The role of metabolic disorders in the development of atherosclerosis.

Atherosclerosis is a major risk factor for cardiovascular disease (CVD), which is the leading cause of death worldwide. Atherosclerosis is initiated by endothelial activation, followed by a cascade of events (accumulation of lipids, fibrous elements, and calcification) triggering vasoconstriction and activation of inflammatory pathways. This review focuses on the various stages in the development of atherosclerosis, ranging from endothelial dysfunction to plaque rupture. In addition, disorders of lipid, glucose and amino acid metabolism in atherosclerosis are considered here. The key pathological stages of metabolism disruption and their role in atherosclerosis are considered in detail which may be helpful for the more better understanding of atherosclerosis pathogenesis. Finally, some therapeutic approaches aimed at modulating lipid metabolism will also be presented which show the therapeutic targets (enzymes and transport proteins) which modulation can prevent further deterioration of patients symptoms.

Evaluating the Psychometric Properties of a Physical Activity and Sedentary Behavior Identity Scale: Survey Study With Two Independent Samples of Adults in the United States.

BACKGROUND: Emerging evidence suggests a positive association between relevant aspects of one's psychological identity and physical activity engagement, but the current understanding of this relationship is primarily based on scales designed to assess identity as a person who exercises, leaving out essential aspects of physical activities (eg, incidental and occupational physical activity) and sedentary behavior. OBJECTIVE: The goal of this study is to evaluate the validity of a new physical activity and sedentary behavior (PA/SB) identity scale using 2 independent samples of US adults. METHODS: In study 1, participants answered 21 candidate items for the PA/SB identity scale and completed the International Physical Activity Questionnaire-Short Form (IPAQ-SF). Study 2 participants completed the same PA/SB identity items twice over a 1-week interval and completed the IPAQ-SF at the end. We performed factor analyses to evaluate the structure of the PA/SB identity scale, evaluated convergent validity and test-retest reliability (in study 2) of the final scale scores, and examined their discriminant validity using tests for differences in dependent correlations. RESULTS: The final PA/SB identity measure was comprised of 3 scales: physical activity role identity (F1), physical activity belief (F2), and sedentary behavior role identity (F3). The scales had high test-retest reliability (Pearson correlation coefficient: F1, r=0.87; F2, r=0.75; F3, r=0.84; intraclass correlation coefficient [ICC]: F1: ICC=0.85; F2: ICC=0.75; F3: ICC=0.84). F1 and F2 were positively correlated with each other (study 1, r=0.76; study 2, r=0.69), while both were negatively correlated with F3 (Pearson correlation coefficient between F1 and F3: r=-0.58 for study 1 and r=-0.73 for study 2; F2 and F3: r=-0.46 for studies 1 and 2). Data from both studies also demonstrated adequate discriminant validity of the scale developed. Significantly larger correlations with time in vigorous and moderate activities and time walking and sitting assessed by IPAQ-SF with F1, compared with F2, were observed. Significantly larger correlations with time in vigorous and moderate activities with F1, compared with F3, were also observed. Similarly, a larger correlation with time in vigorous activities and a smaller correlation with time walking were observed with F2, compared with F3. CONCLUSIONS: This study provided initial empirical evidence from 2 independent studies on the reliability and validity of the PA/SB identity scales for adults.

Radiotherapy and theranostics: a Lancet Oncology Commission.

