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Research Letters |

Invited Commentary—Global Arrhythmia Burden: The Public Health Implications of the Rise in Atrial Fibrillation
Comment on “The Increasing Burden of Atrial Fibrillation Compared With Heart Failure and Myocardial Infarction”
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Rajat Deo, MD, MTR; Paul D. Varosy, MD
[+] Author Affiliations

Author Affiliations: Division of Cardiovascular Medicine, Section of Electrophysiology, University of Pennsylvania, Philadelphia (Dr Deo); and Section of Cardiac Electrophysiology, University of Colorado Denver, Colorado Cardiovascular Outcomes Research (CCOR) Group, and VA Eastern Colorado Health Care System, Denver (Dr Varosy).


Arch Intern Med. 2012;172(9):741-742. doi:10.1001/archinternmed.2012.1294.
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Several recent studies have noted a rise in the prevalence and incidence of atrial fibrillation (AF). The population burden of AF is expected to double over the next 40 years and will likely affect between 6 to 12 million Americans by 2050.13 In this issue of the Archives, Wong and colleagues4 confirm that this phenomenon is not limited to the United States. Using administrative data, these investigators demonstrate that the number of hospitalizations for AF in Australia tripled over a 15-year period between 1993 and 2007. In comparison, the number of hospitalizations for myocardial infarction and heart failure increased only modestly during this time.

What accounts for this rise in AF? As Wong and colleagues4 propose, an increasing population of older patients may explain part of this trend. Patients with coronary artery disease and congestive heart failure are surviving longer and contributing to the growing population at risk for AF. Increasing age is associated with other comorbidities, including valvular heart disease, diabetes mellitus, hypertension, and peripheral arterial disease, all of which are risk factors not only for the development of AF but also for AF-associated thromboembolic complications. Increasing use of ambulatory electrocardiography devices and implantable arrhythmia devices such as pacemakers, defibrillators, and cardiac resynchronization therapy devices have likely enhanced detection of asymptomatic and minimally symptomatic arrhythmias. These possibilities, however, likely explain only a part of the increase in AF hospitalizations.

A larger and older population with AF will increase the burden of morbidity and mortality associated with AF. Even with appropriate risk stratification and anticoagulation, the risk of thromboembolic stroke is increased in AF, especially among patients with risk factors.5 Even brief, asymptomatic episodes of AF that are detected incidentally in patients with implantable arrhythmia devices are associated with ischemic strokes or peripheral emboli.6 More ominously, incident AF is associated with an increased risk of all-cause mortality in health care professionals7 and other cohorts.8,9 These findings portend a potentially dramatic rise in hospitalizations, stroke, and AF-associated mortality by 2050 unless our therapeutic options evolve adequately to counter these challenges.

Unfortunately, no single therapeutic breakthrough alone is likely to mitigate the rising burden of AF. Although all AF is characterized by chaotic atrial electrical activity, the arrhythmia is a final common pathway of multiple heterogeneous conditions, including electrical triggers (especially in the pulmonary veins), underlying structural heart disease, long-standing hypertension, genetic disorders, cardiomyopathies, and, almost certainly, other conditions we do not yet understand. Currently, guideline-based treatment strategies for AF begin with assessment and appropriate reduction of stroke risk (with aspirin, warfarin, or other anticoagulants) followed by treatment of AF-associated symptoms beginning first with control of the ventricular response to AF. If a rate control strategy fails or is otherwise unacceptable to the patient, efforts to achieve and maintain normal sinus rhythm can include cardioversion, antiarrhythmic drugs, and/or ablation by either catheter-based or surgical approaches. Unfortunately, patients continue to be hospitalized with poor ventricular rate control despite the use of rate controlling drugs. Furthermore, even when control of the rhythm is desired, antiarrhythmic drugs have both incomplete efficacy and substantive toxicities. Although promising in some, catheter ablation in the best candidates has both nontrivial procedural risk and a likelihood of success for a first procedure on the order of 60% to 85%, even with concomitant antiarrhythmic drug therapy.10 At a fundamental level, all of these treatments address a condition that has already afflicted the heart without addressing the upstream causes.

Clearly, both in the United States and abroad, the public health burden of AF is increasing. The good news is that anticoagulation with warfarin in appropriately risk-stratified patients has reduced (but not eliminated) stroke risk, and recent randomized trials suggest that simpler regimens with new anticoagulants are as efficacious as warfarin. Better insights into the mechanisms of AF have identified patients with structurally normal hearts and pulmonary venous atrial tachycardia triggers as particularly good candidates for AF ablation. Unfortunately, though, the burden of AF is increasing despite these and other advances.

