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  • Atrial fibrillation involves an irregular heart rhythm and is an important risk factor for stroke.
  • While age, sex, and genetics are non-modifiable risk factors for atrial fibrillation, physical activity levels, obesity, smoking, and management of comorbid conditions are some of the major modifiable risk factors.
  • Socioeconomic factors and access to health care also influence the management of atrial fibrillation and comorbid conditions.
  • A recent review summarized evidence on the role of the multitude of risk factors in atrial fibrillation incidence and morbidity.
  • These risk factors tend to vary from one person to another and thus underscore the need for individualized care for atrial fibrillation.

Atrial fibrillation is the most common type of arrhythmia or irregular heartbeat, with a global prevalence of over 59 million.

In addition to widely known risk factors associated with cardiovascular health, such as physical activity, diabetes, obesity, and smoking, the presence of chronic conditions, such as cardiovascular, respiratory, metabolic, and mental health conditions, are also associated with an increased risk of atrial fibrillation.

A recent review published inThe Lancet Regional Healthpresented data accumulated by prior studies on lifestyle factors, comorbid conditions, and socioeconomic factors that may influence the risk of atrial fibrillation.

The review highlights the need for multidisciplinary, individualized care to help manage atrial fibrillation and reduce the risk of death and of developing other health conditions.

Dr. Stephen Tang, MD, a board-certified cardiac electrophysiologist at Providence Saint John’s Health Center in Santa Monica, CA, not involved in this research, explained to Medical News Today:

“The comprehensive management of atrial fibrillation goes well beyond oral anticoagulation for stroke prevention or rate or rhythm control with medication or ablation. This complex disease is driven by numerous risk factors and comorbidities.”

“If these are not controlled, atrial fibrillation will continue to occur despite ablation. Identifying and optimizing these risk factors is essential in the management and control of atrial fibrillation long term,” added Dr. Tang.

Atrial fibrillation, sometimes shortened to “AFib,” is a heart condition involving an abnormal heart rhythm caused by the irregular beating of the left upper heart chamber or atrium. An irregular heart rhythm can result in the formation of a blood clot in the atrium.

This blood clot can dislodge from the upper chamber of the heart and travel to the brain. The clot can block blood flow in the arteries in the brain and cause a stroke. Notably, atrial fibrillation is an important risk factor for stroke.

Genetic factors, sex, and increased age are nonmodifiable risk factors for atrial fibrillation. Other risk factors for atrial fibrillation include lifestyle factors, comorbid conditions, and socioeconomic factors.

Lifestyle changes and medications can help manage this cardiovascular condition. Blood thinners, also known as anticoagulants, can reduce the risk of blood clot formation and stroke.

Drugs that target vitamin K, such as warfarin, have been conventionally used as oral anticoagulants. More recently, nonvitamin K antagonist oral anticoagulants (NOACs) that block other factors have become the first line of treatment for atrial fibrillation.

Other drugs, such as beta-blockers and calcium channel blockers, are useful in controlling the heart rate. When lifestyle modifications and medications are not effective in managing atrial fibrillation, individuals may require invasive procedures, such as catheter ablation, to restore a normal heart rhythm.

Similar to other cardiovascular conditions, lifestyle factors such as physical activity levels, obesity, smoking, and consumption of alcohol are associated with an increased risk of atrial fibrillation incidence and symptom severity.

Physical activity

Physical activity is associated with a lower risk of atrial fibrillation incidence, recurrence, morbidity, and mortality. In contrast, a sedentary lifestyle is associated with an increased risk of atrial fibrillation.

Individuals meeting the prescribed physical activity levels of at least 150 minutes of moderate-to-vigorous training per week are at a lower risk of atrial fibrillation.

Regular moderate-to-vigorous training and high-intensity interval training are effective in reducing morbidity and improving the quality of life in individuals with atrial fibrillation.

While studies have shown that individuals with atrial fibrillation who perform moderate-to-vigorous physical activity are at reduced risk of heart failure and cardiovascular-associated mortality, such evidence supporting the role of physical activity in preventing stroke is lacking.

Obesity

As with other cardiovascular conditions, obesity is a major risk factor for the development of atrial fibrillation. Obesity can also increase the likelihood of atrial fibrillation recurrence, complications during catheter ablation, stroke, and death.

