annual risk of stroke can be estimated at 2.2% per year in isolated diabetes.610 Since asymptomatic (silent) AF is not uncommon, patients with diabetes should be opportunistically screened for AF by palpating pulse or by ECG.611 Patients with diabetes at high risk of AF would likely benefit from an active screening for AF, but more data are needed to define optimal AF screening strategies also including modern equipment, such as wearable digital devices in patients with diabetes (Supplementary data online, Table S16).612,613 Before starting treatment, clinical AF should Downloaded from academic.oup.com/eurheartj/article/44/39/4043/7238227 by guest on 07 October 2026