Following on from the 2015 Lancet Oncology Commission on expanding global access to radiotherapy, Radiotherapy and theranostics: a Lancet Oncology Commission was created to assess the access and availability of radiotherapy to date and to address the important issue of access to the promising field of theranostics at a global level. A marked disparity in the availability of radiotherapy machines between high-income countries and low-income and middle-income countries (LMICs) has been identified previously and remains a major problem. The availability of a suitably trained and credentialled workforce has also been highlighted as a major limiting factor to effective implementation of radiotherapy, particularly in LMICs. We investigated initiatives that could mitigate these issues in radiotherapy, such as extended treatment hours, hypofractionation protocols, and new technologies. The broad implementation of hypofractionation techniques compared with conventional radiotherapy in prostate cancer and breast cancer was projected to provide radiotherapy for an additional 2·2 million patients (0·8 million patients with prostate cancer and 1·4 million patients with breast cancer) with existing resources, highlighting the importance of implementing new technologies in LMICs. A global survey undertaken for this Commission revealed that use of radiopharmaceutical therapy-other than 131I-was highly variable in high-income countries and LMICs, with supply chains, workforces, and regulatory issues affecting access and availability. The capacity for radioisotope production was highlighted as a key issue, and training and credentialling of health professionals involved in theranostics is required to ensure equitable access and availability for patient treatment. New initiatives-such as the International Atomic Energy Agency's Rays of Hope programme-and interest by international development banks in investing in radiotherapy should be supported by health-care systems and governments, and extended to accelerate the momentum generated by recognising global disparities in access to radiotherapy. In this Commission, we propose actions and investments that could enhance access to radiotherapy and theranostics worldwide, particularly in LMICs, to realise health and economic benefits and reduce the burden of cancer by accessing these treatments.

A Rare Noncoding Enhancer Variant in SCN5A Contributes to the High Prevalence of Brugada Syndrome in Thailand.

BACKGROUND: Brugada syndrome (BrS) is a cardiac arrhythmia disorder that causes sudden death in young adults. Rare genetic variants in the SCN5A gene encoding the Nav1.5 sodium channel and common noncoding variants at this locus are robustly associated with the condition. BrS is particularly prevalent in Southeast Asia but the underlying ancestry-specific factors remain largely unknown. METHODS: Genome sequencing of BrS probands and population-matched controls from Thailand was performed to identify rare noncoding variants at the SCN5A-SCN10A locus that were enriched in patients with BrS. A likely causal variant was prioritized by computational methods and introduced into human induced pluripotent stem cell (hiPSC) lines using CRISPR-Cas9. The effect of the variant on SCN5A expression and Nav1.5 sodium channel current was then assessed in hiPSC-derived cardiomyocytes (hiPSC-CMs). RESULTS: A rare noncoding variant in an SCN5A intronic enhancer region was highly enriched in patients with BrS (detected in 3.9% of cases with a case-control odds ratio of 45.2). The variant affects a nucleotide conserved across all mammalian species and predicted to disrupt a Mef2 transcription factor binding site. Heterozygous introduction of the enhancer variant in hiPSC-CMs caused significantly reduced SCN5A expression from the variant-containing allele and a 30% reduction in Nav1.5-mediated sodium current density compared with isogenic controls, confirming its pathogenicity. Patients with the variant had severe phenotypes, with 89% experiencing cardiac arrest. CONCLUSIONS: This is the first example of a functionally validated rare noncoding variant at the SCN5A locus and highlights how genome sequencing in understudied populations can identify novel disease mechanisms. The variant partly explains the increased prevalence of BrS in this region and enables the identification of at-risk variant carriers to reduce the burden of sudden cardiac death in Thailand.

Crystal structure of bis-(ß-alaninium) tetra-bromidoplumbate.

The title compound, poly[bis-(ß-alaninium) [[di-bromido-plumbate]-di-µ-di-bromido]] {(C2H8NO2)2[PbBr4]} n or (ß-AlaH)2PbBr4, crystallizes in the monoclinic space group P21/n. The (PbBr4)2- anion is located on a general position and has a two-dimensional polymeric structure. The Pb center is holodirected. The supra-molecular network is mainly based on O-H⋯Br, N-H⋯Br and N-H⋯O hydrogen bonds.

Crystal structure of hexa-glycinium dodeca-iodo-triplumbate.

