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Atrial fibrillation: the current epidemic

Atrial fibrillation: the current epidemic Atrial fibrillation (AF) is the most common arrhythmia diagnosed in clinical practice. The consequences of AF have been clearly estab- lished in multiple large observational cohort studies and include increased stroke and systemic embolism rates if no oral anticoagulation is prescribed, with increased morbidity and mortality. With the worldwide aging of the population characterized by a large influx of “baby boomers” with or without risk factors for developing AF, an epidemic is forecasted within the next 10 to 20 years. Although not all studies support this evidence, it is clear that AF is on the rise and a significant amount of health resources are invested in detecting and managing AF. This review focuses on the worldwide burden of AF and reviews global health strategies focused on improving detection, prevention and risk stratification of AF, recently recommended by the World Heart Federation. J Geriatr Cardiol 2017; 14: 195203. doi:10.11909/j.issn.1671-5411.2017.03.011 Keywords: Aging; Anticoagulation; Atrial fibrillation; Heart failure; Hypertension; Stroke nary management of AF envisioned by the World Heart 1 Introduction [1,2,7–12] Federation. As the population ages globally, atrial fibrillation (AF) is predicted to affect 6–12 million people in the USA by 2050 [1–3] 2 AF global burden and 17.9 million in Europe by 2060. AF utilizes signifi- [4] cant health resources globally, and constitutes a public AF is the most frequently encountered arrhythmia in [5] [3] health challenge with high comorbidity, and increased clinically practice. Between 1990 and 2013, although the [6] mortality risk. The reasons for the increase in the preva- global prevalence rate of AF decreased slightly, the overall [7,8] [13] lence of AF remain elusive and are related to multiple number of AF cases increased (Table 1). AF is associated factors including; enhanced detection, increased incidence, with an increase in morbidity, as measured by disability- [9–11] and greater survival after onset of AF. The purpose of adjusted life years (DALYs). Estimates of prevalence of AF, this review is to assess the evidence related with the in- and DALYs associated with AF, are likely to underestimate creased overall prevalence of AF and to propose a global true burden due to the high prevalence of asymptomatic [3] strategy focused on enhanced detection and multidiscipli- AF. AF also leads to increased health care resource utili- zation and may have a significant impact on global health [14–17] Correspondence to: Carlos A Morillo, MD, Department of Cardiac budgets. Several long-term cohorts have clearly estab- Sciences, Division of Cardiology, Libin Cardiovascular Institute, University lished that several clinical outcomes are increased in pa- [18] of Calgary, Population Health Research Institute, McMaster University, tients with AF. Among other clinical outcomes, AF is th Foothills Medical Centre, Room C823, 1403 29 Street NW, Calgary, AB associated with increased risk of stroke and is found in one T2N 2T9, Canada. [19] third of all ischemic strokes. E-mails: carlos.morillo@ucalgary.ca, morillc@mcmaster.ca AF burden has regional variations, with high-income Telephone: +1-403-944-2670 Fax: +1-403-944-2906 countries experiencing a higher prevalence, incidence, Received: January 25, 2017 Revised: February 8, 2017 DALYs and mortality associated with AF than low-middle Accepted: March 8, 2017 Published online: March 28, 2017 http://www.jgc301.com; jgc@jgc301.com | Journal of Geriatric Cardiology 196 Morillo CA, et al. The current epidemic of AF [3] income countries (LMIC). However, estimates of the ex- the lower rates of AF documented in developing countries tent of this difference should be interpreted with caution, as may be related to under reporting, limited access to health [3,20] care services and geographical disparity in published data. Table 1. Global burden of AF in 1990 and 2013, data from [13] Estimating the global burden of AF is challenging and Global Burden of Disease Study 2013. few studies have systematically reviewed population-based Global Rate per 100,000 Cases (All ages) [3] AF studies (Figure 1). Chugh, et al., reviewed all popula- Prevalence (Age-standardized) Year Mean 95% UI Mean 95% UI tion based AF studies between 1980 to 2010, from 21 global 1990 6841147 (6602764, 7114686) 213.7 (205.9, 222.6) burden of disease regions. These investigators estimated 2013 11178627 (10655102, 11683727) 191.3 (182.1, 200.1) global/regional prevalence, incidence, and morbidity and Global Rate per 100,000 mortality related to AF. The estimated number of individu- Cases (All ages) DALYs (Age-standardized) als with AF globally in 2010, was 33.5 million (20.9 million Year Mean 95% UI Mean 95% UI men and 12.6 million women) with significant regional 1990 854714 (693332, 1049075) 26.7 (21.7, 32.7) variations and heterogeneity (Table 1). Mortality associated 2013 1888690 (1590032, 2224863) 32.5 (27.5, 38.2) with AF was increased by 2-fold in both genders from 1990 Cases rounded to the nearest whole number. DALYs: disability-adjusted [3] life years; UI: uncertainty interval. to 2010 (Figures 2–4). [3] Figure 1. Global age-adjusted prevalence rates of AF (per 100,000 persons). Reproduced with permission from Chugh, et al. AF: atrial fibrillation. [3] Figure 2. Mortality associated with AF: 1990–2010 (per 100,000 persons). Reproduced with permission from Chugh, et al. AF: atrial fibrillation; UI: uncertainty interval. Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com Morillo CA, et al. The current epidemic of AF 197 Figure 3. Mortality associated with AF by gender and region (developed vs. developing). Reproduced with permission from Chugh, et [3] al. AF: atrial fibrillation. [3] Figure 4. Global mortality associated with AF in 2010. Colors represent percentages. Reproduced with permission from Chugh, et al. AF: atrial fibrillation. Furthermore, in all countries regardless of development, The occurrence of death and stroke in patients presenting [21] a substantial proportion of AF cases are subclinical, lim- to a hospital emergency department vary widely across iting the ability to appropriately identify and detect AF geographical regions. The RELY-AF Registry recently re- without advanced medical technology. Recent data from ported the 1-year mortality and stroke rates in patients from [23] the ASSERT II trial suggests that the prevalence of sub- 47 countries. Marked and unexplained differences in clinical AF > 5 min in subjects over 65 years with either a mortality and stroke rates were observed. Over 15,000 indi- CHA DS VASc ≥ 2, sleep apnoea or body mass index viduals were enrolled and 1758 (11%) died within 1 year. 2 2 (BMI) > 30 kg/m with no evidence of clinical AF is around Fewer deaths occurred among patients presenting to the 30%, indicating that subclinical AF may be detected in al- emergency department with primary AF compared with most 1/3 of the population that otherwise has a low-inter- those with secondary AF, 6% vs. 16% (P < 0.0001). Twice mediate risk of developing symptomatic AF and subsequent as many patients had died by 1 year in South America (17%) [22] AF associated comorbidities. and Africa (20%) compared with North America, Western http://www.jgc301.com; jgc@mail.sciencep.com | Journal of Geriatric Cardiology 198 Morillo CA, et al. The current epidemic of AF Europe, and Australia (10%, P < 0.0001). Heart failure was the most common cause of death (30%); stroke caused deaths (8%), and 4% patients had had a stroke by 1 year; 3% of those with primary AF and 5% with secondary AF (P < 0.0001). The highest number of strokes occurred in pa- Figure 5. AF stages and proposed interventions. Modified tients in Africa (8%), China (7%), and Southeast Asia (7%) from the WHF AF roadmap. AF: atrial fibrillation. WHF: world and the lowest occurred in India (< 1%). Only 3% of the hemophilia federation. patients in North America, Western Europe, and Australia and some intervention studies seem to indicate that out- had a stroke. comes after AF ablation may be better when modifiable risk Patients with AF in LMIC tend to be a decade younger, [37] factors are aggressively approached. Although the bene- are more likely to experience heart failure, and are less fits of interventions to manage risk factors such as weight, likely to be managed according to recommended AF guide- blood pressure, smoking and diabetes for health outcomes lines (i.e., patients with AF in LMIC have significantly generally are well-established and relevant to populations lower use of oral anticoagulants (OACs), and lower time in globally, primary prevention trials for AF have yet to estab- therapeutic range which may be related with limited access [24] lish a role for interventions for specific risk factors (Figure 5). to health care systems. Differences in AF burden among There is an urgent need for research that can inform primary LMIC and high-income countries should also be interpreted prevention efforts for AF in more geographically and ra- in light of the risk factor profile of this condition. European cially diverse populations, while also evaluating the effec- ancestry has been identified as a risk factor for AF (com- [25,26] tiveness of preventative strategies aimed at reducing the risk pared to African or Asian ancestry), the risk of AF [27] [38] of AF globally. mainly increases with age, and is higher among those with CVD such as myocardial infarction and CVD risk fac- tors that include hypertension, diabetes mellitus, obesity, 4 Screening [25,28–34] smoking, and alcohol use. Other non-conventional Identifying individuals at risk of developing AF is im- risk factor such as sleep apnoea have also been identified as [35] portant, however, there is stronger evidence that early detec- potential markers of increased AF prevalence. As these tion and treatment of modifiable risk factors can reduce risk factors continue to increase in LMIC, likely will the morbidity and mortality due to AF. Current guidelines ad- burden of morbidity and mortality from AF. This burden vocate that “all patients who present with symptoms of may be further compounded by the shortage of health care AF―breathlessness, palpitations, syncope, chest discomfort resources in many LMIC, as successful management of AF or stroke―should have their pulse checked for irregularities requires consistent and long-term interaction between the [39] as well as 12-lead ECG”. Prolonged ECG monitoring patient and health care system and clear public health poli- may be especially useful in patients with heart failure and cies addressed to controlling modifiable risk factors such as post-stroke, in order to enhance detection and reduce health hypertension, obesity, etc. resource utilization and costs, depending on local resource and expertise. The role of routine screening of individuals at 3 Primary prevention risk for asymptomatic AF, remains debatable and probably untenable as a population intervention. Nonetheless, a re- Primary prevention of AF, i.e., reducing the risk of first cent randomized trial comparing routine practice versus onset by targeting modifiable risk factors (Figure 1), is the targeted population-based screening and opportunistic ultimate goal. However, this approach is challenging due to screening, opportunistic palpation (pulse-taking) of patients significant knowledge gaps related with understanding the aged 65 and over, with or without known AF risk factors multiple mechanisms of AF. Some models such as (with follow-up ECG for those with an irregular pulse) was CHARGE-AF have been developed to predict the risk of found to be the cheapest and most effective method of AF, and identify patients who may benefit from preventa- screening for AF [opportunistic screening was found to de- tive interventions, based on age, race, height, weight, blood tect similar numbers of new cases compared with systematic pressure, smoking, use of antihypertensive medication, dia- [40] screening (1.64% vs. 1.62%, and requires fewer resources)]. betes, and history of myocardial infarction and heart fail- [36] One limitation of opportunistic pulse palpation is the high ure. However, this model has only been validated for [36] number of false positives that can result in unnecessary populations in the United States and Western Europe. ECGs. A recent meta-analysis has suggested that newer There is some evidence of causality between BMI and AF Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com Morillo CA, et al. The current epidemic of AF 199 technologies such as modified blood pressure monitors temic embolism in patients with AF is clearly established (BPMs) and single-lead ECGs may be more accurate in and today several options are available. The main chal- [41] detecting AF, and at-home BPMs have been estimated to lenges are related with the perceived threat of bleeding in reduce strokes and save costs by the UK National Institute contrast to the prevention of a disabling stroke. Populations [42] of Clinical Evaluation. However, these technologies are that derive the greatest benefit from OACs are the elderly not widely available and therefore their use for popula- that are also at higher risk of bleeding; nonetheless multiple tion-wide screening initiatives is limited. databases demonstrate the evidence that OACs and most likely direct oral anticoagulants are the preferred strategy. Anticoagulation for medium- and high-risk non-valvular AF 5 Diagnosis is identified as a recommended policy option by the World Although an irregular pulse may point to AF, an ECG is Health Organization (WHO) in the WHO Global Action [51] still required to confirm the diagnosis. A negative ECG does Plan for the Prevention and Control of NCDs 2013–2020. not exclude the diagnosis of AF by pulse-taking since AF Nevertheless, warfarin remains the most widely available may be paroxysmal. In patients with suspected AF, diagno- anticoagulant and is the only anticoagulant on the World [52] sis should be confirmed using a single-lead rhythm strip or Health Organization’s Essential Medicines list. Aspirin, [43,44] 12-lead ECG documenting ≥ 30 s of AF. A 12-lead which is widely used as an antithrombotic therapy for AF is ECG can detect other abnormalities such as left ventricular neither effective nor safe and has very limited indications [53] hypertrophy, ischemia, and other clinical features. At first and is rarely indicated by most guidelines. The combina- diagnosis, AF can be classified as one of four types: parox- tion of aspirin plus clopidogrel is more effective than aspirin ysmal (self-terminating, usually within 48 h), persistent alone but less effective than warfarin, and has no advantage [54] (lasts longer than 7 days), long-standing persistent (has lasted over warfarin in terms of major bleeding. However, this one year or more) or permanent (when presence of arrhyth- combination may be an alternative particularly in LMIC and mia is accepted and no rhythm control, i.e., stabilizing sinus for patients that live in remote rural areas where proper [55] rhythm, is attempted). Although paroxysmal AF is associ- OAC follow-up may be unrealistic. ated with somewhat lesser risk of stroke and systemic em- The decision to initiate OAC therapy to reduce risk of [45] bolism than non-paroxysmal AF, all types of AF are as- stroke must be weighed against the risk of major bleeding sociated with sufficiently increased risk, especially for complications associated with anticoagulant therapy, the [46] [56] stroke, making detection of even paroxysmal AF critical