Vagal atrial fibrillation: What is it and should we treat it?

- Vagal AF is more common in younger patients with structurally normal hearts.
- Although underdiagnosed, there are no universal diagnostic criteria.
- Ganglionated plexi are potential anatomical sites of origin.
- It remains unclear whether vagal AF progresses or conveys equivalent stroke risk.
- Pharmacotherapy differs in use although catheter ablation shows increasing promise.

Vagal atrial fibrillation (AF) remains an under-recognised entity, affecting younger patients often with structurally normal hearts. Although there remains no universal definition or diagnostic criteria, in this review we describe recognised triggers and associated features, including a well-established association with athletic training. We explore potential mechanisms, including the role of the autonomic nervous system and ganglionated plexi in initiating and maintaining arrhythmia. We discuss the limited evidence base addressing the question of progression to persistent AF, and debate the merits of anti-arrhythmic treatment, as well as uncertainty regarding the risk of stroke. Differences in suggested pharmacological therapy are highlighted and as is the emerging promise of radiofrequency catheter ablation as a therapeutic option. As we recognise the emerging burden of vagal AF, we hope to explore the important similarities and differences crucial to developing our understanding of the disorder, and highlight some significant questions which remain unanswered.