The crystal structure of hexa-glycinium tetra-µ-iodido-octa-iodido-triplumbate, (C2H6NO2)6[Pb3I12] or (GlyH)6[Pb3I12], is reported. The compound crystallizes in the triclinic space group P. The [Pb3I12]6- anion is discrete and located around a special position: the central Pb ion located on the inversion center is holodirected, while the other two are hemidirected. The supra-molecular nature is mainly based on C-H⋯I, N-H⋯I, O-H⋯I and N-H⋯O hydrogen bonds. Dimeric cations of type (A +⋯A +) for the amino acid glycine are observed for the first time.

Prediction of sudden cardiac death using artificial intelligence: Current status and future directions.

Sudden cardiac death (SCD) remains a pressing health issue, affecting hundreds of thousands each year globally. The heterogeneity among people who suffer a SCD, ranging from individuals with severe heart failure to seemingly healthy individuals, poses a significant challenge for effective risk assessment. Conventional risk stratification, which primarily relies on left ventricular ejection fraction, has resulted in only modest efficacy of implantable cardioverter-defibrillators for SCD prevention. In response, artificial intelligence (AI) holds promise for personalized SCD risk prediction and tailoring preventive strategies to the unique profiles of individual patients. Machine and deep learning algorithms have the capability to learn intricate nonlinear patterns between complex data and defined end points, and leverage these to identify subtle indicators and predictors of SCD that may not be apparent through traditional statistical analysis. However, despite the potential of AI to improve SCD risk stratification, there are important limitations that need to be addressed. We aim to provide an overview of the current state-of-the-art of AI prediction models for SCD, highlight the opportunities for these models in clinical practice, and identify the key challenges hindering widespread adoption.

The dominant white color trait of the melon fruit rind is associated with epicuticular wax accumulation.

MAIN CONCLUSION: Microscopic analyses and chemical profiling demonstrate that the white rind phenotype in melon fruit is associated with the accumulation of n-alkanes, fatty alcohols, aldehydes and wax esters. Serving as an indicator of quality, the rind (or external) color of fruit directly affects consumer choice. A fruit's color is influenced by factors such as the levels of pigments and deposited epicuticular waxes. The latter produces a white-grayish coating often referred to as "wax bloom". Previous reports have suggested that some melon (Cucumis melo L.) accessions may produce wax blooms, where a dominant white rind color trait was genetically mapped to a major locus on chromosome 7 and suggested to be inherited as a single gene named Wi. We here provide the first direct evidence of the contribution of epicuticular waxes to the dominant white rind trait in melon fruit. Our light and electron microscopy and gas chromatography-mass spectrometry (GC-MS) comparative analysis of melon accessions with white or green rinds reveals that the rind of melon fruit is rich in epicuticular waxes. These waxes are composed of various biochemical classes, including fatty acids, fatty alcohols, aldehydes, fatty amides, n-alkanes, tocopherols, triterpenoids, and wax esters. We show that the dominant white rind phenotype in melon fruit is associated with increased accumulation of n-alkanes, fatty alcohols, aldehydes and wax esters, which are linked with the deposition of crystal-like wax platelets on their surfaces. Together, this study broadens the understanding of natural variation in an important quality trait of melon fruit and promotes the future identification of the causative gene for the dominant white rind trait.

Proximity labeling expansion microscopy (PL-ExM) evaluates interactome labeling techniques.

Understanding protein-protein interactions (PPIs) through proximity labeling has revolutionized our comprehension of cellular mechanisms and pathology. Various proximity labeling techniques, such as HRP, APEX, BioID, TurboID, and µMap, have been widely used to biotinylate PPIs or organelles for proteomic profiling. However, the variability in labeling precision and efficiency of these techniques often results in limited reproducibility in proteomic detection. We address this persistent challenge by introducing proximity labeling expansion microscopy (PL-ExM), a super-resolution imaging technique that combines expansion microscopy with proximity labeling techniques. PL-ExM enabled up to 17 nm resolution with microscopes widely available, providing visual comparison of the labeling precision, efficiency, and false positives of different proximity labeling methods. Our mass spectrometry proteomic results confirmed that PL-ExM imaging is reliable in guiding the selection of proximity labeling techniques and interpreting the proteomic results with new spatial information.