most treacherous of which is intra-cerebral hemorrhage. and warranting oral anticoagulation therapy in the majority The highest the risk of stroke estimated by most risk scores; of those aged 65 years or more. Further prolonged monitor- the higher the risk of bleeding. From the population per- ing techniques may be indicated but are not cost-effective spective implementation of all these scores is impractical and of limited value from a population based perspec- particularly if detection of subjects at risk in LMIC and rural [47–50] tive. Inexpensive smart phone-based rhythm monitor- areas globally is primarily implemented by non-physicians. ing equipment has potential applications in LMIC, but sys- A simplistic approach called CHADS 65 implemented by tems for deployment and validation require further assess- the Canadian Cardiovascular Society may be more approa- [57] ment. chable from the global perspective. Presence of CVD and other risk factors affects the risk of Monitoring of AF patients by primary health care pro- stroke and prognosis in patients with AF, and should be viders also presents the opportunity to monitor and treat [58,59] systematically assessed. An in-depth discussion of the mul- co-morbid cardiovascular conditions, in particular hy- tiple risk scores for identification of patients at higher risk of pertension, heart failure, diabetes and valvular abnormalities. stroke is out of the scope of this review. It is important to Valvular AF is not the focus of this review, but nonetheless highlight that many of these scores are underutilized by management of AF should include consideration of the primary care physicians and therefore significant propor- management of rheumatic heart disease and valvular heart tions of patients globally remain under diagnosed and un- disease, which are common in LMIC and associated with [60] dertreated with oral anticoagulation therapies and poor con- development of AF in a significant proportion. trol of modifiable risk factors. 7 The “ideal” patient care pathway for AF 6 Management policy recommendations patients The role of OACs for the prevention of stroke and sys- The ideal patient care pathway will vary among geogra- http://www.jgc301.com; jgc@mail.sciencep.com | Journal of Geriatric Cardiology 200 Morillo CA, et al. The current epidemic of AF [76] [77] phies and is primarily based on health resource availability. 62% in Senegal, 30.1%–67.3% in Turkey, 13%–53.9% [78] [79] [80] Key global recommendations for detection, diagnosis and in Serbia, 27% in Kosovo, and 7.1% in Moldova. management of AF, or the “ideal patient pathway” for AF The Gulf SAFE registry revealed similarly low rates of an- patients, are summarized in Figure 2. Stepwise approach ticoagulation use (49% of patients) in six Gulf countries includes: (1) screening of individuals with known AF risk (Bahrain, Kuwait, Oman, Qatar, United Arab Emirates and [80] factors and opportunistic screening of patients 65 years or Yemen). older; (2) 12-lead ECG to confirm suspected AF; (3) as- Most evidence on AF knowledge-practice gaps LMIC sessment of stroke risk; and (4) initiation of anticoagulant focuses on gaps in management of stroke risk among AF therapy, combined with lifestyle modification advice if ap- patients with OACs. However, there is evidence of gaps propriate (e.g., weight reduction, smoking cessation). Fur- across the continuum of care for AF globally, which are ther management strategies are clearly established and are likely to apply in LMIC. For example, research in Canada not the focus of these recommendations. suggested that non-cardiologist physicians lack sufficient knowledge, skills and confidence to diagnose AF, with di- agnosis of paroxysmal or asymptomatic AF being particularly 8 Strategies for global AF care improvement challenging, and that continuous professional education and Several lines of evidence derived from administrative development is necessary to strengthen the capacity of phy- [81] databases and registries clearly indicate both under diagno- sicians to navigate AF screening and diagnosis guidelines. sis and under utilization of appropriate guideline recom- mended therapy of both modifiable risk factors and oral 9 Improving accessibility and availability of anticoagulation. Opportunistic pulse palpation of individuals screening for rural populations [40] over 65 years of age, with confirmatory ECG, despite being documented in only one randomized clinical trial is The World Heart Federation recommends that screening sensible and easily implemented from the population per- for AF is best conducted via opportunistic palpation spective. (pulse-taking) of patients aged 65 and over, with or without The GARFIELD registry, a study of 19 countries in known AF risk factors, with follow up ECG for those with 2009–2011, revealed that 38.0% of patients with high risk an irregular pulse. Following this recommendation may be of stroke had not received anticoagulant therapy, whereas challenging, particularly in remote settings in LMICs, and [61] 42.5% of those at low risk (score 0) did. The PINNACLE the opportunity to utilize non-physician health professionals Study in the United States found that less than half of who are trained to implement novel technologies that allow [62] high-risk patients were receiving OACs therapy. In the for cardiac rhythm assessment by non-specialist health care [82] EURObservational Research Programme-Atrial Fibrillation workers may be feasible. Further studies are needed to (EORP-AF) general registry of nine European countries, implement this strategy. while use of OACs was higher (approximately 81% of high stroke risk patients), persistence of therapy was still not 10 Summary and conclusions optimal (84% of those prescribed with vitamin K antagonist remained on therapy 1 year later), and despite guidelines, AF affects millions of people worldwide and, left un- anti-platelet therapy (commonly aspirin) was used in 15% treated, increases the risk and severity of stroke, heart fail- [63] of low risk patients, and in 31% of high-risk patients. ure and death. The global aging of the population will de- Treatment and management gaps exist worldwide and termine an endemic that will result in significant burden on older populations are the ones at highest risk but remain health care systems and physicians taking care of these pop- largely untreated due to the perceived risk of bleeding; these ulations. There exist significant gaps globally that put gaps vary in degree across countries, but are more promi- LMICs at higher risk of negative outcomes that merit a [64] nent in LMIC. Data from LMIC are limited and suggest global approach that promotes conscious identification and very low rates of oral anticoagulation therapy among AF management of modifiable risk factors as well as proper risk [38,59] patients. A few studies reported that estimated rates stratification and treatment. Further education of both of anticoagulant use range from only 2.7%–50% in non-specialists and non physician workers may improve [59,65–67] [68] [69] China, 26%–44% in Pakistan, 16% in Malaysia, screening, detection and appropriate management of AF that [70] [71] 46.7%–57.8% in Brazil, 36.8% in Mexico, 72.7% in may in turn improve global outcomes. The World Heart [72] [73] Argentina, 33% in South Africa, 34.2% in Camer- Federation is committed to promote this approach in an at- [74] [75] oon, from 11.5% (rural) to 26.5% (urban) in Zimbabwe, tempt to halt the progression of the inevitable endemic. Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com Morillo CA, et al. The current epidemic of AF 201 16 Bruggenjurgen B, Rossnagel K, Roll S, et al. The impact of References atrial fibrillation on the cost of stroke: the berlin acute stroke 1 Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in study. Value Health 2007; 10: 137–143. incidence of atrial fibrillation in Olmsted County, Minnesota, 17 Thrall G, Lane D, Carroll D, Lip GY. Quality of life in pa- 1980 to 2000, and implications on the projections for future tients with atrial fibrillation: a systematic review. Am J Med prevalence. Circulation 2006; 114: 119–125. 