We must do better—even greater support for scientific discovery may lead to better understanding of the mechanisms leading to AF and novel therapeutic approaches. Hopefully, new strategies with better profiles of safety and efficacy than those of our current therapeutic arsenal will mitigate the future symptoms and risks of adverse AF-associated outcomes. We are even more hopeful that other strategies may eventually emerge to prevent AF. Without such advances, the burden of AF will weigh heavily on our world in the coming decades.

ARTICLE INFORMATION

Correspondence: Dr Varosy, VA Eastern Colorado Health Care System, Cardiology Section (111B), 1055 Clermont St, Denver, CO 80220 (paul.varosy@va.gov).

Financial Disclosure: None reported.

Funding/Support: This study was funded in part by grant K23DK089118 from the National Institutes of Health (Dr Deo) and a Research Career Development Award (RCD 04-115-2) from the Veterans Administration Office of Health Services Research (Dr Varosy).

Roger VL, Go AS, Lloyd-Jones DM,  et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee.  Executive summary: heart disease and stroke statistics—2012 update: a report from the American Heart Association.  Circulation. 2012;125(1):188-197
PubMed   |  Link to Article
Go AS, Hylek EM, Phillips KA,  et al.  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(18):2370-2375
PubMed   |  Link to Article
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(2):119-125
PubMed   |  Link to Article
Wong CX, Brooks AG, Leong DP, Roberts-Thomson KC, Sanders P. The increasing burden of atrial fibrillation compared with heart failure and myocardial infarction: a 15-year study of all hospitalizations in Australia.  Arch Intern Med. 2012;172(9):739-740
Olesen JB, Lip GY, Hansen ML,  et al.  Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study.  BMJ. 2011;342:d124
PubMed   |  Link to Article
Healey JS, Connolly SJ, Gold MR,  et al; ASSERT Investigators.  Subclinical atrial fibrillation and the risk of stroke.  N Engl J Med. 2012;366(2):120-129
PubMed   |  Link to Article
Conen D, Chae CU, Glynn RJ,  et al.  Risk of death and cardiovascular events in initially healthy women with new-onset atrial fibrillation.  JAMA. 2011;305(20):2080-2087
PubMed   |  Link to Article
Benjamin EJ, Wolf PA, D’Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study.  Circulation. 1998;98(10):946-952
PubMed
Miyasaka Y, Barnes ME, Bailey KR,  et al.  Mortality trends in patients diagnosed with first atrial fibrillation: a 21-year community-based study.  J Am Coll Cardiol. 2007;49(9):986-992
PubMed   |  Link to Article
Wilber DJ, Pappone C, Neuzil P,  et al; ThermoCool AF Trial Investigators.  Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial.  JAMA. 2010;303(4):333-340
PubMed   |  Link to Article

Figures

Tables

References

Roger VL, Go AS, Lloyd-Jones DM,  et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee.  Executive summary: heart disease and stroke statistics—2012 update: a report from the American Heart Association.  Circulation. 2012;125(1):188-197
PubMed   |  Link to Article
Go AS, Hylek EM, Phillips KA,  et al.  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(18):2370-2375
PubMed   |  Link to Article
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(2):119-125
PubMed   |  Link to Article
Wong CX, Brooks AG, Leong DP, Roberts-Thomson KC, Sanders P. The increasing burden of atrial fibrillation compared with heart failure and myocardial infarction: a 15-year study of all hospitalizations in Australia.  Arch Intern Med. 2012;172(9):739-740
Olesen JB, Lip GY, Hansen ML,  et al.  Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study.  BMJ. 2011;342:d124
PubMed   |  Link to Article
Healey JS, Connolly SJ, Gold MR,  et al; ASSERT Investigators.  Subclinical atrial fibrillation and the risk of stroke.  N Engl J Med. 2012;366(2):120-129
PubMed   |  Link to Article
Conen D, Chae CU, Glynn RJ,  et al.  Risk of death and cardiovascular events in initially healthy women with new-onset atrial fibrillation.  JAMA. 2011;305(20):2080-2087
PubMed   |  Link to Article
Benjamin EJ, Wolf PA, D’Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study.  Circulation. 1998;98(10):946-952
PubMed
Miyasaka Y, Barnes ME, Bailey KR,  et al.  Mortality trends in patients diagnosed with first atrial fibrillation: a 21-year community-based study.  J Am Coll Cardiol. 2007;49(9):986-992
PubMed   |  Link to Article
Wilber DJ, Pappone C, Neuzil P,  et al; ThermoCool AF Trial Investigators.  Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial.  JAMA. 2010;303(4):333-340
PubMed   |  Link to Article

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