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The Epidemiologic Threat of Atrial FibrillationPrevention of Atrial Fibrillation: Need for Secondary, Primary, and Primordial Prevention FREE TO VIEW

Giuseppe Boriani, MD, PhD
Author and Funding Information

From the Institute of Cardiology, DIMES, University of Bologna.

CORRESPONDENCE TO: Giuseppe Boriani, MD, PhD, Institute of Cardiology, DIMES, University of Bologna, Policlinico S. Orsola-Malpighi, via Massarenti 9, 40138 Bologna, Italy; e-mail: giuseppe.boriani@unibo.it


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(1):9-10. doi:10.1378/chest.14-1565
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Published online

A series of epidemiologic studies has shown how atrial fibrillation (AF) is becoming an emerging epidemiologic threat.1 Epidemiologic data have been traditionally derived from populations of North America and Europe and have shown that AF, even in an asymptomatic stage, increases the risk of ischemic stroke, has complex interrelations with heart failure and increased mortality,2 and induces a growing financial burden on health-care systems.3

From a worldwide perspective, there is an absolute need to fill the gap in our knowledge regarding the global epidemiologic burden of AF.4 This requirement is easily explained by the consideration that in the year 2013, North America and Europe accounted for populations of 352 million and 740 million inhabitants, respectively, while the overall global population was > 7.1 billion people, with China being the most populous country in the world (> 1.3 billion people) and Asia as a continent accounting for > 60% of the world population.5

In this issue of CHEST (see page 109), an interesting article by Guo et al6 reports on the epidemiology of AF in China, focusing on the trends in age-adjusted AF prevalence, incidence, and lifetime risk for AF, as well as on risk factors for incident AF. The study is based on inpatient data derived from a large medical insurance database of southwestern China, including > 10 million people, over an 11-year period (2001-2012).6 The study shows that during that observation period, the prevalence of AF increased 20-fold, with the occurrence of AF-related stroke increasing 13-fold. For adults aged > 55 years, the lifetime risk for AF was approximately one in five, slightly lower than what is reported by studies from Europe and North America, where it was approximately one in four.6 However, the age-dependence of AF in China was even more pronounced than in Western countries, since a really substantial increase in the lifetime risk of AF at age ≥ 65 years was found.6 According to this report, the implications of AF-related stroke risk in China appear worrisome, since use of appropriate antithrombotic prophylaxis was limited to aspirin in around one-third of patients with AF, while warfarin was prescribed to only 4% of cases, despite a median CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years [doubled], diabetes, previous stroke [doubled], vascular disease, age 65-74 years, sex category [female]) score of 2.6

The article by Guo et al6 also shows that in China, a series of risk factors for incident AF can be identified: elderly age, diabetes, hypertension, coronary artery disease, heart failure, rheumatic heart disease, dilated cardiomyopathy, hyperthyroidism, and COPD.6 Risk-factors clustering using CHADS2 (congestive heart failure, hypertension, age ≥ 75 years, diabetes, prior stroke [doubled]) and CHA2DS2-VASc scores also predicted incident AF, with the latter score better than the former. This approach is in line with what is done in Western countries, where risk factors and risk markers for AF have been identified.7

The authors have to be commended for their contribution to increasing the awareness of the epidemiologic burden of AF as the basis for planning future policies in this specific geographic area. According to study methods, a substantial risk of underweighting the actual occurrence of AF in the population is expected, since, as reported by the authors, the study was based on inpatient records and did not take into account the cases of AF detected on an outpatient basis. Moreover, specific strategies for enhancing the detection of asymptomatic AF, such as opportunistic screening, applicable even with simple pulse palpation, were not considered.

There is a general perception that the AF epidemic is going to represent a worldwide threat also in geographic areas such as Asia, where its epidemiologic burden is not easily quantifiable, although attempts to improve knowledge about AF and AF-related stroke are attracting increasing interest by many stakeholders.8 In this complex and evolving scenario, where the burden of AF is strongly affected by rapid changes in social and economic conditions,4 it is worth considering a paradigm shift for health care. This could imply overcoming the conventional approaches to the care of patients with AF and AF-related consequences, based on the traditional concepts of primary and secondary prevention. Maybe, in terms of policymaking, it is time to go beyond primary prevention of AF, based on treatment of AF risk factors, considering instead the potential for a “primordial” prevention, defined as prevention of the development of risk factors in the first place.9 This approach, aimed at avoiding the penetration of risk factors into the population, has been proposed in general terms for the prevention of cardiovascular disease9 and should imply combined efforts of policymakers, regulatory and social service agencies, providers, physicians, community leaders, and consumers in an attempt to improve social and environmental conditions, as well as individual behaviors, in the perspective of adopting healthy lifestyles.

