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.

中文翻译：

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肥胖症或2型糖尿病和房颤的大多数患者是否也患有未确诊的心力衰竭？用于理解机制并改善诊断和治疗的关键概念框架。

肥胖和糖尿病可导致射血分数（HFpEF）升高而导致心力衰竭，这可能是因为它们都引起心外膜脂肪组织的扩张和炎症，从而导致微血管功能障碍和下层左心室纤维化。相同的过程也会引起心房肌病，在临床上以房颤（AF）的形式表现出来。因此，AF可能是HFpEF的首发表现。许多明显孤立的房颤患者都有潜在的HFpEF或随后患上HFpEF。大多数患有AF和运动不耐症的肥胖症或糖尿病患者，即使在没有确诊的HFpEF的情况下，在静息或运动过程中左心房压力也会升高。在患有AF的患者中，也有潜在HFpEF的患者发生全身血栓栓塞和死亡的风险增加。肥胖或糖尿病患者中HFpEF的鉴定改变了通常处方治疗的风险与获益之间的关系。减肥手术和他汀类药物可以改善房颤并降低发生HFpEF的风险。相反，促进脂肪生成或引起钠retention留的降血糖药（胰岛素和噻唑烷二酮）可能会增加潜在的心室肌病患者发生心力衰竭的风险。肥胖和糖尿病患者接受导管消融治疗房颤的风险增加，消融后肺静脉压升高，心力衰竭加重，特别是如果同时存在HFpEF时。因此，AF可能是肥胖或2型糖尿病患者中HFpEF的最早指标，对HFpEF的识别会改变这些患者的治疗方法。