2006; 119: 448 e1–19. 2 Krijthe BP, Kunst A, Benjamin EJ, et al. Projections on the 18 Camm AJ, Kirchhof P, Lip GY, et al. Guidelines for the number of individuals with atrial fibrillation in the European management of atrial fibrillation: the task force for the man- Union, from 2000 to 2060. Eur Heart J 2013; 34: 2746–2751. agement of atrial fibrillation of the European Society of Car- 3 Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide diology (ESC). Eur Heart J 2010; 31: 2369–429. epidemiology of atrial fibrillation: a Global Burden of Disease 19 Freedman B, Potpara TS, Lip GY. Stroke prevention in atrial 2010 Study. Circulation 2014; 129: 837–847. fibrillation. Lancet 2016; 388: 806–817. 4 Kim MH, Johnston SS, Chu BC, et al. Estimation of total 20 Chugh SS, Roth GA, Gillum RF, Mensah GA. Global burden incremental health care costs in patients with atrial fibrillation of atrial fibrillation in developed and developing nations. Glob in the United States. Circ Cardiovasc Qual Outcomes 2011; 4: Heart 2014; 9: 113–119. 313–320. 21 Flaker GC, Belew K, Beckman K, et al. Asymptomatic atrial 5 Andersson T, Magnuson A, Bryngelsson IL, et al. All-cause fibrillation: demographic features and prognostic information mortality in 272,186 patients hospitalized with incident atrial from the Atrial Fibrillation Follow-up Investigation of Rhy- fibrillation 1995–2008: a Swedish nationwide long-term case- thm Management (AFFIRM) study. Am Heart J 2005; 149: control study. Eur Heart J 2013; 34: 1061–1067. 657–663. 6 Wattigney WA, Mensah GA, Croft JB. Increased atrial fibril- 22 Healey JS. ASSERT-II Sub-Clinical AF (SCAF) in older lation mortality: United States, 1980–1998. Am J Epidemiol asymptomatic patients. Presented at AHA Late Breaking 2002; 155: 819–826. Clinical Trials Session, New Orleans, LO, USA, November 7 Go AS, Hylek EM, Phillips KA, et al. Prevalence of diag- nosed atrial fibrillation in adults: national implications for 23 Healey JS, Oldgren J, Ezekowitz M, et al. Occurrence of rhythm management and stroke prevention: the AnTicoagula- death and stroke in patients in 47 countries 1 year after pre- tion and Risk Factors in Atrial Fibrillation (ATRIA) Study. senting with atrial fibrillation: a cohort study. Lancet 2016; JAMA 2001; 285: 2370–2375. 388: 1161–1169. 8 Stefansdottir H, Aspelund T, Gudnason V, Arnar DO. Trends 24 Oldgren J, Healey JS, Ezekowitz M, et al. Variations in cause in the incidence and prevalence of atrial fibrillation in Iceland and management of atrial fibrillation in a prospective registry and future projections. Europace 2011; 13: 1110–1117. of 15,400 emergency department patients in 46 countries: the 9 Frost L, Vestergaard P, Mosekilde L, Mortensen LS. Trends RE-LY Atrial Fibrillation Registry. Circulation 2014; 129: in incidence and mortality in the hospital diagnosis of atrial 1568–1576. fibrillation or flutter in Denmark, 1980–1999. Int J Cardiol 25 Marcus GM, Alonso A, Peralta CA, et al. European ancestry 2005; 103: 78–84. as a risk factor for atrial fibrillation in African Americans. 10 Piccini JP, Hammill BG, Sinner MF, et al. Incidence and Circulation 2010; 122: 2009–2015. prevalence of atrial fibrillation and associated mortality among 26 Lau CP, Gbadebo TD, Connolly SJ, et al. Ethnic differences Medicare beneficiaries, 1993–2007. Circ Cardiovasc Qual in atrial fibrillation identified using implanted cardiac devices. Outcomes 2012; 5: 85–93. J Cardiovasc Electrophysiol 2013; 24: 381–387. 11 Colilla S, Crow A, Petkun W, et al. Estimates of current and 27 Benjamin EJ, Levy D, Vaziri SM, et al. Independent risk factors for atrial fibrillation in a population-based cohort. The future incidence and prevalence of atrial fibrillation in the U.S. Framingham Heart Study. JAMA 1994; 271: 840-844. adult population. Am J Cardiol 2013; 112: 1142–1174. 28 Heeringa J, Kors JA, Hofman A, et al. Cigarette smoking and 12 Murphy A, Banerjee A, Breidthart G, et al. World Heart Fed- risk of atrial fibrillation: the Rotterdam Study. Am Heart J eration Global Atrial Fibrillation Roadmap, 2017; Http://www. 2008; 156: 1163–1169. world-heart-federation.org/what-we-do/whf-roadmaps/atrial-fi 29 Conen D, Tedrow UB, Cook NR, et al. Alcohol consumption brillation-roadmap/ (accessed on Jan 10, 2017). and risk of incident atrial fibrillation in women. JAMA 2008; 13 The Global Burden of Disease Study 2013. Http://www. 300: 2489–2496. healthdata.org/gbd (accessed on Jan 7, 2017). 30 Frost L, Vestergaard P. Alcohol and risk of atrial fibrillation 14 Stewart S, Murphy NF, Walker A, et al. Cost of an emerging or flutter: a cohort study. Arch Intern Med 2004; 164: epidemic: an economic analysis of atrial fibrillation in the UK. 1993–1998. Heart 2004; 90: 286–292. 31 Kodama S, Saito K, Tanaka S, et al. Alcohol consumption and 15 Blomstrom Lundqvist C, Lip GY, Kirchhof P. What are the risk of atrial fibrillation: a meta-analysis. J Am Coll Cardiol costs of atrial fibrillation? Europace 2011; 13 (Suppl 2): 2011; 57: 427–436. S9–S12 http://www.jgc301.com; jgc@mail.sciencep.com | Journal of Geriatric Cardiology 202 Morillo CA, et al. The current epidemic of AF 32 Frost L, Hune LJ, Vestergaard P. Overweight and obesity as rillation Project. Int J Cardiol 2013; 167: 2682–2687. risk factors for atrial fibrillation or flutter: the Danish Diet, 47 Jabaudon D, Sztajzel J, Sievert K, et al. Usefulness of ambu- Cancer, and Health Study. Am J Med 2005; 118: 489–495. latory 7-day ECG monitoring for the detection of atrial fibril- 33 Gami AS, Hodge DO, Herges RM, et al. Obstructive sleep lation and flutter after acute stroke and transient ischemic at- apnea, obesity, and the risk of incident atrial fibrillation. J Am tack. Stroke 2004; 35: 1647–1651. Coll Cardiol 2007; 49: 565–571. 48 Binici Z, Intzilakis T, Nielsen OW, et al. Excessive supraven- 34 Wang TJ, Parise H, Levy D, et al. Obesity and the risk of tricular ectopic activity and increased risk of atrial fibrillation new-onset atrial fibrillation. JAMA 2004; 292: 2471–2477. and stroke. Circulation 2010; 121: 1904–1911. 35 Otero L, Hidalgo P, González R, Morillo CA. Association of 49 Haeusler KG, Kirchhof P, Heuschmann PU, et al. Impact of cardiovascular disease and sleep apnea at different altitudes. standardized monitoring for detection of atrial fibrillation in High Alt Med Biol 2016; 17: 336–341. ischemic stroke (MonDAFIS): rationale and design of a pro- 36 Alonso A, Krijthe BP, Aspelund T, et al. Simple risk model spective randomized multicenter study. Am Heart J 2016; 172: predicts incidence of atrial fibrillation in a racially and geo- 19–25. graphically diverse population: the CHARGE-AF consortium. 50 World Health Organization. Global action plan for the pre- J Am Heart Assoc 2013; 2: e000102. vention and control of noncommunicable diseases. Geneva: 37 Pathak RK, Elliott A, Middeldorp ME, et al. Impact of cardio- WHO, 2013. respiratory fitness on arrhythmia recurrence in obese indi- 51 World Health Organization. The WHO Essential Medicines viduals with atrial fibrillation: The CARDIO-FIT Study. J Am List. Http://www.who.int/medicines/publications/essentialmedi- Coll Cardiol 2015; 66: 985–996. cines/en/ (accessed on February 15, 2016). 