Clinical, Genetic, and Histopathological Characteristics of CRX-associated Retinal Dystrophies.

PURPOSE: To describe phenotypic, genotypic, and histopathological features of inherited retinal dystrophies associated with the CRX gene (CRX-RDs). DESIGN: Retrospective multicenter cohort study including histopathology. SUBJECTS: Thirty-nine patients from 31 families with pathogenic variants in the CRX gene. METHODS: Clinical data of 152 visits were collected from medical records. The median follow-up time was 9.1 years (interquartile range (IQR), 3.3-15.3 years; range, 0.0-48.8 years). Histopathologic examination of the eye of a 17-year-old patient with advanced early-onset CRX-RD was performed. MAIN OUTCOME MEASURES: Visual acuity, retinal imaging, electroretinography, genotype-phenotype correlation, and histopathological examination were evaluated. RESULTS: The age at onset ranged from birth to the eighth decade of life. Median visual acuity was 1.00 logarithm of the minimum angle of resolution (logMAR) (IQR, 0.69-1.48 logMAR; range, 0.06-3.00 logMAR) at a mean age of 52.0 ± 19.9 years (range, 4.6-81.9 years). Sufficient imaging was available for 36 out of 39 patients (92.3%), and all showed degeneration of at least the macula. Of these 36 patients, 22 (61.1%) had only macular dystrophy. Another 10 patients (27.8%) had additional degeneration beyond the vascular arcades, and 4 patients (11.1%) panretinal degeneration. Two patients (5.1%) had Leber congenital amaurosis. In total, 21 different disease-associated heterozygous CRX variants were identified (10 frameshift, 7 missense, 2 deletion, 1 nonsense, 1 deletion-insertion variants). Missense variants in the CRX homeodomain and 2 variants deleting all functional domains, thus causing haploinsufficiency, generally tended to cause milder late-onset phenotypes. Histopathologic examination of the eye of a 17-year-old patient with advanced early-onset retinal dystrophy due to a heterozygous deletion of exons 3 and 4 of the CRX gene revealed loss of laminar integrity and widespread photoreceptor degeneration especially in the central retina, with extensive loss of photoreceptor nuclei and outer segments. CONCLUSIONS: This study illustrates the large clinical and genetic heterogenic spectrum of CRX-RDs, ranging from Leber congenital amaurosis to mild late-onset maculopathy resembling occult macular dystrophy. Haploinsufficiency and missense variants tended to be associated with milder phenotypes. Patients showed degeneration predominantly affecting the central retina on imaging. The histopathological findings also mirror these clinical findings and features similar to previously reported animal models of CRX-RDs. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Effect of posture on position of subcutaneous implantable cardioverter-defibrillator.

BACKGROUND: The PRAETORIAN score was developed as an alternative for defibrillation testing after subcutaneous implantable cardioverter-defibrillator implantation to assess 3 aspects of implant position on a bidirectional chest radiograph. The score is validated on a standard standing chest radiograph with arms elevated in the lateral view. OBJECTIVE: We aimed to evaluate the effect of different anatomic positions on the PRAETORIAN score. METHODS: Thirty patients with a subcutaneous implantable cardioverter-defibrillator underwent standard posterior-anterior and lateral chest radiography, including additional lateral views in 2 positions: standing with arms down and supine with arms alongside the body. PRAETORIAN score and weighted κ coefficient were calculated for each position. RESULTS: In 8 of 30 patients, the PRAETORIAN score was ≥90 in standard position. The agreement in PRAETORIAN score was substantial (κ = 0.677) for the position with the arms down and fair (κ = 0.399) for the supine position. With the arms down, the PRAETORIAN score decreased in 10 patients (33%), 4 of whom changed to a lower risk category. In supine position, the PRAETORIAN score decreased in 16 patients (53%), 7 of whom changed to a lower risk category, 1 from high to low risk. CONCLUSION: A supine or arms-down position during chest radiography can result in lower PRAETORIAN scores and underestimation of associated risk on defibrillation testing failure. This emphasizes the importance of correct anatomic positioning (arms up) during chest radiography when the PRAETORIAN score is used.

