Beyond cardioversion, ablation and pharmacotherapies: Risk factors, lifestyle change and behavioral counseling strategies in the prevention and treatment of atrial fibrillation

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Abstract

Importance

It has been suggested that atrial fibrillation (AF) is the new cardiovascular disease epidemic of the 21st century. Clinical cardiology has largely focused on AF treatment and associated stroke prevention rather than preventing AF itself. To reduce the global consequences and associated costs of AF, it is critical to now embrace prevention as a priority. Proactively addressing the risk factors for AF and the underlying unhealthy lifestyle habits that contribute to them, using research-based counseling approaches, represents a complementary and adjunctive alternative in combatting this disease burden.

Observations

Encouraging and sustaining patient involvement to reduce AF incidence and improve outcomes begins with screening to identify risk factors, unhealthy lifestyle habits, and characteristics associated with failed attempts at favorably modifying these causalities. Modulators of and common barriers to achieving risk reduction and lifestyle change include self-efficacy, social support, age, sex, marital and socioeconomic status, education, employment, and psychosocial factors such as depression, isolation, anxiety and chronic life stress. Focused behavioral counseling approaches, including assessing the patient's readiness to change, motivational interviewing and using the 5 A's (assess, advise, agree, assist, arrange), along with employing initial downscaled goals to overcome inertia, are proven methodologies to overcome these common barriers to favorably modifying risk factors and unhealthy lifestyle habits.

Conclusions and relevance

To complement and enhance the current armamentarium for the medical management of cardiac arrhythmias, there is an urgent need to proactively address the causative factors triggering new-onset, recurrent and persistent AF. Beyond the counseling skills of highly trained professionals (eg, psychiatrists, psychologists), this narrative review highlights the need for and potential impact on lifestyle modification that non-behavioral scientists, including internal medicine, cardiology, and allied health professionals, can have on the patients they serve.

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.

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