38 Rahman F, Kwan GF, Benjamin EJ. Global epidemiology of 52 Ben Freedman S, Gersh BJ, Lip GY. Misperceptions of aspi- atrial fibrillation. Nat Rev Cardiol 2014; 11: 639–654. rin efficacy and safety may perpetuate anticoagulant underuti- 39 Davis M, Rodgers S, Rudolf M, et al. Guideline Development lization in atrial fibrillation. Eur Heart J 2015; 36: 653–656. Group for the Nice clinical guideline for the management of 53 Investigators A, Connolly SJ, Pogue J, et al. Effect of clopi- atrial fibrillation. Patient care pathway, implementation and dogrel added to aspirin in patients with atrial fibrillation. N audit criteria for patients with atrial fibrillation. Heart 2007; Engl J Med 2009; 360: 2066–2078. 93: 48–52. 54 Connolly SJ, Eikelboom JW, Ng J, et al. Net clinical benefit 40 Fitzmaurice DA, Hobbs FD, Jowett S, et al. Screening versus of adding clopidogrel to aspirin therapy in patients with atrial routine practice in detection of atrial fibrillation in patients fibrillation for whom vitamin K antagonists are unsuitable. aged 65 or over: cluster randomized controlled trial. BMJ Ann Intern Med 2011; 155: 579–586. 2007; 335: 383. 55 Pisters R, Lane DA, Nieuwlaat R, et al. A novel user-friendly 41 Taggar JS, Coleman T, Lewis S, et al. Accuracy of methods score (HAS-BLED) to assess 1-year risk of major bleeding in for detecting an irregular pulse and suspected atrial fibrillation: patients with atrial fibrillation: the Euro Heart Survey. Chest A systematic review and meta-analysis. Eur J Prev Cardiol 2010; 138: 1093–1100. 2016; 23: 1330–1338. 56 Macle L, Cairns J, Leblanc K, et al. 2016 Focused update of 42 Willits I, Keltie K, Craig J, Sims A. WatchBP Home A for the Canadian Cardiovascular Society guidelines for the manage- opportunistically detecting atrial fibrillation during diagnosis ment of atrial fibrillation. Can J Cardiol 2016; 32: 1170–1185. and monitoring of hypertension: a NICE Medical Technology 57 Adler AJ, Prabhakaran D, Bovet P, et al. Reducing cardio- Guidance. Appl Health Econ Health Policy 2014; 12: 255–265. vascular mortality through prevention and management of 43 Camm AJ, Lip GY, De Caterina R, et al. 2012 focused update raised blood pressure: a world heart federation roadmap. of the ESC Guidelines for the management of atrial fibrilla- Global Heart 2015; 10: 111–122. tion: an update of the 2010 ESC Guidelines for the manage- 58 Perel P, Avezum A, Huffman M, et al. Reducing premature ment of atrial fibrillation. Developed with the special contri- cardiovascular morbidity and mortality in people with athero- bution of the European Heart Rhythm Association. Eur Heart sclerotic vascular disease: The World Heart Federation road- J 2012; 33: 2719–2747. map for secondary prevention of cardiovascular disease. 44 Akeroyd JM, Chan WJ, Kamal AK, et al. Adherence to car- Global Heart 2015; 10: 99–110. diovascular medications in the South Asian population: A 59 Nguyen TN, Hilmer SN, Cumming RG. Review of epidemi- systematic review of current evidence and future directions. ology and management of atrial fibrillation in developing World J Cardiol 2015; 7: 938–947. countries. Int J Cardiol 2013; 167: 2412–2420. 45 Ganesan AN, Chew DP, Hartshorne T, et al. The impact of 60 Wen-Hang QI, Society of Cardiology CMA. Retrospective atrial fibrillation type on the risk of thromboembolism, mor- investigation of hospitalized patients with atrial fibrillation in tality, and bleeding: a systematic review and meta-analysis. mainland China. Int J Cardiol 2005; 105: 283–287. Eur Heart J 2016; 37: 1591–1602 61 Kakkar AK, Mueller I, Bassand JP, et al. Risk profiles and 46 Banerjee A, Taillandier S, Olesen JB, et al. Pattern of atrial antithrombotic treatment of patients newly diagnosed with fibrillation and risk of outcomes: the Loire Valley Atrial Fib- atrial fibrillation at risk of stroke: perspectives from the inter- Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com Morillo CA, et al. The current epidemic of AF 203 national, observational, prospective GARFIELD registry. 73 Ntep-Gweth M, Zimmermann M, Meiltz A, et al. Atrial fib- PloS one 2013; 8: e63479. rillation in Africa: clinical characteristics, prognosis, and ad- 62 Hsu J, Maddox T, Kennedy K, et al. Oral anticoagulant ther- herence to guidelines in Cameroon. Europace 2010; 12: apy prescription in patients with atrial fibrillation across the 482–487. spectrum of stroke risk: insights from the NCDR PINNACLE 74 Bhagat K, Tisocki K. Prescribing patterns for the use of anti- registry. JAMA 2016; 1: 55–62. thrombotics in the management of atrial fibrillation in Zim- 63 Lip GY, Laroche C, Ioachim PM, et al. Prognosis and treat- babwe. Cent Afr J Med 1999; 45: 287–290. ment of atrial fibrillation patients by European cardiologists: 75 Mbaye A, Pessinaba S, Bodian M, Mouhamadou BN, Mbaye one year follow-up of the eurobservational research programme- F, Kane A, et al. [Atrial fibrillation, frequency, etiologic fac- atrial fibrillation general registry pilot phase (EORP-AF pilot tors, evolution and treatment in a cardiology department in registry). Eur Heart J 2014; 35: 3365–3376. Dakar, Senegal]. Pan Afr Med J 2010; 6: 16. [Article in 64 Lang K, Bozkaya D, Patel AA, et al. Anticoagulant use for the French]. prevention of stroke in patients with atrial fibrillation: findings 76 Karacaglar E, Atar I, Yetis B, Corut H, Ersoy B, Yilmaz K, et from a multi-payer analysis. BMC Health Serv Res 2014; 14: al. [The frequency of embolic risk factors and adequacy of an- 329. ti-embolic treatment in patients with atrial fibrillation: a single 65 Zhou Z, Hu D. An epidemiological study on the prevalence of tertiary center experience]. Anadolu Kardiyol Derg 2012; 12: atrial fibrillation in the Chinese population of mainland China. 384–390. [Article in Turkish]. J Epidemiol 2008; 18: 209–216. 77 Potpara TS, Stankovic GR, Beleslin BD, et al. A 12-year 66 QI WH; Society of Cardiology, Chinese Medical Association. follow-up study of patients with newly diagnosed lone atrial fi Retrospective investigation of hospitalized patients with atrial brillation: implications of arrhythmia progression on progno- fibrillation in mainland China. Int J Cardiol 2005; 105: 283–287. sis: the Belgrade atrial fibrillation study. Chest 2012; 141: 67 Rasool S, Haq Z. Anticoagulation therapy in high risk patients 339–347. with atrial fi brillation: retrospective study in a regional hos- 78 Elezi S, Qerkini G, Bujupi L, et al. Management and comor- pital. J Liaquat Uni Med Health Sci 2009; 8: 136–138. bidities of atrial fibrillation in patients admitted in cardiology 68 Freestone B, Rajaratnam R, Hussain N, Lip GY. Admissions service in Kosovo: a single-center study. Anadolu Kardiyol with atrial fibrillation in a multiracial population in Kuala Derg 2010; 10: 36–40. Lumpur, Malaysia. Int J Cardiol 2003; 91: 233–238. 79 Diaconu N, Grosu A, Gratii C, Pavlic G. Stroke prevention in 69 Fornari LS, Calderaro D, Nassar IB, et al. Misuse of anti- atrial fibrillation—a major problem in the Republic of Mol- thrombotic therapy in atrial fi brillation patients: frequent, per- dova. Eur J Neurol 2011; 18. vasive and persistent. J Thromb Thrombolysis 2007; 23: 65–71. 80 Apostolakis S, Zubaid M, Rashed WA, et al. Assessment of 70 Cortes-Ramirez J, Cortes-De La Torre J, Cortes-De La Torre stroke risk in Middle Eastern patients with atrial fibrillation: R, et al. Atrial fibrillation in a general hospital. Rev Mex Car- the Gulf SAFE registry. Int J Cardiol 2013; 168: 1644–1646. diol 2011; 22: 145–8. 81 Murray S, Lazure P, Pullen C, et al. Atrial fibrillation care: 71 Fitz Maurice M, Di Tommaso F, Zgaig M, et al. Thrombo- challenges in clinical practice and educational needs assess- prophylaxis of atrial fibrillation. Analysis of the argetinean ment. Can J Cardiol 2011; 27: 98–104. national register of atrial fibrillation and atrial flutter (RE- 82 Gaziano TA, Abrahams-Gessel S, Denman CA, et al. An NAFA). 2011; 22: S102. assessment of community health workers’ ability to screen for 72 Sliwa K, Carrington MJ, Klug E, et al. Predisposing factors cardiovascular disease risk with a simple, non-invasive risk and incidence of newly diagnosed atrial fibrillation in an ur- assessment instrument in Bangladesh, Guatemala, Mexico, ban African community: insights from the Heart of Soweto and South Africa: an observational study. Lancet Glob Health Study. Heart 2010; 96: 1878–1882. 2015; 3: e556–e563. This article is part of a Special Issue “Atrial fibrillation in the elderly”. Guest Editors: Manuel Martínez-Sellés & Antoni Bayés de Luna http://www.jgc301.com; jgc@mail.sciencep.com | Journal of Geriatric Cardiology http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Geriatric Cardiology : JGC Pubmed Central

