1-s2.0-S2405500X23001172.pdf

Simultaneous activation of the sympathetic and parasympathetic nervous systems is crucial for the initiation of atrial fibrillation (AF) in a subset of patients. However, unbalanced activation of the sympathetic system is characteristic of autonomic remodeling in long-standing AF. Metabolic remodeling provides the complex substrate for the persistence of AF by promoting delayed electrophysiological and structural changes in the atrium. Adrenergic activation aggravates metabolic remodeling whereas cholinergic activation ameliorates metabolic derangement in face of metabolic challenges. Selective inhibition of the sympathetic system along with restoration of the balance of the cholinergic system by neuromodulation may delay the progression of AF by mitigation of metabolic remodeling.