{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T13:26:10Z","timestamp":1789997170223,"version":"4.0.1"},"reference-count":255,"publisher":"Oxford University Press (OUP)","issue":"2","license":[{"start":{"date-parts":[[2019,12,17]],"date-time":"2019-12-17T00:00:00Z","timestamp":1576540800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"},{"start":{"date-parts":[[2019,12,17]],"date-time":"2019-12-17T00:00:00Z","timestamp":1576540800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2020,2,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Obesity and diabetes can lead to heart failure with preserved ejection fraction (HFpEF), potentially because they both cause expansion and inflammation of epicardial adipose tissue and thus lead to microvascular dysfunction and fibrosis of the underlying left ventricle. The same process also causes an atrial myopathy, which is clinically evident as atrial fibrillation (AF); thus, AF may be the first manifestation of HFpEF. Many patients with apparently isolated AF have latent HFpEF or subsequently develop HFpEF. Most patients with obesity or diabetes who have AF and exercise intolerance have increased left atrial pressures at rest or during exercise, even in the absence of diagnosed HFpEF. Among patients with AF, those who also have latent HFpEF have increased risk for systemic thromboembolism and death. The identification of HFpEF in patients with obesity or diabetes alters the risk-to-benefit relationship of commonly prescribed treatments. Bariatric surgery and statins can ameliorate AF and reduce the risk for HFpEF. Conversely, antihyperglycaemic drugs that promote adipogenesis or cause sodium retention (insulin and thiazolidinediones) may increase the risk for heart failure in patients with an underlying ventricular myopathy. Patients with obesity and diabetes who undergo catheter ablation for AF are at increased risk for AF recurrence and for post-ablation increases in pulmonary venous pressures and worsening heart failure, especially if HFpEF coexists. Therefore, AF may be the earliest indicator of HFpEF in patients with obesity or type 2 diabetes, and recognition of HFpEF alters the management of these patients.<\/jats:p>","DOI":"10.1002\/ejhf.1646","type":"journal-article","created":{"date-parts":[[2019,12,17]],"date-time":"2019-12-17T22:35:24Z","timestamp":1576622124000},"page":"214-227","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":59,"title":["Do Most Patients with Obesity or Type 2 Diabetes, and Atrial Fibrillation, Also have Undiagnosed Heart Failure? A Critical Conceptual Framework for Understanding Mechanisms and Improving Diagnosis and Treatment"],"prefix":"10.1093","volume":"22","author":[{"given":"Milton","family":"Packer","sequence":"first","affiliation":[{"name":"Baylor Heart and Vascular Institute, Baylor University Medical Center , Dallas, TX ,","place":["USA"]},{"name":"Imperial College London , London ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2019,12,17]]},"reference":[{"key":"2026011721335926000_ejhf1646-bib-0001","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1161\/CIRCULATIONAHA.116.026807","article-title":"Evidence supporting the existence of a distinct obese phenotype of heart failure with preserved ejection fraction","volume":"136","author":"Obokata","year":"2017","journal-title":"Circulation"},{"key":"2026011721335926000_ejhf1646-bib-0002","doi-asserted-by":"crossref","first-page":"633","DOI":"10.1016\/j.jchf.2018.01.009","article-title":"Obesity-related heart failure with a preserved ejection fraction: the mechanistic rationale for combining inhibitors of aldosterone, neprilysin, and sodium-glucose cotransporter-2","volume":"6","author":"Packer","year":"2018","journal-title":"JACC Heart Fail"},{"key":"2026011721335926000_ejhf1646-bib-0003","doi-asserted-by":"crossref","first-page":"11","DOI":"10.2337\/dci17-0052","article-title":"Heart failure: the most important, preventable, and treatable cardiovascular complication of type 2 diabetes","volume":"41","author":"Packer","year":"2018","journal-title":"Diabetes Care"},{"key":"2026011721335926000_ejhf1646-bib-0004","doi-asserted-by":"crossref","first-page":"2591","DOI":"10.1161\/CIRCULATIONAHA.119.040057","article-title":"Effects of canagliflozin on heart failure outcomes associated with preserved and reduced ejection fraction in type 2 diabetes: results from the CANVAS program","volume":"139","author":"Figtree","year":"2019","journal-title":"Circulation"},{"key":"2026011721335926000_ejhf1646-bib-0005","doi-asserted-by":"crossref","first-page":"2739","DOI":"10.1016\/j.jacc.2017.09.1111","article-title":"Abdominal obesity is associated with an increased risk of all-cause mortality in patients with HFpEF","volume":"70","author":"Tsujimoto","year":"2017","journal-title":"J Am Coll Cardiol"},{"key":"2026011721335926000_ejhf1646-bib-0006","doi-asserted-by":"crossref","first-page":"1609","DOI":"10.1056\/NEJMoa1908655","article-title":"PARAGON-HF Investigators and Committees. 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