Sex differences in atrial fibrillation-related atrial remodelling: the end of the debate?

This commentary refers to ‘Sex differences in atrial fibrillation-related atrial remodelling assessed by electroanatomic mapping and biopsy’, by K. Nakashima et al., https://doi.org/10.1093/eurheartj/ehaf768 and the discussion piece ‘Interpreting Sex Differences in Atrial Voltage: Low-voltage Areas and Global Atrial Voltage’, by K. Nakashima and T. Yamaguchi, https://doi.org/10.1093/eurheartj/ehag046. We read with great interest the article by Nakashima et al. describing sex differences in atrial fibrillation-related atrial remodelling, assessed through electroanatomic mapping and biopsy.1 In particular, it was interesting to find histological confirmation of previously described findings on this topic, potentially resolving a longstanding controversy.2 It has been previously reported that female patients tend to exhibit more extensive atrial remodelling compared with males.2,3 However, it has remained unclear whether the observed lower atrial voltages in women were a consequence of more advanced atrial myopathy3 or simply due to thinner atrial walls.2 The data presented by Nakashima et al. provide important evidence supporting the former hypothesis and reinforce previous suggestions that sex-specific voltage thresholds should be applied in the evaluation of atrial substrate.2