Thus, weight loss can reduce the risk of atrial fibrillation recurrence and morbidity.

Smoking and alcohol consumption

Smoking and moderate-to-heavy alcohol consumption are risk factors for atrial fibrillation. Specifically, studies have demonstrated current smoking is associated with atrial fibrillation risk in a dose-dependent manner.

While moderate-to-heavy alcohol consumption is associated with atrial fibrillation risk, the data on low levels of alcohol intake is mixed.

Analysis of data from multiple studies suggests a dose-dependent relationship between alcohol consumption and atrial fibrillation risk.

Chronic cardiovascular, respiratory, and mental health conditions are not only risk factors for atrial fibrillation but can also increase the complications associated with this condition.

Obstructive sleep apnea

Obstructive sleep apnea involves the complete or partial blocking of the airways during sleep and is estimated to occur in 21–74% of atrial fibrillation patients.

These disruptions in breathing associated with obstructive sleep apnea can increase the risk of the formation of blood clots and change the structural and electrical properties of the heart.

In addition to being a risk factor, obstructive sleep apnea can increase the risk of atrial fibrillation recurrence after catheter ablation.

The use of a continuous positive airway pressure (CPAP) machine for the management of sleep apnea can reduce the risk of atrial fibrillation incidence, recurrence, or progression.

Cardiovascular conditions

Individuals with pre-existing cardiovascular conditions, including coronary artery disease, hypertension, heart failure, and cardiomyopathies, are at an increased risk of atrial fibrillation.

Notably, hypertension is one of the most well-known risk factors for atrial fibrillation patients and is associated with a 1.7–2.5 times higher risk of atrial fibrillation.

Individuals with atrial fibrillation and comorbid cardiovascular conditions are at an increased risk of complications, such as stroke or heart failure, and death.

The management and treatment of comorbid cardiovascular conditions, such as hypertension, can help reduce the risk of atrial fibrillation recurrence or complications such as stroke.

Anticoagulant therapy or catheter ablation is vital for reducing the risk of complications associated with these cardiovascular conditions.

While the use of anticoagulants is necessary for maintaining a regular heart rhythm, they need to be used judiciously in patients undergoing minimally invasive surgery for coronary artery disease due to the risk of bleeding.

Metabolic conditions

Diabetes is associated with an increased risk of atrial fibrillation incidence and complications. One study reported that the risk of atrial fibrillation increases with a decline in the ability to control blood glucose levels.

However, results from other studies have been mixed. Achieving better control of blood glucose (sugar) levels and reducing weight can reduce the risk of atrial fibrillation.

While high total cholesterol and low-density lipoprotein levels are risk factors for cardiovascular diseases, they are associated with a lower risk of atrial fibrillation.

In contrast, higher levels of triglycerides are associated with an increased risk of atrial fibrillation.

Kidney function

Nearly half of all individuals with atrial fibrillation show impaired renal function. Severe impairment of kidney function can interfere with the metabolism of anticoagulant drugs, increasing the risk of adverse effects.

Moreover, individuals with atrial fibrillation and kidney disease are also more likely to show complications during catheter ablation.

Respiratory conditions

Chronic obstructive pulmonary disease (COPD), a chronic lung condition involving the obstruction of the airways, is linked to a twofold higher risk of atrial fibrillation.

Some of the medications used for the management of COPD, such as beta-2 adrenergic receptor agonists, are associated with tachyarrhythmia, involving faster heart rhythms.

However, there are other medications for COPD, such as corticosteroids and beta-1 agonists, that do not have adverse effects in individuals with atrial fibrillation.

In addition to COPD, short-term exposure to air pollution has also been linked to an increased risk of atrial fibrillation.

Mental health

Studies have shown that psychological factors, such as stress and depression, are also associated with an increased risk of atrial fibrillation. In addition, individuals using antidepressants are at a higher risk of atrial fibrillation, and the risk decreases with an improvement in depressive symptoms

Although there is a lack of evidence to support cognitive impairment and dementia as risk factors for atrial fibrillation, dementia is associated with poor outcomes in individuals with this cardiovascular condition.

The mechanisms through which mental health conditions, including stress and depression, impact heart rhythms are not understood.

