Mechanistic Insights into Sex Differences in Atrial Electrophysiology and Arrhythmia Vulnerability through Sex-specific Computational Models.

Abstract

Atrial fibrillation (AF), the most common cardiac arrhythmia, is characterized by notable sex differences in clinical presentation, treatment response, and outcomes. Although prevalence is similar between sexes, women often experience more severe symptoms, higher rates of adverse drug effects, and reduced treatment efficacy. To investigate the underlying sex-specific AF mechanisms, we developed and validated male and female human atrial cardiomyocyte models that integrate known sex-based differences in electrophysiology and calcium (Ca2+) handling under normal sinus rhythm (nSR) and chronic AF (cAF) conditions. While the model parameterizations were based on limited human data, and the assumptions may not capture the full spectrum of clinical variability, the models reproduced key reported sex-dependent differences in human atrial cardiomyocyte action potential (AP) and Ca2+ transient (CaT) dynamics. Simulations revealed that both sexes exhibited shortened effective refractory periods and wavelengths in cAF vs. nSR. However, females were more prone to delayed afterdepolarizations (DADs), while males were more susceptible to AP duration (APD) and CaT amplitude (CaTAmp) alternans. Population-based modeling identified distinct parameter associations with arrhythmia mechanisms, whereby DAD vulnerability was associated with enhanced ryanodine receptor sensitivity to Ca2+ (in females), and alternans in males correlated with reduced L-type Ca2+ current maximal conductance. Pharmacological simulations revealed sex-specific responses to antiarrhythmic therapies. In males, multiple drug combinations proved effective in restoring APD at 90% repolarization (APD90), CaTAmp, and reducing alternans susceptibility, whereas females responded to only one combination improving APD90 and CaTAmp but with minimal impact on DAD risk. These findings underscore the need for sex-specific therapeutic strategies and support the use of computational modeling in guiding precision medicine approaches against AF. Key pointsO_LIAtrial fibrillation (AF) is a common heart rhythm disorder that presents differently in males and females, but how the underlying mechanisms differ in males and females is not fully understood. C_LIO_LIWe developed and validated computer models of male and female human atrial cardiomyocytes that incorporate known sex differences in ion channels and calcium handling under normal sinus rhythm and AF conditions. C_LIO_LIUnder normal rhythm, males and females showed distinct electrical activity, which became less pronounced in AF. In AF, both sexes showed reduced effective refractory period and wavelength and depressed calcium transients. Males were more susceptible to electrical alternans, while females showed a greater tendency for calcium-driven delayed afterdepolarizations. C_LIO_LISimulated drug treatments showed greater benefit in male models, particularly with combinations targeting multiple potassium channels, while female models showed limited response. These results highlight the need for sex-specific approaches to treating AF and may help guide future drug development. C_LI