Atrial fibrillation: the current epidemic

Journal of Geriatric Cardiology : JGC , Volume 14 (3) – Mar 1, 2017

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Pubmed Central
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Institute of Geriatric Cardiology
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1671-5411
DOI
10.11909/j.issn.1671-5411.2017.03.011
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Abstract

Atrial fibrillation (AF) is the most common arrhythmia diagnosed in clinical practice. The consequences of AF have been clearly estab- lished in multiple large observational cohort studies and include increased stroke and systemic embolism rates if no oral anticoagulation is prescribed, with increased morbidity and mortality. With the worldwide aging of the population characterized by a large influx of “baby boomers” with or without risk factors for developing AF, an epidemic is forecasted within the next 10 to 20 years. Although not all studies support this evidence, it is clear that AF is on the rise and a significant amount of health resources are invested in detecting and managing AF. This review focuses on the worldwide burden of AF and reviews global health strategies focused on improving detection, prevention and risk stratification of AF, recently recommended by the World Heart Federation. J Geriatr Cardiol 2017; 14: 195203. doi:10.11909/j.issn.1671-5411.2017.03.011 Keywords: Aging; Anticoagulation; Atrial fibrillation; Heart failure; Hypertension; Stroke nary management of AF envisioned by the World Heart 1 Introduction [1,2,7–12] Federation. As the population ages globally, atrial fibrillation (AF) is predicted to affect 6–12 million people in the USA by 2050 [1–3] 2 AF global burden and 17.9 million in Europe by 2060. AF utilizes signifi- [4] cant health resources globally, and constitutes a public AF is the most frequently encountered arrhythmia in [5] [3] health challenge with high comorbidity, and increased clinically practice. Between 1990 and 2013, although the [6] mortality risk. The reasons for the increase in the preva- global prevalence rate of AF decreased slightly, the overall [7,8] [13] lence of AF remain elusive and are related to multiple number of AF cases increased (Table 1). AF is associated factors including; enhanced detection, increased incidence, with an increase in morbidity, as measured by disability- [9–11] and greater survival after onset of AF. The purpose of adjusted life years (DALYs). Estimates of prevalence of AF, this review is to assess the evidence related with the in- and DALYs associated with AF, are likely to underestimate creased overall prevalence of AF and to propose a global true burden due to the high prevalence of asymptomatic [3] strategy focused on enhanced detection and multidiscipli- AF. AF also leads to increased health care resource utili- zation and may have a significant impact on global health [14–17] Correspondence to: Carlos A Morillo, MD, Department of Cardiac budgets. Several long-term cohorts have clearly estab- Sciences, Division of Cardiology, Libin Cardiovascular Institute, University lished that several clinical outcomes are increased in pa- [18] of Calgary, Population Health Research Institute, McMaster University, tients with AF. Among other clinical outcomes, AF is th Foothills Medical Centre, Room C823, 1403 29 Street NW, Calgary, AB associated with increased risk of stroke and is found in one T2N 2T9, Canada. [19] third of all ischemic strokes. E-mails: carlos.morillo@ucalgary.ca, morillc@mcmaster.ca AF burden has regional variations, with high-income Telephone: +1-403-944-2670 Fax: +1-403-944-2906 countries experiencing a higher prevalence, incidence, Received: January 25, 2017 Revised: February 8, 2017 DALYs and mortality associated with AF than low-middle Accepted: March 8, 2017 Published online: March 28, 2017 http://www.jgc301.com; jgc@jgc301.com | Journal of Geriatric Cardiology 196 Morillo CA, et al. The current epidemic of AF [3] income countries (LMIC). However, estimates of the ex- the lower rates of AF documented in developing countries tent of this difference should be interpreted with caution, as may be related to under reporting, limited access to health [3,20] care services and geographical disparity in published data. Table 1. Global burden of AF in 1990 and 2013, data from [13] Estimating the global burden of AF is challenging and Global Burden of Disease Study 2013. few studies have systematically reviewed population-based Global Rate per 100,000 Cases (All ages) [3] AF studies (Figure 1). Chugh, et al., reviewed all popula- Prevalence (Age-standardized) Year Mean 95% UI Mean 95% UI tion based AF studies between 1980 to 2010, from 21 global 1990 6841147 (6602764, 7114686) 213.7 (205.9, 222.6) burden of disease regions. These investigators estimated 2013 11178627 (10655102, 11683727) 191.3 (182.1, 200.1) global/regional prevalence, incidence, and morbidity and Global Rate per 100,000 mortality related to AF. The estimated number of individu- Cases (All ages) DALYs (Age-standardized) als with AF globally in 2010, was 33.5 million (20.9 million Year Mean 95% UI Mean 95% UI men and 12.6 million women) with significant regional 1990 854714 (693332, 1049075) 26.7 (21.7, 32.7) variations and heterogeneity (Table 1). Mortality associated 2013 1888690 (1590032, 2224863) 32.5 (27.5, 38.2) with AF was increased by 2-fold in both genders from 1990 Cases rounded to the nearest whole number. DALYs: disability-adjusted [3] life years; UI: uncertainty interval. to 2010 (Figures 2–4). [3] Figure 1. Global age-adjusted prevalence rates of AF (per 100,000 persons). Reproduced with permission from Chugh, et al. AF: atrial fibrillation. [3] Figure 2. Mortality associated with AF: 1990–2010 (per 100,000 persons). Reproduced with permission from Chugh, et al. AF: atrial fibrillation; UI: uncertainty interval. Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com Morillo CA, et al. The current epidemic of AF 197 Figure 3. Mortality associated with AF by gender and region (developed vs. developing). Reproduced with permission from Chugh, et [3] al. AF: atrial fibrillation. [3] Figure 4. Global mortality associated with AF in 2010. Colors represent percentages. Reproduced with permission from Chugh, et al. AF: atrial fibrillation. Furthermore, in all countries regardless of development, The occurrence of death and stroke in patients presenting [21] a substantial proportion of AF cases are subclinical, lim- to a hospital emergency department vary widely across iting the ability to appropriately identify and detect AF geographical regions. The RELY-AF Registry recently re- without advanced medical technology. Recent data from ported the 1-year mortality and stroke rates in patients from [23] the ASSERT II trial suggests that the prevalence of sub- 47 countries. Marked and unexplained differences in clinical AF > 5 min in subjects over 65 years with either a mortality and stroke rates were observed. Over 15,000 indi- CHA DS VASc ≥ 2, sleep apnoea or body mass index viduals were enrolled and 1758 (11%) died within 1 year. 2 2 (BMI) > 30 kg/m with no evidence of clinical AF is around Fewer deaths occurred among patients presenting to the 30%, indicating that subclinical AF may be detected in al- emergency department with primary AF