Blood Clots

Atrial Fibrillation: Early Detection and Risk Reduction

In this guest post by Drs. Nidhi Madan and Annabelle Volgman discuss why early detection of AFib can lead to a significant reduction of risk.

Nidhi Madan, MD, MPH; Annabelle S. Volgman, MD, FACC, FAHA 

Atrial fibrillation (AFib) is the most common cardiac arrhythmia, with its prevalence projected to increase from 5.2 million in 2010 to 12.1 million cases in 2030 in the United States.1 AFib confers a higher risk of stroke, heart failure, cognitive decline and mortality.2,3 Early identification of AFib is imperative to reduce morbidity and mortality. Several factors cause structural and electrical remodeling of the atria resulting in AFIB. Established non-modifiable risk factors for AFib include advanced age and male sex. Female sex is a risk factor for strokes for patients with AFib. Other modifiable risk factors include smoking, alcohol use, obesity, diabetes, hypertension, sleep apnea, myocardial infarction, valve disease and heart failure.

Early identification of #AFib is imperative to reduce morbidity and mortality Click To Tweet

AFib impairs atrial contraction causing stasis of blood in the left atrium and decreases cardiac output. Symptoms include palpitations, dyspnea, and reduced exercise tolerance. However, about one third of AFib patients can be asymptomatic. AFib can be classified as paroxysmal (recurrent episodes terminating in less than 7 days), persistent (AFib lasting > 7 days), long standing persistent (AFib >12 months in duration) and permanent (patient and physician have jointly decided to stop further attempts at restoring/maintaining sinus rhythm).4

History and physical examination are the first steps for diagnosing AFib. Presence of an irregular pulse and often a rapid pulse on physical exam are common findings suggestive of AFib. Other findings are murmur, jugular venous distension, crackles or peripheral edema. AFib can be confirmed with a 12 lead electrocardiogram. Longer term ambulatory rhythm monitoring can establish AFib. Other monitors include portable electrocardiographic recorders that patients can purchase and bring or transmit to their healthcare providers. Blood pressure monitors can also indicate an irregular pulse in which case patients their healthcare providers should be informed. An echocardiogram should be obtained in all AFIB patients to evaluate cardiac structure and function.

Optimal management of AFib involves careful review of patient specific factors, co-morbidities, and degree of symptoms. Intensive risk factor reduction has been shown to reduce the likelihood of AFib recurrences.5

Rate and rhythm control and prevention of stroke and thromboembolism are key components of AFib management. Rate control can be achieved with use of beta-blockers, non-dihydropyridine calcium channel blockers, and if necessary, amiodarone.4 Rhythm control strategy includes anti-arrhythmic agents, cardioversion and/or catheter ablation.4,6 Referral to an electrophysiologist should be sought to pursue rhythm control strategies.

Stroke is a devastating complication of AFib and the widely validated CHA2DS2VASc score is used to assess this risk. Points are assigned as follows: (Congestive heart failure (1); Hypertension (1); Age (2 for age >75); Diabetes (1); Stroke or TIA (2); Vascular disease (1); Age (1 for ≥ 65-74); SC – sex category (1 for female sex). A CHA2DS2VASc score ≥2 requires consideration of systemic anticoagulation such as warfarin or direct acting oral anticoagulants (dabigatran, rivaroxaban, apixaban, and edoxaban) for stroke risk reduction. Assessment of the balance between the risks of stroke vs. bleeding should be made in all AFIB patients and discussing the choice with the patient.

Risks of #stroke vs. bleeding should be made in all #AFIB patients Click To Tweet

In this modern era of precision medicine, a personalized approach focusing on individual risk profile and patient preference is recommended in AFIB management.

References:

  1. Colilla S, Crow A, Petkun W, Singer DE, Simon T, Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. The American journal of cardiology 2013;112:1142-7.
  2. 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;98:946-52.
  3. Haywood LJ, Ford CE, Crow RS, et al. Atrial fibrillation at baseline and during follow-up in ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). Journal of the American College of Cardiology 2009;54:2023-31.
  4. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology 2014;64:e1-76.
  5. Pathak RK, Middeldorp ME, Lau DH, et al. Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: the ARREST-AFIB cohort study. Journal of the American College of Cardiology 2014;64:2222-31.
  6. Ferrari R, Bertini M, Blomstrom-Lundqvist C, et al. An update on atrial fibrillation in 2014: From pathophysiology to treatment. Int J Cardiol 2016;203:22-9.

Nidhi Madan, MD, MPH
Dr. Nidhi Madan is a fellow at the Rush University Medical Center and a resident in internal medicine at Jacobi Medical Center, Albert Einstein College of Medicine, and she is pursuing a Masters in Public Health at the Johns Hopkins University Bloomberg School of Public Health. Her research interests are focused on cardiovascular disease epidemiology, particularly preventive cardiology. She is a contributor for U.S. News and World Report.

Annabelle S. Volgman, MD, FACC, FAHA:
Dr Volgman is a Professor of Medicine and Senior Attending Physician at Rush Medical College and Rush University Medical Center. She is also the Medical Director of the Rush Heart Center for Women and the recipient of the Madeleine and James McMullan-Carl E. Eybel, MD Chair of Excellence in Clinical Cardiology. My research interests include preventive and management strategies of atrial fibrillation, especially antiarrhythmic drugs and anticoagulants for the prevention of stroke in atrial fibrillation. She is an active member of the American Heart Association and the American College of Cardiology. She has written numerous abstracts and articles on multiple topics, including women, stroke and heart disease, as well as cardiac electrophysiology.

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