Beyond cardioversion, ablation and pharmacotherapies: Risk factors, lifestyle change and behavioral counseling strategies in the prevention and treatment of atrial fibrillation
Introduction
More than 33 million patients >55 years of age are affected by atrial fibrillation (AF) worldwide, with a 37% lifetime incidence. Currently, between 3 and 6 million Americans are afflicted with AF, and this number is expected to continue to rise. Today, AF is the most commonly treated arrhythmia in clinical practice and adds $26 billion to US health care costs.1,2 Common risk factors for AF include increasing age, atherosclerotic and structural heart disease, hypertension, overweight/obesity, metabolic abnormalities (e.g., diabetes mellitus), excessive alcohol intake, obstructive sleep apnea, or combinations thereof.1
The management of AF involves anticoagulation for stroke prevention in eligible patients, rate regulation, and rhythm control.2 Although there have been great strides in the development of medications to reduce the associated thromboembolic risk and advances in cardioversion and catheter ablation interventions, the success of AF rhythm control has not risen proportionately.3 A major component of the AF prevention and treatment algorithm remains woefully underemphasized, that is, favorably modifying associated risk factors, including obesity,4 exercise/habitual physical activity, cardiorespiratory fitness (CRF), diabetes,5 hypertension,6 and alcohol consumption,7 which can be addressed with patient engagement, education and counseling. The Aggressive Risk Factor Reduction Study for Atrial Fibrillation and Implications for the Outcome of Ablation (ARREST AF) study found that in the absence of electrophysiology intervention, risk factor modification could significantly reduce AF duration, severity and frequency. This benefit was further enhanced with the addition of ablative modalities, highlighting the value of risk factor modification prior to considering therapeutic options with attendant risks.8 There also is emerging evidence that derangements in gut microbiota and alterations in metabolic patterns are associated with AF,9 offering potential prevention and treatment options in the future. This review examines complementary interventions to prevent the development of AF and/or its recurrence. In addition, we explore social modulators and behavioral counseling strategies in favorably modifying these risk factors to effectively empower and support those patients who may struggle to implement and maintain therapeutic lifestyle interventions.
Section snippets
Overweight/obesity
Population studies have shown that obesity increases the risk for AF by 1.5-fold, with a 4% increase in AF risk for every unit increase in body mass index (BMI). Others have reported significant correlations between the severity of obesity and the risk of developing AF.4,10 A meta-analysis of 51 studies examining the relations between height, weight and AF burden found that the likelihood of incident AF increased in a dose dependent manner relative to BMI.11
Animal models have helped to clarify
Alcohol consumption
Moderate-to-heavy alcohol consumption is a major risk factor for AF. Alcohol slows atrial conduction velocity and shortens the effective refractory period. Accordingly, it acts as a trigger for AF.25 The NORWEGIAN HUNT (Nord-Trøndelag Health) study, a population-based cohort investigation, reported a curvilinear increase in the risk of AF with alcohol consumption. However, the investigators found no association between AF and alcohol at more moderate intakes, specifically <1 drink/day for women
Exercise and cardiorespiratory fitness
Regular physical activity is generally considered a protective intervention against AF. In a study of 5446 adults ≥65 years who were followed for a total of 47,280 person-years, 1061 new diagnoses of AF were documented.28 Overall, 20% of the study subjects developed AF during the 12-year follow-up. Regression analysis showed leisure-time physical activity was associated with a lower AF incidence in a graded manner, with 25% (HR 0.75, 95% confidence interval [CI] 0.61–0.90), 22% (HR 0.78, 95% CI
Cigarette smoking
Tobacco use also has been associated with an increased risk of AF. A meta-analysis of 29 prospective studies helped clarify this association. The RR of AF was 1.33 (95% CI 1.12–1.56) for current smokers, 1.09 (95% CI 1.00–1.18) for former smokers, and 1.21 (95% CI 1.12–1.31) for ever smokers, versus never smokers.43 A study of 201 subjects who received index catheter ablation for persistent AF found no overall difference in long-term outcomes between smokers and nonsmokers; however, there was a
Caffeine
The impact of caffeine on the incidence of AF remains controversial. Although a quarter of patients with AF report caffeine as a potential trigger,45 a meta-analysis of 230,000 patients identified only a weak association between caffeine intake and the risk of AF.46 Accordingly, there is no compelling evidence to support the premise that lowering of caffeine consumption confers protection against AF incidence or burden.45
Obstructive sleep apnea
Obstructive sleep apnea (OSA) is often found in the AF population with a prevalence ranging from 50 to 80%.47 A recent meta-analysis that included nine studies reported that the risk of developing AF was higher in the OSA group (7582 patients) compared with a control cohort (12,255 patients, OR 2.120, P < .001).48 Another meta-analysis of seven studies (n = 4572 patients) evaluated the association between OSA and AF recurrence in patients undergoing AF ablation. Not only was OSA associated with a
Diabetes
In a large Swedish population study, type 2 diabetes was associated with a 35% higher risk of AF compared with age- and sex-matched controls. This risk increased with poor glycemic control and/or renal dysfunction.50 The baseline incidence of diabetes was ~30% in the Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort: A Long-Term Follow-Up Study (LEGACY) trial and diabetes remained an independent predictor of AF recurrence (HR 1.8) in multivariate analysis of
Hypertension
Hypertension is very common among patients with AF. The baseline incidence of hypertension was up to 80% in the LEGACY trial.21 Due to the high prevalence of hypertension, it carries the highest attributable risk of AF.1 The risk factor modification trial focused heavily on hypertension control with blood pressure measurements three times/day and used exercise-induced hypertension (>200/100 mmHg) as the cut point to manage hypertension. Renin-angiotensin-aldosterone system antagonists were used
Social modulators of behavioral change
Because previous trials aimed at AF risk factor reduction were able to recruit only 40–60% of the proposed study participants,8,21 it is pivotal to understand the most efficient methods to introduce the importance of lifestyle change in a busy AF clinic and triage patients who may require more intensive counseling. Although few data are available regarding the specific impact of social determinants of health on AF, we have learned from related research experiences in populations with and
Favorably modifying unhealthy lifestyle habits: a new paradigm for preventing and managing atrial fibrillation
The 4 major behavioral causes of AF, including obesity, physical inactivity/low CRF, excess alcohol consumption, and tobacco usage, are attributed to unhealthy dietary and lifestyle choices. These adverse health behaviors are most prevalent among the less fortunate: those with low socioeconomic status, less education, and limited access to health care.56 Regardless of the precise mechanisms, it appears that aggressive lifestyle modification and intensive risk factor reduction can decrease
Advising patients regarding behavior change: are we doing enough?