It is noteworthy that according to studies from Western countries,10 more than one-half of incident AF events proved to be attributable to elevated or borderline levels of risk factors for AF, namely, elevated BP, excess weight/obesity, diabetes mellitus, smoking, and prior cardiac disease. This supports the perspective that a substantial number of AF events could be avoided through prevention of the development of these cardiovascular risk factors, and that it could be possible to minimize AF by reducing exposure to the same risk factors, as occurs with other forms of cardiovascular disease. A structured weight-management program leading to improvement of multiple cardiometabolic risk factors was effective in highly symptomatic patients with AF, thus potentiating the implications of counteracting the emerging facilitating or causative role of a series of frequently interrelated cardiovascular risk factors such as obesity, diabetes, high BP, smoking, alcohol consumption, and sleep apnea.11

The effects of preventive interventions on AF through prevention or control of risk factors in China and Asia are not known, but it is well known that risk factors traditionally typical of Western countries, such as diabetes and obesity, are increasing in China and in Asia, generally.12 The scenario of AF and of cardiovascular disease prevention, in general, in these countries suggest the needs for multistaged approaches, including strategies of both intervention and prevention at different levels (clinically overt disease, asymptomatic disease, risk factors), with synergetic perspectives focused not only on the current epidemiologic threat but, even more, on the potentially even more challenging future epidemics. Combined efforts of all the stakeholders will play a crucial role in reaching this goal.13

References

Boriani G, Diemberger I, Martignani C, Biffi M, Branzi A. The epidemiological burden of atrial fibrillation: a challenge for clinicians and health care systems. Eur Heart J. 2006;27(8):893-894. [CrossRef] [PubMed]
 
Leong DP, Eikelboom JW, Healey JS, Connolly SJ. Atrial fibrillation is associated with increased mortality: causation or association? Eur Heart J. 2013;34(14):1027-1030. [CrossRef] [PubMed]
 
Wodchis WP, Bhatia RS, Leblanc K, Meshkat N, Morra D. A review of the cost of atrial fibrillation. Value Health. 2012;15(2):240-248. [CrossRef] [PubMed]
 
Boriani G, Diemberger I. Globalization of the epidemiologic, clinical, and financial burden of atrial fibrillation. Chest. 2012;142(6):1368-1370. [CrossRef] [PubMed]
 
Population Reference Bureau. 2013 world population data sheet. http://www.prb.org/pdf13/2013-population-data-sheet_eng.pdf. Accessed on June 24, 2014.
 
Guo Y, Tian Y, Wang H, Si Q, Wang Y, Lip GYH. Prevalence, incidence, and lifetime risk of atrial fibrillation in China: new insights into the global burden of atrial fibrillation. Chest. 2015;147(1):109-119.
 
Kirchhof P, Lip GY, Van Gelder IC, et al. Comprehensive risk reduction in patients with atrial fibrillation: emerging diagnostic and therapeutic options—a report from the 3rd Atrial Fibrillation Competence NETwork/European Heart Rhythm Association consensus conference. Europace. 2012;14(1):8-27. [CrossRef] [PubMed]
 
Lip GYH, Brechin CM, Lane DA. The global burden of atrial fibrillation and stroke: a systematic review of the epidemiology of atrial fibrillation in regions outside North America and Europe. Chest. 2012;142(6):1489-1498. [CrossRef] [PubMed]
 
Weintraub WS, Daniels SR, Burke LE, et al; American Heart Association Advocacy Coordinating Committee; Council on Cardiovascular Disease in the Young; Council on the Kidney in Cardiovascular Disease; Council on Epidemiology and Prevention; Council on Cardiovascular Nursing; Council on Arteriosclerosis; Thrombosis and Vascular Biology; Council on Clinical Cardiology, and Stroke Council. Value of primordial and primary prevention for cardiovascular disease: a policy statement from the American Heart Association. Circulation. 2011;124(8):967-990. [CrossRef] [PubMed]
 
Huxley RR, Lopez FL, Folsom AR, et al. Absolute and attributable risks of atrial fibrillation in relation to optimal and borderline risk factors: the Atherosclerosis Risk in Communities (ARIC) study. Circulation. 2011;123(14):1501-1508. [CrossRef] [PubMed]
 
