Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2023 May 8;13(5):1139.
doi: 10.3390/life13051139.

The Autonomic Coumel Triangle: A New Way to Define the Fascinating Relationship between Atrial Fibrillation and the Autonomic Nervous System

Marco Rebecchi  1 , Francesca Fanisio  1 , Fabio Rizzi  1 , Alessandro Politano  1 , Ermenegildo De Ruvo  1 , Cinzia Crescenzi  1 , Germana Panattoni  1 , Marianna Squeglia  1 , Annamaria Martino  1 , Stefano Sasso  2 , Paolo Golia  1 , Giulia Pugliese  2 , Sofia Del Gigante  2 , Domenico Giamundo  2 , Pietro Desimone  2 , Domenico Grieco  1 , Lucia De Luca  1 , Ignazio Giordano  2 , Francesco Barillà  2 , Marco Alfonso Perrone  3 , Leonardo Calò  1 , Ferdinando Iellamo  3
Affiliations
Review

The Autonomic Coumel Triangle: A New Way to Define the Fascinating Relationship between Atrial Fibrillation and the Autonomic Nervous System

Marco Rebecchi et al. Life (Basel). .

Abstract

Arrhythmogenic substrate, modulating factors, and triggering factors (the so-called Coumel's triangle concept) play a primary role in atrial fibrillation (AF) pathophysiology. Several years have elapsed since Coumel and co-workers advanced the concept of the relevance of autonomic nervous system (ANS) influences on atrial cells' electrophysiological characteristics. The ANS is not only associated with cardiac rhythm regulation but also exerts an important role in the triggering and maintenance of atrial fibrillation. This review aims to describe in detail the autonomic mechanisms involved in the pathophysiology of atrial fibrillation (AF), starting from the hypothesis of an "Autonomic Coumel Triangle" that stems from the condition of the fundamental role played by the ANS in all phases of the pathophysiology of AF. In this article, we provide updated information on the biomolecular mechanisms of the ANS role in Coumel's triangle, with the molecular pathways of cardiac autonomic neurotransmission, both adrenergic and cholinergic, and the interplay between the ANS and cardiomyocytes' action potential. The heterogeneity of the clinical spectrum of the ANS and AF, with the ANS playing a relevant role in situations that may promote the initiation and maintenance of AF, is highlighted. We also report on drug, biological, and gene therapy as well as interventional therapy. On the basis of the evidence reviewed, we propose that one should speak of an "Autonomic Coumel's Triangle" instead of simply "Coumel's Triangle".

Keywords: ablation techniques; atrial fibrillation; autonomic nervous system; ion channels; parasympathetic; pharmacological therapy; sympathetic.

PubMed Disclaimer

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Autonomic nervous system and atrial fibrillation. Biomolecular mechanisms and the influence of the ANS on triggers and atrial reentry mechanisms. See text for explanation.
Figure 2
Figure 2
The Autonomic Coumel’s Triangle. See text for explanation.
See this image and copyright information in PMC

References

    1. Coumel P. Paroxysmal Atrial Fibrillation: A Disorder of Autonomic Tone? Eur. Heart J. 1994;15((Suppl. A)):9–16. doi: 10.1093/eurheartj/15.suppl_A.9. - DOI - PubMed
    1. Janes R.D., Christopher Brandys J., Hopkins D.A., Johnstone D.E., Murphy D.A., Armour J.A. Anatomy of human extrinsic cardiac nerves and ganglia. Am. J. Cardiol. 1986;57:299–309. doi: 10.1016/0002-9149(86)90908-2. - DOI - PubMed
    1. Armour J.A., Murphy D.A., Yuan B.-X., MacDonald S., Hopkins D.A. Gross, and microscopic anatomy of the human intrinsic cardiac nervous system. Anat. Rec. 1997;247:289–298. doi: 10.1002/(SICI)1097-0185(199702)247:2<289::AID-AR15>3.0.CO;2-L. - DOI - PubMed
    1. Ardell J.L. The cardiac neuronal hierarchy and susceptibility to arrhythmias. Heart Rhythm. 2011;8:590–591. doi: 10.1016/j.hrthm.2010.12.019. - DOI - PMC - PubMed
    1. Pauza D.H., Skripka V., Pauziene N., Stropus R. Morphology, distribution, and variability of the epicardiac neural ganglionated subplexuses in the human heart. Anat. Rec. 2000;259:353–382. doi: 10.1002/1097-0185(20000801)259:4<353::AID-AR10>3.0.CO;2-R. - DOI - PubMed

LinkOut - more resources