All About AFib
September is Atrial Fibrillation Awareness Month, and it is likely no surprise to cardiovascular clinicians that the incidence of atrial fibrillation (AFib) continues to escalate. The prevalence has increased threefold in the previous 50 years,[i] and in 2014, lifetime estimates were 1 in 3 white individuals and 1 in 5 Black individuals.[ii] By 2050, the disease is expected to impact between 6 and 16 million individuals in the U.S. alone,[iii],[iv] making the implementation of effective, guideline-directed risk reduction, diagnosis, and treatment strategies in the clinical setting all the more imperative.
For those interested in learning all about AFib management in clinical practice, there are three tenets described in more detail below: prevention, diagnosis, and treatment.
Prevention of AFib
Like many cardiovascular diseases, the ideal strategy is that of prevention—and it is never too early to start. By reducing the development of any risk factors, patients can reduce their lifetime risk for many diseases including AFib. For young adults and individuals without known comorbidities, primordial prevention includes reducing future risk by maintaining a healthy weight, not smoking, and healthy eating habits that can reduce the risk of hypertension and diabetes. It is important to consider psychosocial factors and social determinants of health in these—and all—patients, to help reduce the risk of AFib and other acute and chronic diseases.
Primary prevention of AFib recognizes that individuals with risk factors such as tobacco and alcohol use, hypertension, diabetes, and obesity are at higher risk for AFib. Knowing that AFib can lead to stroke, heart failure, acute coronary syndrome (ACS), and death (with complications that may occur within 12 months of AFib diagnosis) can be a significant motivator for both clinicians and patients to address underlying causes of AFib.
Diagnosis of AFib
Because of its prevalence, diagnosis of AFib should be front of mind for clinicians when working with patients of any age, but particularly in those 40 and older. Because AFib can be episodic in nature, and many patients do not have obvious symptoms, diagnosis can be challenging. Many patients discover they have AFib as an incidental finding during a provider visit. There are many modifiable and nonmodifiable risk factors of which patients and providers need to be aware:
Heart-related Risk Factors
- Coronary artery disease
- Heart failure
- Heart attack at a young age
- Recent heart surgery
- Heart valve problems
Lifestyle Risk Factors
- Heavy alcohol use
- Recreational drug use
- Excessive caffeine consumption
- Extreme stress
- Overweight, obesity
- Thyroid issues
- Kidney disease
- Sleep apnea
- Previous stroke
- Lung problems
Because AFib may not be present when patients are in the clinical setting, getting a good family and medical history is important. This includes asking about subtle findings that may include:
- A heartbeat that is fast, and/or irregular
- Being able to describe these episodes is essential: rapid onset and rapid or gradual offset; episode duration; any provoking activity i.e., after a glass of wine, or energy drink consumption
- Dizzy or faint feeling
- Feeling very tired, even after sleeping or resting
- Difficulty completing normal day-to-day activities
- Shortness of breath
- Chest pain or discomfort
- Leg swelling
- Feeling anxious or stressed
- Mental confusion
In addition to getting a history, many people are using health apps/watches/activity monitors that may assist providers in observing heart rate trends over time. Some applications actually record ECG tracings, which can be shared during the clinical visit or even transmitted electronically to a provider.
Treatment of AFib
Improved patient outcomes and quality of life are the goals of guideline-directed practice. The American Heart Association’s scientific statement in 2018 indicated that it was important to move beyond the binary ‘AF present’ or ‘AF absent’ mindset to consider the overall burden of AFib—at its simplest, how much AFib an individual has—and the relationship between AFib pattern and stroke risk, which could inform better decision-making in stroke prevention.[vii]
Along with lifestyle modifications, medications and surgical treatments are used to control AFib symptoms, address heart rate and heart rhythm, and improve patient quality of life. It is important for clinicians to overcome the inertia to treat, even in recently-diagnosed patients. Effective treatment can reduce the risk of stroke, morbidity, and mortality in patients of all ages.