Abed HS, Wittert GA, Leong DP, et al. Effect of weight reduction and cardiometabolic risk factor management on symptom burden and severity in patients with atrial fibrillation: a randomized clinical trial. JAMA. 2013;310(19):2050-2060. [CrossRef] [PubMed]
 
Nguyen HN, Fujiyoshi A, Abbott RD, Miura K. Epidemiology of cardiovascular risk factors in Asian countries. Circ J. 2013;77(12):2851-2859. [CrossRef] [PubMed]
 
Boriani G, Maniadakis N, Auricchio A, et al. Health technology assessment in interventional electrophysiology and device therapy: a position paper of the European Heart Rhythm Association. Eur Heart J. 2013;34(25):1869-1874. [CrossRef] [PubMed]
 

Figures

Tables

References

Boriani G, Diemberger I, Martignani C, Biffi M, Branzi A. The epidemiological burden of atrial fibrillation: a challenge for clinicians and health care systems. Eur Heart J. 2006;27(8):893-894. [CrossRef] [PubMed]
 
Leong DP, Eikelboom JW, Healey JS, Connolly SJ. Atrial fibrillation is associated with increased mortality: causation or association? Eur Heart J. 2013;34(14):1027-1030. [CrossRef] [PubMed]
 
Wodchis WP, Bhatia RS, Leblanc K, Meshkat N, Morra D. A review of the cost of atrial fibrillation. Value Health. 2012;15(2):240-248. [CrossRef] [PubMed]
 
Boriani G, Diemberger I. Globalization of the epidemiologic, clinical, and financial burden of atrial fibrillation. Chest. 2012;142(6):1368-1370. [CrossRef] [PubMed]
 
Population Reference Bureau. 2013 world population data sheet. http://www.prb.org/pdf13/2013-population-data-sheet_eng.pdf. Accessed on June 24, 2014.
 
Guo Y, Tian Y, Wang H, Si Q, Wang Y, Lip GYH. Prevalence, incidence, and lifetime risk of atrial fibrillation in China: new insights into the global burden of atrial fibrillation. Chest. 2015;147(1):109-119.
 
Kirchhof P, Lip GY, Van Gelder IC, et al. Comprehensive risk reduction in patients with atrial fibrillation: emerging diagnostic and therapeutic options—a report from the 3rd Atrial Fibrillation Competence NETwork/European Heart Rhythm Association consensus conference. Europace. 2012;14(1):8-27. [CrossRef] [PubMed]
 
Lip GYH, Brechin CM, Lane DA. The global burden of atrial fibrillation and stroke: a systematic review of the epidemiology of atrial fibrillation in regions outside North America and Europe. Chest. 2012;142(6):1489-1498. [CrossRef] [PubMed]
 
Weintraub WS, Daniels SR, Burke LE, et al; American Heart Association Advocacy Coordinating Committee; Council on Cardiovascular Disease in the Young; Council on the Kidney in Cardiovascular Disease; Council on Epidemiology and Prevention; Council on Cardiovascular Nursing; Council on Arteriosclerosis; Thrombosis and Vascular Biology; Council on Clinical Cardiology, and Stroke Council. Value of primordial and primary prevention for cardiovascular disease: a policy statement from the American Heart Association. Circulation. 2011;124(8):967-990. [CrossRef] [PubMed]
 
Huxley RR, Lopez FL, Folsom AR, et al. Absolute and attributable risks of atrial fibrillation in relation to optimal and borderline risk factors: the Atherosclerosis Risk in Communities (ARIC) study. Circulation. 2011;123(14):1501-1508. [CrossRef] [PubMed]
 
Abed HS, Wittert GA, Leong DP, et al. Effect of weight reduction and cardiometabolic risk factor management on symptom burden and severity in patients with atrial fibrillation: a randomized clinical trial. JAMA. 2013;310(19):2050-2060. [CrossRef] [PubMed]
 
Nguyen HN, Fujiyoshi A, Abbott RD, Miura K. Epidemiology of cardiovascular risk factors in Asian countries. Circ J. 2013;77(12):2851-2859. [CrossRef] [PubMed]
 
Boriani G, Maniadakis N, Auricchio A, et al. Health technology assessment in interventional electrophysiology and device therapy: a position paper of the European Heart Rhythm Association. Eur Heart J. 2013;34(25):1869-1874. [CrossRef] [PubMed]
 
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