Trends in adoption of extravascular cardiac implantable electronic devices: the Dutch cohort.

INTRODUCTION: Conventional implantable cardioverter-defibrillators (ICDs) and pacemakers carry a risk of pocket- and lead-related complications in particular. To avoid these complications, extravascular devices (EVDs) have been developed, such as the subcutaneous ICD (S-ICD) and leadless pacemaker (LP). However, data on patient or centre characteristics related to the actual adoption of EVDs are lacking. OBJECTIVE: To assess real-world nationwide trends in EVD adoption in the Netherlands. METHODS: Using the Netherlands Heart Registration, all consecutive patients with a de novo S­ICD or conventional single-chamber ICD implantation between 2012-2020, or de novo LP or conventional single-chamber pacemaker implantation between 2014-2020 were included. Trends in adoption are described for various patient and centre characteristics. RESULT: From 2012-2020, 2190 S­ICDs and 10,683 conventional ICDs were implanted; from 2014-2020, 712 LPs and 11,103 conventional pacemakers were implanted. The general use has increased (S-ICDs 8 to 21%; LPs 1 to 8%), but this increase seems to have reached a plateau. S­ICD recipients were younger than conventional ICD recipients (p < 0.001) and more often female (p < 0.001); LP recipients were younger than conventional pacemaker recipients (p < 0.001) and more often male (p = 0.03). Both S­ICDs and LPs were mainly implanted in high-volume centres with cardiothoracic surgery on-site, although over time S­ICDs were increasingly implanted in centres without cardiothoracic surgery (p < 0.001). CONCLUSION: This nationwide study demonstrated a relatively quick adoption of innovative EVDs with a plateau after approximately 4 years. S­ICD use is especially high in younger patients. EVDs are mainly implanted in high-volume centres with cardiothoracic surgery back-up, but S­ICD use is expanding beyond those centres.

Diagnosis of Brugada Syndrome With a Sodium-Channel-Blocker Test: Who Should Be Tested? Who Should Not?

Intravenous infusion of sodium-channel blockers (SCB) with either ajmaline, flecainide, procainamide, or pilsicainide to unmask the ECG of Brugada syndrome is the drug challenge most commonly used for diagnostic purposes when investigating cases possibly related to inherited arrhythmia syndromes. For a patient undergoing an SCB challenge, the impact of a positive result goes well beyond its diagnostic implications. It is, therefore, appropriate to question who should undergo a SCB test to diagnose or exclude Brugada syndrome and, perhaps more importantly, who should not. We present a critical review of the benefits and drawbacks of the SCB challenge when performed in cardiac arrest survivors, patients presenting with syncope, family members of probands with confirmed Brugada syndrome, and asymptomatic patients with suspicious ECG.

Transdermal delivery of bisphosphonates using dissolving and hydrogel-forming microarray patches: Potential for enhanced treatment of osteoporosis.

As of 2023, more than 200 million people worldwide are living with osteoporosis. Oral bisphosphonates (BPs) are the primary treatment but can cause gastrointestinal (GI) side effects, reducing patient compliance. Microarray (MAP) technology has the potential to overcome GI irritation by facilitating the transdermal delivery of BPs. This study examines the delivery of alendronic acid (ALN) and risedronate sodium (RDN) using dissolving and hydrogel-forming MAPs for osteoporosis treatment. In vivo testing on osteoporotic female Sprague Dawley rats demonstrated the efficacy of MAPs, showing significant improvements in mean serum and bone alkaline phosphatase levels, bone volume, and porosity compared to untreated bilateral ovariectomy (OVX) controls. Specifically, MAP treatment increased mean bone volume to 55.04 ± 2.25 % versus 47.16 ± 1.71 % in OVX controls and reduced porosity to 44.30 ± 2.97 % versus 52.84 ± 1.70 % in the distal epiphysis of the femur. In the distal metaphysis, bone volume increased to 43.32 ± 3.24 % in MAP-treated rats compared to 24.31 ± 3.21 % in OVX controls, while porosity decreased to 55.39 ± 5.81 % versus 75.69 ± 3.21 % in OVX controls. This proof-of-concept study indicates that MAP technology has the potential to be a novel, patient-friendly alternative for weekly osteoporosis management.

