ADVERTISEMENT
The Atrial Fibrillation Pandemic
Dear Readers,
As the COVID-19 pandemic has subsided and health care professionals try to return to normal, many are asking how the public health problem of atrial fibrillation (AF) has become so massive. Is the increase in patients with AF because there is more awareness of and screening for AF? Have patients with AF been suffering quietly for generations, or is the prevalence of AF growing?
Twenty-five years ago, the legendary Dr Eugene Braunwald wrote a piece in the New England Journal of Medicine declaring the emergence of 2 new epidemics: heart failure (HF) and AF.1 “In addition to HF, the number of hospital discharges for AF more than doubled from 111,000 in 1984 to 270,000 in 1994. This is worrisome…With the aging of the baby-boom cohort, the prevalence of age-related arrhythmia will only increase further.”1
In 2020, the American Heart Association recommended targeting the prevention of AF.2 They noted that in the past decade, there were 2.7 million Americans with AF, including 750,000 AF-related hospitalizations per year and 130,000 deaths. Based on these estimates, an average of 2054 Americans are admitted with AF to the hospital every day. How does this compare to the current COVID-19 pandemic? Based on statistics from the Centers for Disease Control and Prevention (CDC), during the week of August 10-16, 2022, the 7-day daily average for new hospital admissions with COVID-19 was 5690.3 This is much lower than at the peak of the pandemic, but it is important to note that the number of patients with AF being admitted to the hospital this summer was more than one-third the number of patients admitted with COVID-19.
The prediction is that the AF pandemic will continue to expand. It is estimated that AF prevalence will grow by 4.6% per year and increase to 1.8-2.6 million new cases of AF per year in the United States by 2030.2 Prevalence of AF may exceed 16 million by 2050. What is driving this rise in AF? Certainly, an aging population is one factor. Other risk factors for AF include hypertension, alcohol consumption, sleep apnea, smoking, diabetes, and obesity. Obesity is a major driving force. It is associated with chronic inflammation, obstructive sleep apnea, activation of the sympathetic and renin-angiotensin systems, diabetes, coronary artery disease, hypertension, and HF. The hazards of progression from paroxysmal to permanent AF is twofold when the body mass index exceeds 35.4 The prevalence of obesity has exploded in the United States. According to the CDC, most states had an obesity rate of less than 18% in 1994, but by 2010, this rate was over 26%.5
What can be done to address obesity and its role in AF? One intervention would be an increase in physical activity. There are multiple health benefits to physical activity, including an increase in insulin sensitivity, reductions in inflammation, and increased muscle mass. However, despite widespread awareness that a better diet, calorie restriction, and exercise can help with weight loss, it is projected that the issue of obesity will continue to increase. Mohebi et al recently published a projection of future cardiovascular risk factors and cardiovascular disease using data from the National Health and Nutrition Examination Survey combined with the 2020 United States Census projection counts for 2025-2060.6 They predicted that by the year 2060, obesity will increase by 18% to 126 million Americans. Diabetes will increase by 39% and hypertension will increase by 27%.
Fortunately, there has been recent development and availability of better drugs to treat obesity. One example is tirzepatide, a glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist, which has been shown to reduce body weight by 20% in obese patients.7
As the COVID-19 pandemic recedes, more attention should be given to other worldwide noninfectious public health crises, including AF. Recent guidelines have emphasized the importance of comprehensive risk factor management to optimize AF outcomes.8 Continued emphasis on AF prevention, including a focus on lifestyle modification and development of better treatments for risk factors such as obesity, are needed.
Disclosures: Dr. Knight has served as a paid consultant to Medtronic, the sponsor of the EV ICD study, served on the EV ICD Steering Committee, and was an investigator in the trial. Dr Knight also reports he has served as a consultant, speaker, investigator, and/or has received EP fellowship grant support from Abbott, AtriCure, Baylis Medical, Biosense Webster, Biotronik, Boston Scientific, CVRx, Medtronic, Philips, and Sanofi. He has no equity or ownership in any of these companies.
Reference
1. Braunwald E. Shattuck lecture—cardiovascular medicine at the turn of the millennium: triumphs, concerns, and opportunities. N Engl J Med. 1997;337(19):1360-1369. doi:10.1056/NEJM199711063371906
2. Kornej J, Börschel CS, Benjamin EJ, Schnabel RB. Epidemiology of atrial fibrillation in the 21st century. Circ Res. 2020;127(1):4-20. doi:10.1161/CIRCRESAHA.120.316340
3. The update on “up to date”. Centers for Disease Control and Prevention. Published September 30, 2022. Accessed October 11, 2022. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html
4. Tsang RSM, Barnes ME, Miyasaka Y, et al. Obesity as a risk factor for the progression of paroxysmal to permanent atrial fibrillation: a longitudinal cohort study of 21 years. Eur Heart J. 2008;29(18):2227-2233. doi:10.1093/eurheartj/ehn324
5. Diabetes data and statistics. Centers for Disease Control and Prevention. Published March 9, 2022. Accessed October 11, 2022. http://www.cdc.gov/diabetes/statistics
6. Mohebi R, Chen C, Ibrahim NE, et al. Cardiovascular disease projections in the United States based on the 2020 census estimates. J Am Coll Cardiol. 2022;80(6):565-578. doi:10.1016/j.jacc.2022.05.033
7. Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide once weekly for the treatment of obesity. N Engl J Med. 2022;387(3):205-216. doi:10.1056/NEJMoa2206038
8. Hindricks G, Potpara T, Dagres N, et al, ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373-498. doi:10.1093/eurheartj/ehaa612
