Atrial fibrillation in transthyretin amyloid cardiomyopathy: Mechanisms, prognostic implications, and management

Atrial fibrillation (AF) is common in transthyretin amyloid cardiomyopathy (ATTR-CM), affecting over 70% of patients and often preceding cardiomyopathy diagnosis. Amyloid infiltration promotes structural, mechanical, and electrical atrial remodeling, creating an arrhythmogenic substrate and increasing thromboembolic risk that may be independent of Congestive heart failure, Hypertension, Age, Diabetes, Stroke, Vascular disease, Age, and Sex category score, supporting a low threshold for anticoagulation. AF management in ATTR-CM is challenging because restrictive physiology, autonomic dysfunction, and conduction disease limit conventional rate-control strategies. Rhythm control may be advantageous, especially when initiated early. Antiarrhythmic therapy and direct-current cardioversion remain common first-line approaches, although recurrence is frequent. Catheter ablation is an emerging option for selected patients, with observational data suggesting better arrhythmia control, symptom improvement, and fewer hospitalizations, particularly in earlier-stage disease. As disease-modifying therapies, including tafamidis, acoramidis, and vutrisiran, improve survival, optimizing atrial arrhythmia management is increasingly important. This review summarizes mechanisms, prognosis, and contemporary AF management in ATTR-CM, with emphasis on early rhythm control and ablation.