Temporal progression of tau pathology and neuroinflammation in a rhesus monkey model of Alzheimer's disease.

INTRODUCTION: The understanding of the pathological events in Alzheimer's disease (AD) has advanced dramatically, but the successful translation from rodent models into efficient human therapies is still problematic. METHODS: To examine how tau pathology can develop in the primate brain, we injected 12 macaques with a dual tau mutation (P301L/S320F) into the entorhinal cortex (ERC). An investigation was performed using high-resolution microscopy, magnetic resonance imaging (MRI), positron emission tomography (PET), and fluid biomarkers to determine the temporal progression of the pathology 3 and 6 months after the injection. RESULTS: Using quantitative microscopy targeting markers for neurodegeneration and neuroinflammation, as well as fluid and imaging biomarkers, we detailed the progression of misfolded tau spreading and the consequential inflammatory response induced by glial cells. DISCUSSION: By combining the analysis of several in vivo biomarkers with extensive brain microscopy analysis, we described the initial steps of misfolded tau spreading and neuroinflammation in a monkey model highly translatable to AD patients. HIGHLIGHTS: Dual tau mutation delivery in the entorhinal cortex induces progressive tau pathology in rhesus macaques. Exogenous human 4R-tau coaptates monkey 3R-tau during transneuronal spread, in a prion-like manner. Neuroinflammatory response is coordinated by microglia and astrocytes in response to tau pathology, with microglia targeting early tau pathology, while astrocytes engaged later in the progression, coincident with neuronal death. Monthly collection of CSF and plasma revealed a profile of changes in several AD core biomarkers, reflective of neurodegeneration and neuroinflammation as early as 1 month after injection.

Using Multiscale Molecular Modeling to Analyze Possible NS2b-NS3 Protease Inhibitors from Philippine Medicinal Plants.

Within the field of Philippine folkloric medicine, the utilization of indigenous plants like Euphorbia hirta (tawa-tawa), Carica papaya (papaya), and Psidium guajava (guava) as potential dengue remedies has gained attention. Yet, limited research exists on their comprehensive effects, particularly their anti-dengue activity. This study screened 2944 phytochemicals from various Philippine plants for anti-dengue activity. Absorption, distribution, metabolism, excretion, and toxicity (ADMET) profiling provided 1265 compounds demonstrating pharmacokinetic profiles suitable for human use. Molecular docking targeting the dengue virus NS2b-NS3 protease's catalytic triad (Asp 75, Ser 135, and His 51) identified ten ligands with higher docking scores than reference compounds idelalisib and nintedanib. Molecular dynamics simulations confirmed the stability of eight of these ligand-protease complexes. Molecular Mechanics/Poisson-Boltzmann Surface Area (MM/PBSA) analysis highlighted six ligands, including veramiline (-80.682 kJ/mol), cyclobranol (-70.943 kJ/mol), chlorogenin (-63.279 kJ/mol), 25beta-Hydroxyverazine (-61.951 kJ/mol), etiolin (-59.923 kJ/mol), and ecliptalbine (-56.932 kJ/mol) with favorable binding energies, high oral bioavailability, and drug-like properties. This integration of traditional medical knowledge with advanced computational drug discovery methods paves new pathways for the development of treatments for dengue.

Mycorrhizae in mine wasteland reclamation.