Despite the well-established benefits of regular physical activity, weight reduction and smoking cessation, less than half of all patients with cardiovascular diseases report being counseled about one or more of these risk-reduction strategies during their most recent office visit.61 Collectively, these and other relevant reports62 suggest that physicians and/or their support staff often miss opportunities to counsel patients regarding the need for substantive behavior change to facilitate
Conclusion
The comprehensive management of AF is critically important, as therapies, including medications, cardioversion, and catheter ablation interventions, are often significantly more successful by preemptively modifying the patient's lifestyle habits and risk factor profile (Fig. 3).57., 58., 59. Initiation of research-based lifestyle counseling strategies prior to invasive interventions can have a profound and favorable impact on long-term outcomes.69 Identifying modulators that influence a
Declaration of competing interest
None.
Acknowledgments
The authors thank Brenda White for her assistance with the preparation of this manuscript.
References (69)
- et al.
2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society
J Am Coll Cardiol
(2014) - et al.
2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation
Heart Rhythm
(2017) - et al.
Meta-analysis of cohort and case-control studies of type 2 diabetes mellitus and risk of atrial fibrillation
Am J Cardiol
(2011) - et al.
Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: the ARREST-AF cohort study
J Am Coll Cardiol
(2014) - et al.
Obesity and the risk of incident, post-operative, and post-ablation atrial fibrillation: a meta-analysis of 626,603 individuals in 51 studies
J Am Coll Cardiol EP
(2015) - et al.
Electrophysiological, electroanatomical, and structural remodeling of the atria as consequences of sustained obesity
J Am Coll Cardiol
(2015) - et al.
Weight change modulates epicardial fat burden: a 4-year serial study with non-contrast computed tomography
Atherosclerosis
(2012) - et al.
Electroanatomical remodeling of the atria in obesity: impact of adjacent epicardial fat
J Am Coll Cardiol EP
(2018) - et al.
Long-term effect of goal-directed weight management in an atrial fibrillation cohort: a long-term follow-up study (LEGACY)
J Am Coll Cardiol
(2015) - et al.
Cost-effectiveness and clinical effectiveness of the risk factor management clinic in atrial fibrillation: the CENT study
J Am Coll Cardiol Clin Electrophysiol
(2017)
Bariatric surgery and the risk of new-onset atrial fibrillation in Swedish obese subjects
J Am Coll Cardiol
Electrophysiologic properties of alcohol in man
J Electrocardiol
Impact of CARDIOrespiratory FITness on arrhythmia recurrence in obese individuals with atrial fibrillation: the CARDIO-FIT Study
J Am Coll Cardiol
Exercise capacity and atrial fibrillation risk in veterans: a cohort study
Mayo Clin Proc
Exercising for health and longevity vs peak performance: different regimens for different goals
Mayo Clin Proc
Physical fitness, physical activity, exercise training, and atrial fibrillation: first the good news, then the bad
J Am Coll Cardiol
Patient-reported triggers of paroxysmal atrial fibrillation
Heart Rhythm
Caffeine intake and atrial fibrillation incidence: dose response meta-analysis of prospective cohort studies
Can J Cardiol
Sleep-disordered breathing and chronic atrial fibrillation
Sleep Med
The benefits and challenges of multiple health behavior change in research and in practice
Prev Med
Obesity and atrial fibrillation prevalence, pathogenesis, and prognosis
J Am Coll Cardiol
Atrial fibrillation in the 21st century: a current understanding of risk factors and primary prevention strategies
Mayo Clin Proc
Lifestyle modification in the prevention and treatment of atrial fibrillation
Prog Cardiovasc Dis
Diet and physical activity counseling during ambulatory care visits in the United States
Prev Med
Motivational interviewing in health settings: a review
Patient Educ Couns
Is atrial fibrillation a preventable disease?
J Am Coll Cardiol
Lifestyle and risk factor modification for reduction of atrial fibrillation: a Scientific Statement from the American Heart Association
Circulation
Lifetime risk for development of atrial fibrillation: the Framingham Heart Study
Circulation
Independent risk factors for atrial fibrillation in a population based cohort: the Framingham Heart Study
JAMA
The “holiday heart”: electrophysiologic studies of alcohol effects in alcoholics
Ann Intern Med
Disordered gut microbiota and alterations in metabolic patterns are associated with atrial fibrillation
GigaScience
Obesity and the risk of new onset atrial fibrillation
JAMA
Effects of a high-fat diet on the electrical properties of porcine atria
J Arrhythm
The relationship between epicardial fat and indices of obesity and the metabolic syndrome: a systematic review and meta-analysis
Metab Syndr Relat Disord
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