Rate vs. Rhythm Control in AFib
While rate control is often the first goal of providers in order to improve symptoms, rhythm-control therapy is associated with a lower risk of cardiovascular outcomes than usual care (particularly for those that have new-onset AFib).[viii],[ix],[x] While the goal of both strategies is to improve symptoms, early rhythm control can additionally halt the progression of symptoms, may effectively reduce irreversible atrial remodeling, and prevent deaths in high-risk patients including those from AFib, heart failure, and stroke.[viii] Treatment of AFib can include medications to control rate, medications to try and maintain sinus rhythm (antiarrhythmics), chemical or electrical cardioversion to return AFib to regular rhythm, and ablation to try and eliminate the electrical pathways responsible for symptoms. Providing access to electrophysiologists will allow patients and families to make the best informed decisions about their plan of care.
Stroke Prevention and AFib
One of the most important aspects of care in patients who have AFib is the prevention of stroke. The goal of care is to assess the risk using a CHA2DS2-VASc scoring system and the HAS-BLED bleeding risk score and then discuss risk and treatment options available with the patient and family. There are many tools for shared decision-making that providers can use to guide these discussions for AFib (see ‘Resources’ section below).
A wide variety of resources all about AFib for healthcare providers (HCPs) and their patients are available through PCNA and other sources.
- Cardiosmart risk calculator
- Series of decision aids from the American College of Cardiology that addresses stroke risk and various CHA2DS2-VASc scores
- PCNA’s resources for health care providers, including the Stroke/AFib pocket resource and AFib screening toolkit.
- PCNA patient handouts, including a fact sheet, booklet, and handout on smart devices.
- AFib Management in Clinical Practice podcast episode
- AFib and Sleep Apnea podcast episode
[i] Schnabel RB, Yin X, Gona P, et al. 50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: a cohort study. Lancet. 2015; 386:154–162. doi: 10.1016/S0140-6736(14)61774-8
[ii] Mou L, Norby FL, Chen LY, et al. Lifetime Risk of Atrial Fibrillation by Race and Socioeconomic Status: ARIC Study (Atherosclerosis Risk in Communities). Circ Arrhythm Electrophysiol. 2018;11:e006350. doi: 10.1161/CIRCEP.118.006350
[iii] Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation. 2006;114:119–125. doi: 10.1161/CIRCULATIONAHA.105.595140
[iv] Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001;285:2370–2375. doi: 10.1001/jama.285.18.2370
[vi] Mazurek M, Shantsila E, Lane DA, et al. Secondary Versus Primary Stroke Prevention in Atrial Fibrillation: Insights From the Darlington Atrial Fibrillation Registry. Stroke. 2017;48:2198–2205 https://doi.org/10.1161/STROKEAHA.116.016146
[vii] Chen LY, Chung MK, Allen LA, et al, on behalf of the American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Stroke Council. Atrial Fibrillation Burden: Moving Beyond Atrial Fibrillation as a Binary Entity: A Scientific Statement From the American Heart Association. Circ. 2018;137:e623-e644. doi: 10.1161/CIR.0000000000000568
[viii] Roberts JR. Atrial Fibrillation: Rate Control v. Rhythm Control. Emergency Medical News. 2021;43(11)2021. doi: 10.1097/01.EEM.0000800520.09662.02
[ix] Kirchhof P, Camm AJ, Goette A, et al. for the EAST-AFTNET 4 Trial Investigators. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med 2020;383:1305-1316. doi: 10.1056/NEJMoa2019422
[x] Camm AJ, Naccarelli GV, Mittal, S, et al. The Increasing Role of Rhythm Control in Patients with Atrial Fibrillation: JACC State-of-the-Art Review. J Am Coll Cardiol. 2022;79(19):1932-1948. Doi: https://www.jacc.org/doi/10.1016/j.jacc.2022.03.337