Mycorrhizae are found on about 70-80 % of the roots of all plant species; ectomycorrhizae (ECM) are mostly found on woody plants and gymnosperms, whereas arbuscular mycorrhizal fungi (AMF) are found on 80-90 % of all plant species. In abandoned mining sites, woody plants dominate, while non-woody species remain scarce. However, this pattern depends on the specific mine site and its ecological context. This review article explores the potential of using mycorrhizae-plant associations to enhance and facilitate the remediation of mine wastelands and metal-polluted sites. In this review, we employed reputable databases to collect articles and relevant information on mycorrhizae and their role in plant growth and soil fertility spanning from the 1990s up to 2024. Our review found that the abilities of plants selected for minewasteland reclamation can be harnessed effectively if their mycorrhizae utilization is known and considered. Our findings indicate that AMF facilitates plant cohabitation by influencing species richness, feedback effects, shared mycelial networks, and plant-AMF specificity. Several types of mycorrhizae have been isolated from mine wastelands, including Glomus mosseae, which reduces heavy metal accumulation in plants, and Rhizophagus irregularis, which enhances plant growth and survival in revegetated mine sites. Additionally, studies on ECM in surface mine spoil restoration stands highlight their role in enhancing fungal biodiversity and providing habitats for rare and specialized fungal species. Recent research shows that ECM and AMF fungi can interact synergistically to enhance plant growth, with ECM improving plant nitrogen absorption and AMF increasing nitrogen use efficiency. Our review also found that despite their critical role in improving plant growth and resilience, there remains limited knowledge about the specific mechanisms by which mycorrhizae communicate with each other and other microorganisms, such as bacteria, root-associated fungi, soil protozoa, actinomycetes, nematodes, and endophytes, within the soil matrix. This article highlights the connection between mycorrhizae and plants and other microorganisms in mine wastelands, their role in improving soil structure and nutrient cycling, and how mycorrhizae can help restore soil fertility and promote plant growth, thus improving the overall environmental quality of mine wasteland sites.

Genetic testing in early-onset atrial fibrillation.

Atrial fibrillation (AF) is a globally prevalent cardiac arrhythmia with significant genetic underpinnings, as highlighted by recent large-scale genetic studies. A prominent clinical and genetic overlap exists between AF, heritable ventricular cardiomyopathies, and arrhythmia syndromes, underlining the potential of AF as an early indicator of severe ventricular disease in younger individuals. Indeed, several recent studies have demonstrated meaningful yields of rare pathogenic variants among early-onset AF patients (∼4%-11%), most notably for cardiomyopathy genes in which rare variants are considered clinically actionable. Genetic testing thus presents a promising opportunity to identify monogenetic defects linked to AF and inherited cardiac conditions, such as cardiomyopathy, and may contribute to prognosis and management in early-onset AF patients. A first step towards recognizing this monogenic contribution was taken with the Class IIb recommendation for genetic testing in AF patients aged 45 years or younger by the 2023 American College of Cardiology/American Heart Association guidelines for AF. By identifying pathogenic genetic variants known to underlie inherited cardiomyopathies and arrhythmia syndromes, a personalized care pathway can be developed, encompassing more tailored screening, cascade testing, and potentially genotype-informed prognosis and preventive measures. However, this can only be ensured by frameworks that are developed and supported by all stakeholders. Ambiguity in test results such as variants of uncertain significance remain a major challenge and as many as ∼60% of people with early-onset AF might carry such variants. Patient education (including pretest counselling), training of genetic teams, selection of high-confidence genes, and careful reporting are strategies to mitigate this. Further challenges to implementation include financial barriers, insurability issues, workforce limitations, and the need for standardized definitions in a fast-moving field. Moreover, the prevailing genetic evidence largely rests on European descent populations, underscoring the need for diverse research cohorts and international collaboration. Embracing these challenges and the potential of genetic testing may improve AF care. However, further research-mechanistic, translational, and clinical-is urgently needed.