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Medical [Medical]Atrial Fibrillation Prevention
2017.04.19 10:44
Atrial Fibrillation Prevention: A Three-legged Stool
April 18, 2017
As the incidence of atrial fibrillation continues to increase with the aging population, physicians are increasingly turning their attention to prevention strategies (in addition to treatment) to try to target the causes of AF in an attempt to manage overall disease burden.
A recent comprehensive and thorough review in the Journal of the American College of Cardiology highlights and categorizes prevention strategies into three major approaches, summarized below.
Table 1. Targeting Modifiable Lifestyle Risk Factors
|
AF Modifiable Lifestye Factor |
Relationship to AF |
Clinician Intervention |
|
Alcohol >50% of US adults consume regularly |
>21 drinks/wk increased AF by 39%. >35 drinks/wk increased AF by 45% -90%. In women, ≥2 drinks/day increased AF by 60%. 1.5 drinks/day increased AF by 25-46%. Each drink/day increased AF by ~8%. |
Counsel on avoiding unhealthy drinking and how even light to moderate drinking can increase AF risk. |
|
Physical activity and cardiorespiratory fitness |
Mixed data about relationship between exercise and AF. Overall, vigorous exercise may be associated with ↑ AF; moderate activity appears protective. |
Avoid sedentary lifestyle |
|
Psychosocial |
Anger, tension, hostility increase AF by 10-30%. Panic disorder increased AF by 73%. Job strain increased AF by 23%. Stress triggered 54% of AF episodes. Happiness had protective effect (88% lower risk of AF after adjustment). |
Encourage positive emotions; treat depression, anxiety, stress promptly. |
|
Smoking |
Current or former smoking increased AF by 51%; risk decreases after quitting smoking. Secondhand smoke associated with higher risk. Up to 12% AF cases avoided with quitting smoking. |
Offer smoking cessation interventions. |
|
Healthy diet |
Obesity, DM, dyslipidemia (see Table 2) associated with |
Counsel on healthy food choices and maintenance of healthy weight. |
Comment 4
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I felt that the above tables are useful informations for the aging folks like us.
Atrial Fibrillation is the most common arrhythmia in the elderly which accounts for
some 60 % of all strokes along with other systemic embolizations.
It cannot be overemphasized how important it is to minimize the chances to develop this arrhythmia.
For example, so called social drinks, I know, account for countless cases of atrial fibrillation.
-
Just around me, people died of uncontrollable cardiac arrhythmia secondary to Atrial fibrillation.
They were all heavy drinkers.
It seems that the eventual end of the long-term drinkers are atrial fibrillation and untimely death.
Medical community is not emphasizing enough about the bad complication of drinking.
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- Written by
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The authors provide a thorough review of the data, indicating an increased risk of AF in the presence of the following risk factors: excessive alcohol intake, lack of cardiovascular exercise, emotional stress, smoking, obesity, hypertension, dyslipidemia, obstructive sleep apnea, coronary artery disease, and heart failure. Fairly strong evidence that correction of the risk factor can reduce the risk of AF is available only for hypertension and obesity. Nevertheless, the authors conclude that AF can be prevented in a high proportion of individuals by implementing aggressive risk factor modification strategies, focusing these efforts on high-risk populations, and emphasizing the importance of healthy lifestyle choices in the population as a whole. These are laudable goals that are worthy of implementation but that may be very difficult to achieve. Although in theory AF may be at least in part a preventable disease, whether a reduction in its incidence is achievable by risk factor modification strategies and public education programs is open to question.
(Of note, Dr. Morady at University of Michigan is considered to be one of a few pioneers in cardiac arrhythmias, and
I put on his commentary here regarding the above article.
I have referred a good number of patients to him over many years.)
Table 2. Controlling Cardiovascular Risk Factors and Treating Concurrent Cardiovascular Disease
AF Cardiovascular Risk Factor
Relationship to AF
Clinician Intervention
Obesity (worldwide):
14% of men
10% of women
Obesity increased AF by 49%.
BMI had linear association with AF risk – each unit increase in BMI increased AF by 4-8%.
Weight gain from 20 yrs to midlife of 16-35% increased AF 34% and >35% increased AF by 61%.
18% AF cases preventable by achieving optimal body weight.
Success of AF ablation higher with weight loss.
Achieve weight reduction:
>10% weight loss: 46% freedom from AF.
3-9% weight loss: 22% freedom from AF.
<3% weight loss:
13% freedom from AF.
Hypertension or widened pulse pressure
Every 10 mmHg increase in SBP increases AF by 11%.
Population attributable risk 14-20%.
Each 20 mmHg increase in pulse pressure (reflects aortic stiffness) increases AF by 26%.
Treat BP – ARBs and ACEIs reduce risk in structural (ie, LVH, CHF) and functional heart disease.
Diabetes
DM increases AF risk by 34%.
AF risk increases by 3% for each additional year of DM duration.
Each 1% increase HbA1c increases AF by 13% (DM pts) and 5% (nonDM pts).
Treating DM does not reduce AF risk – unclear if DM may be a “marker” of risk rather than causal.
Dyslipidemia and statins
Each 1-SD increase in LDL-C, AF risk reduced 10%.
HDL-C and TGs not thought to influence AF risk; only LDL-C and TC.
Treat dyslipidemia to prevent MI (as below). Statins do not lower AF risk.
Obstructive sleep apnea: ≥5 apneic episodes/hr of sleep
OSA increased odds of AF 2.2X.
Cause-effect relationship between OSA and AF has been established.
In small study, CPAP reduced AF:
Untreated OSA: 82% AF recurrence.
CPAP-treated: 42% AF recurrence.
No OSA: 53% AF recurrence.
Myocardial infarction
7-12% incidence of new-onset AF after MI.
Prompt reperfusion reduces incidence.
Heart failure (HFREF, HFPEF)
~33% of CHF patients with AF.
CHF increases AF 4.5X in men and 5.9X in women.
Treat risk factors for CHF, start GDMT for CH