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What is the best strategy for managing atrial fibrillation?

What is the best strategy for managing atrial fibrillation?

By John D Day

After personally performing more than 3,000 atrial fibrillation ablation procedures I have to ask myself: am I even making a dent in this disease? I cannot remember seeing so many new patients, even young patients, with atrial fibrillation when I began my cardiology fellowship nearly 20 years ago.

Indeed, based on the work of Sumeet Chugh from the Cedars Sinai Heart Institute in Los Angeles, USA, and colleagues (Circulation 2014;129:837-847), the incidence of atrial fibrillation, in countries like the USA, has increased 71% in the last 20 years.

We have always thought that this was due to our ageing population, but the incidence is rising at a greater magnitude than our ageing population. Therefore, something-that cannot be explained by genetics or an older population-is happening.

We are in the middle of an atrial fibrillation epidemic. Did this epidemic have to happen?

Chugh and colleagues have shown that the epicentre of this atrial fibrillation epidemic is right squarely in North America. The USA is a land of immigrants. We come from Europe, Africa, South America, Asia, and other regions, yet the prevalence of this epidemic is so much greater in the USA than in our ancestral countries.

It is true that genetic factors do play a role in atrial fibrillation. For example Caucasians and men are more prone to the condition. However, genetic factors cannot even begin to explain the 10-fold difference in the incidence of atrial fibrillation between Asia and North America as reported by Chugh et al. What is even more interesting is that once these Asians immigrate to the USA, the incidence of atrial fibrillation closely approximates that of other Americans.

Indeed, Greg Marcus from the University of California, San Francisco, USA, and colleagues also looked at this issue (Circulation 2013; 128:2470-2477). Marcus et al showed that of 375,318 incident atrial fibrillation episodes over 3.2 years in California, there was no difference in the incidence of atrial fibrillation in Asians compared to Hispanics or Blacks. Caucasians, known to be genetically predisposed to atrial fibrillation, had just a 37% greater incidence of atrial fibrillation. It appears that whatever protective effect Asians enjoyed in their native countries was lost once they emigrated to the USA.

However, the problem is not just with the USA. Chugh’s article also shows that this atrial fibrillation epidemic is occurring in most developed countries around the world.

What could explain this phenomenon?

Prash Sanders from the Royal Adelaide Hospital in Australia, published an article in JAMA last year (2013;310(19):2050-2060) which caught the world by surprise. In this study, Sanders and colleagues randomised 150 overweight and obese atrial fibrillation patients to a weight loss/lifestyle modification programme versus general healthy lifestyle advice. Remarkably, both groups of patients saw a reversal in their atrial fibrillation. However, the group that was randomised to a weight loss/lifestyle modification programme not only lost an average of 14.3kg but also experienced a nearly three-fold reduction in their atrial fibrillation burden over 15 months of follow-up as assessed by outpatient telemetry monitoring.

For the first time, in a well-designed partially blinded, randomised controlled study, Sanders and co-workers showed that lifestyle modification, including weight loss, could reverse atrial fibrillation. Could the lifestyle of modern civilisation and our obesity epidemic explain the marked spike in new atrial fibrillation cases we are now seeing?

In the recently concluded 35th Heart Rhythm Society Annual Scientific Sessions, there were studies showing similar findings. Some of these studies are covered in this issue of Cardiac Rhythm News [see page 1 and page 16]. Specifically, the Mayo Clinic group [page 16] showed that bariatric weight loss surgery resulted in nearly a three-fold reduction in atrial fibrillation over seven years of follow-up in comparison to a control group that did not undergo weight loss surgery. In addition, the Adelaide group [page 1] showed that aggressive lifestyle modification following atrial fibrillation ablation procedures could double the success rate of this procedure.

Clearly there is a growing interest in non-pharmacological and procedural driven management of atrial fibrillation to combat this epidemic.

Aggressive DARE lifestyle modification programme for atrial fibrillation

Frustrated that we just could not seem to make a dent in the growing tide of new atrial fibrillation cases, we have recently created a programme (DARE – Drive atrial fibrillation into remission evaluation), which started in January 2014, to encourage aggressive lifestyle modification for our patients with atrial fibrillation.

When I first started this programme, I was sure we were going to have a big drop off rate within a few weeks. Knowing that people quickly give up on New Year’s resolutions and that less than 5% of people can successfully change their lifestyle to maintain long-term weight loss, I thought that for sure we would lose most of our patients after just one month.

To my surprise, 92% of our patients are still actively engaged in this lifestyle modification programme. Moreover, they have lost an average of 16 pounds over the last few months and have experienced a 42% reduction in their atrial fibrillation symptom burden. Even more remarkable is that we have been able to reduce or discontinue medications in 63% of these patients.

The patients engaged in this programme feel better than they have ever felt before. For many, it is as if we reversed the clock 10–20 years. Patients that had failed multiple ablations are now atrial fibrillation free.

Returning back to my original question of what the best strategy for managing atrial fibrillation is, I would now argue that-based on recent data-many cases of atrial fibrillation in the USA could be prevented or reversed with lifestyles focussed on health. While there will always be genetically driven cases of atrial fibrillation, or atrial fibrillation caused by other medical conditions, a large percentage of cases in the USA are unnecessary.

It is time for us, as physicians and healthcare providers, to take the lead and help our patients successfully navigate the toxic lifestyles in the USA and in other developed countries. This is not difficult to do. Now is the time for us to reclaim our health!

John D Day is president-elect of the Heart Rhythm Society and medical director of Heart Rhythm Services for Intermountain Healthcare, Murray, USA