However, mental health conditions could potentially influence adherence to medications and increase the risk of interaction between drugs used for atrial fibrillation and mental health disorders.

Consistent with this, studies show that individuals with mental health disorders, including depression, bipolar disorder, and schizophrenia, are less likely to receive anticoagulant treatment and less likely to persist with treatment.

Individuals with atrial fibrillation are more likely to have other comorbid conditions. These concomitant chronic health conditions, along with aging, can increase the risk of complications such as stroke and mortality in individuals with atrial fibrillation.

The presence of these coexisting chronic conditions requires the use of multiple medications that increase the risk of adverse effects.

Aging also influences the metabolism of drugs and often leads to the prescription of additional drugs to manage the adverse effects of drugs used to manage chronic conditions.

The use of five or more drugs is known as “polypharmacy,” and is associated with the potential for drug-drug interactions and adverse events

Polypharmacy has been shown to be associated with an increased risk of complications in individuals with atrial fibrillation.

Notably, nonvitamin K antagonist oral anticoagulants are associated with fewer adverse events than warfarin in atrial fibrillation patients and can be used after taking adequate precautions.

In addition to lifestyle factors and comorbid conditions, sex, socioeconomic status, and ethnicity/race can influence the risk of atrial fibrillation.

Studies conducted in Europe suggest that individuals of South Asian and African origin are at a lower risk of atrial fibrillation than the white population. This observation is contrary to the higher risk of other cardiovascular conditions in individuals of South Asian origin.

Similarly, data from the United States reported that white individuals are at a higher risk of atrial fibrillation.

In terms of biological sex, atrial fibrillation is more prevalent in men than women, but women are at a higher risk of complications, including stroke and mortality.

The higher risk of complications in women is attributed to differences in biological factors, access to healthcare, and psychological factors, such as stress.

There is some evidence to suggest that women are also less likely to receive anticoagulant therapy than men. This disparity in anticoagulant therapy is potentially due to women declining anticoagulant therapy because of a lack of social support and access to healthcare required to monitor the warfarin dose.

Low socioeconomic status is also associated with an increased risk of heart failure, stroke, and mortality in individuals with pre-existing atrial fibrillation.

Low socioeconomic status may influence access to healthcare, while lower health literacy can influence the patient’s participation in treatment decisions. For instance, individuals with higher socioeconomic status and higher education levels are more likely to get treated using catheter ablation.

Due to the role of a multitude of factors, including lifestyle choices, comorbid conditions, genetics, and socioeconomic factors, a multidisciplinary approach that is tailored for a particular patient is needed.

Explaining the need for individualized care, Dr. Nikhil Warrier, MD, a board-certified cardiac electrophysiologist and medical director of electrophysiology at MemorialCare Heart & Vascular Institute at Orange Coast Medical Center in Fountain Valley, CA, not involved in this research, noted that:

“The underlying risk factors that increase the likelihood of poor [AFib]-related outcomes can be different between every patient. For example, having a conversation that targets alcohol intake reduction and cessation in a patient for whom this is the primary trigger is different than someone who is sedentary, where starting an exercise program may be the conversation during the visit.”

“At the same time, management strategies for [AFib] differ based on the persistence of the arrhythmia along with age and other modifiable risk factors of the patient. In one patient, ablation may be a great first treatment option, while in another patient, that would be a poor option,” added Dr. Warrier.

Similarly, Dr. Yehoshua Levine, a cardiologist at Methodist Le Bonheur Healthcare in Memphis, TN, also not involved in the research, noted that “[o]ptimal management of [AFib] is very patient-dependent and necessarily involves consideration of multiple clinical, socioeconomic, and demographic factors, which are all important in determining the most appropriate treatment approach.“

Although these risk factors for atrial fibrillation have been recognized, there are challenges to achieving optimal results.

“Many of the same risk factors — obesity, lack of exercise, smoking, alcohol, hypertension, diabetes, high cholesterol, and sleep apnea — are the same as traditional risk factors for cardiovascular disease,“ Dr. Tang said.

“The treatment goals of weight loss, heart-healthy eating, exercise, smoking and alcohol cessation, and treatment of sleep disorders are widely recommended by many doctors, but these are difficult to implement in many patients as it require a complete change in lifestyle and habits,“ he cautioned.

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