compared with most 1/3 of the population that otherwise has a low-inter- those with secondary AF, 6% vs. 16% (P < 0.0001). Twice mediate risk of developing symptomatic AF and subsequent as many patients had died by 1 year in South America (17%) [22] AF associated comorbidities. and Africa (20%) compared with North America, Western http://www.jgc301.com; jgc@mail.sciencep.com | Journal of Geriatric Cardiology 198 Morillo CA, et al. The current epidemic of AF Europe, and Australia (10%, P < 0.0001). Heart failure was the most common cause of death (30%); stroke caused deaths (8%), and 4% patients had had a stroke by 1 year; 3% of those with primary AF and 5% with secondary AF (P < 0.0001). The highest number of strokes occurred in pa- Figure 5. AF stages and proposed interventions. Modified tients in Africa (8%), China (7%), and Southeast Asia (7%) from the WHF AF roadmap. AF: atrial fibrillation. WHF: world and the lowest occurred in India (< 1%). Only 3% of the hemophilia federation. patients in North America, Western Europe, and Australia and some intervention studies seem to indicate that out- had a stroke. comes after AF ablation may be better when modifiable risk Patients with AF in LMIC tend to be a decade younger, [37] factors are aggressively approached. Although the bene- are more likely to experience heart failure, and are less fits of interventions to manage risk factors such as weight, likely to be managed according to recommended AF guide- blood pressure, smoking and diabetes for health outcomes lines (i.e., patients with AF in LMIC have significantly generally are well-established and relevant to populations lower use of oral anticoagulants (OACs), and lower time in globally, primary prevention trials for AF have yet to estab- therapeutic range which may be related with limited access [24] lish a role for interventions for specific risk factors (Figure 5). to health care systems. Differences in AF burden among There is an urgent need for research that can inform primary LMIC and high-income countries should also be interpreted prevention efforts for AF in more geographically and ra- in light of the risk factor profile of this condition. European cially diverse populations, while also evaluating the effec- ancestry has been identified as a risk factor for AF (com- [25,26] tiveness of preventative strategies aimed at reducing the risk pared to African or Asian ancestry), the risk of AF [27] [38] of AF globally. mainly increases with age, and is higher among those with CVD such as myocardial infarction and CVD risk fac- tors that include hypertension, diabetes mellitus, obesity, 4 Screening [25,28–34] smoking, and alcohol use. Other non-conventional Identifying individuals at risk of developing AF is im- risk factor such as sleep apnoea have also been identified as [35] portant, however, there is stronger evidence that early detec- potential markers of increased AF prevalence. As these tion and treatment of modifiable risk factors can reduce risk factors continue to increase in LMIC, likely will the morbidity and mortality due to AF. Current guidelines ad- burden of morbidity and mortality from AF. This burden vocate that “all patients who present with symptoms of may be further compounded by the shortage of health care AF―breathlessness, palpitations, syncope, chest discomfort resources in many LMIC, as successful management of AF or stroke―should have their pulse checked for irregularities requires consistent and long-term interaction between the [39] as well as 12-lead ECG”. Prolonged ECG monitoring patient and health care system and clear public health poli- may be especially useful in patients with heart failure and cies addressed to controlling modifiable risk factors such as post-stroke, in order to enhance detection and reduce health hypertension, obesity, etc. resource utilization and costs, depending on local resource and expertise. The role of routine screening of individuals at 3 Primary prevention risk for asymptomatic AF, remains debatable and probably untenable as a population intervention. Nonetheless, a re- Primary prevention of AF, i.e., reducing the risk of first cent randomized trial comparing routine practice versus onset by targeting modifiable risk factors (Figure 1), is the targeted population-based screening and opportunistic ultimate goal. However, this approach is challenging due to screening, opportunistic palpation (pulse-taking) of patients significant knowledge gaps related with understanding the aged 65 and over, with or without known AF risk factors multiple mechanisms of AF. Some models such as (with follow-up ECG for those with an irregular pulse) was CHARGE-AF have been developed to predict the risk of found to be the cheapest and most effective method of AF, and identify patients who may benefit from preventa- screening for AF [opportunistic screening was found to de- tive interventions, based on age, race, height, weight, blood tect similar numbers of new cases compared with systematic pressure, smoking, use of antihypertensive medication, dia- [40] screening (1.64% vs. 1.62%, and requires fewer resources)]. betes, and history of myocardial infarction and heart fail- [36] One limitation of opportunistic pulse palpation is the high ure. However, this model has only been validated for [36] number of false positives that can result in unnecessary populations in the United States and Western Europe. ECGs. A recent meta-analysis has suggested that newer There is some evidence of causality between BMI and AF Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com Morillo CA, et al. The current epidemic of AF 199 technologies such as modified blood pressure monitors temic embolism in patients with AF is clearly established (BPMs) and single-lead ECGs may be more accurate in and today several options are available. The main chal- [41] detecting AF, and at-home BPMs have been estimated to lenges are related with the perceived threat of bleeding in reduce strokes and save costs by the UK National Institute contrast to the prevention of a disabling stroke. Populations [42] of Clinical Evaluation. However, these technologies are that derive the greatest benefit from OACs are the elderly not widely available and therefore their use for popula- that are also at higher risk of bleeding; nonetheless multiple tion-wide screening initiatives is limited. databases demonstrate the evidence that OACs and most likely direct oral anticoagulants are the preferred strategy. Anticoagulation for medium- and high-risk non-valvular AF 5 Diagnosis is identified as a recommended policy option by the World Although an irregular pulse may point to AF, an ECG is Health Organization (WHO) in the WHO Global Action [51] still required to confirm the diagnosis. A negative ECG does Plan for the Prevention and Control of NCDs 2013–2020. not exclude the diagnosis of AF by pulse-taking since AF Nevertheless, warfarin remains the most widely available may be paroxysmal. In patients with suspected AF, diagno- anticoagulant and is the only anticoagulant on the World [52] sis should be confirmed using a single-lead rhythm strip or Health Organization’s Essential Medicines list. Aspirin, [43,44] 12-lead ECG documenting ≥ 30 s of AF. A 12-lead which is widely used as an antithrombotic therapy for AF is ECG can detect other abnormalities such as left ventricular neither effective nor safe and has very limited indications [53] hypertrophy, ischemia, and other clinical features. At first and is rarely indicated by most guidelines. The combina- diagnosis, AF can be classified as one of four types: parox- tion of aspirin plus clopidogrel is more effective than aspirin ysmal (self-terminating, usually within 48 h), persistent alone but less effective than warfarin, and has no advantage [54] (lasts longer than 7 days), long-standing persistent (has lasted over warfarin in terms of major bleeding. However, this one year or more) or permanent (when presence of arrhyth- combination may be an alternative particularly in LMIC and mia is accepted and no rhythm control, i.e., stabilizing sinus for patients that live in remote rural areas where proper [55] rhythm, is attempted). Although paroxysmal AF is associ- OAC follow-up may be unrealistic. ated with somewhat lesser risk of stroke and systemic em- The decision to initiate OAC therapy to reduce risk of [45] bolism than non-paroxysmal AF, all types of AF are as- stroke must be weighed against the risk of major bleeding sociated with sufficiently increased risk, especially for complications associated with anticoagulant therapy, the [46] [56] stroke, making detection of even paroxysmal AF critical most treacherous of which is intra-cerebral hemorrhage. and warranting oral anticoagulation therapy in the majority The highest the risk of stroke estimated by most risk scores; of those aged 65 years or more. Further prolonged monitor- the higher the risk of bleeding. From the population per- ing techniques may be indicated but are not cost-effective spective implementation of all these scores is impractical and of limited value from a population based perspec- particularly if detection of subjects at risk in LMIC and rural [47–50] tive. Inexpensive smart phone-based rhythm monitor- areas globally is primarily implemented by non-physicians. ing equipment has potential applications in LMIC, but sys- A simplistic approach called CHADS 65 implemented by tems for deployment and validation require further assess- the Canadian Cardiovascular Society may be more approa- [57] ment. chable from the global perspective. Presence of CVD and other risk factors affects the risk of Monitoring of AF patients by primary health care pro- stroke and prognosis in patients with AF, and should be viders also presents the opportunity to monitor and treat [58,59] systematically assessed. An in-depth discussion of the mul- co-morbid cardiovascular conditions, in particular hy- tiple risk scores for identification of patients at higher risk of pertension, heart failure, diabetes and valvular abnormalities. stroke is out of the scope of this review. It is important to Valvular AF is not the focus of this review, but nonetheless highlight that many of these scores are underutilized by management of AF should include consideration of the primary care physicians and therefore significant propor- management of rheumatic heart disease and valvular heart tions of patients globally remain under diagnosed and un- disease, which are common in LMIC and associated with [60] dertreated with oral anticoagulation therapies and poor con- development of AF in a significant proportion. trol of modifiable risk factors. 7 The “ideal” patient care pathway for AF 6 Management policy recommendations patients The role of OACs for the prevention of stroke and sys- The ideal patient care pathway will vary among geogra- http://www.jgc301.com; jgc@mail.sciencep.com | Journal of Geriatric Cardiology 200 Morillo CA, et al. The current epidemic of AF [76] [77] phies and is primarily based on health resource availability. 62% in Senegal, 30.1%–67.3% in Turkey, 13%–53.9% [78] [79] [80] Key global recommendations for detection, diagnosis and in Serbia, 27% in Kosovo, and 7.1% in Moldova. management of AF, or the “ideal patient pathway” for AF The Gulf SAFE registry revealed similarly low rates of an- patients, are summarized in Figure 2. Stepwise approach ticoagulation use (49% of patients) in six Gulf countries includes: (1) screening of individuals with known AF risk (Bahrain, Kuwait, Oman, Qatar, United Arab Emirates and [80] factors and opportunistic screening of patients 65 years or Yemen). older; (2) 12-lead ECG to confirm suspected AF; (3) as- Most evidence on AF knowledge-practice gaps LMIC sessment of stroke risk; and (4) initiation of anticoagulant focuses on gaps in management of stroke risk among AF therapy, combined with lifestyle modification advice if ap- patients with OACs. However, there is evidence of gaps propriate (e.g., weight reduction, smoking cessation). Fur- across the continuum of care for AF globally, which are ther management strategies are clearly established and are likely to apply in LMIC. For example, research in Canada not the focus of these recommendations. suggested that non-cardiologist physicians lack sufficient knowledge, skills and confidence to diagnose AF, with di- agnosis of paroxysmal or asymptomatic AF being particularly 8 Strategies for global AF care improvement challenging, and that continuous professional education and Several lines of evidence derived from administrative development is necessary to strengthen the capacity of phy- [81] databases and registries clearly indicate both under diagno- sicians to navigate AF screening and diagnosis guidelines. sis and under utilization of appropriate guideline recom- mended therapy of both modifiable risk factors and oral 9 Improving accessibility and availability of anticoagulation. Opportunistic pulse palpation of individuals screening for rural populations [40] over 65 years of age, with confirmatory ECG, despite being documented in only one randomized clinical trial is The World Heart Federation recommends that screening sensible and easily implemented from the population per- for AF is best conducted via opportunistic palpation spective. (pulse-taking) of patients aged 65 and over, with or without The GARFIELD registry, a study of 19 countries in known AF risk factors, with follow up ECG for those with 2009–2011, revealed that 38.0% of patients with high risk an irregular pulse. Following this recommendation may be of stroke had not received anticoagulant therapy, whereas challenging, particularly in remote settings in LMICs, and [61] 42.5% of those at low risk (score 0) did. The PINNACLE the opportunity to utilize non-physician health professionals Study in the United States found that less than half of who are trained to implement novel technologies that allow [62] high-risk patients were receiving OACs therapy. In the for cardiac rhythm assessment by non-specialist health care [82] EURObservational Research Programme-Atrial Fibrillation workers may be feasible. Further studies are needed to (EORP-AF) general registry of nine European countries, implement this strategy. while use of OACs was higher (approximately 81% of high stroke risk patients), persistence of therapy was still not 10 Summary and conclusions optimal (84% of those prescribed with vitamin K antagonist remained on therapy 1 year later), and despite guidelines, AF affects millions of people worldwide and, left un- anti-platelet therapy (commonly aspirin) was used in 15% treated, increases the risk and severity of stroke, heart fail- [63] of low risk patients, and in 31% of high-risk patients. ure and death. The global aging of the population will de- Treatment and management gaps exist worldwide and termine an endemic that will result in significant burden on older populations are the ones at highest risk but remain health care systems and physicians taking care of these pop- largely untreated due to the perceived risk of bleeding; these ulations. There exist significant gaps globally that put gaps vary in degree across countries, but are more promi- LMICs at higher risk of negative outcomes that merit a [64] nent in LMIC. Data from LMIC are limited and suggest global approach that promotes conscious identification and very low rates of oral anticoagulation therapy among AF management of modifiable risk factors as well as proper risk [38,59] patients. A few studies reported that estimated rates stratification and treatment. Further education of both of anticoagulant use range from only 2.7%–50% in non-specialists and non physician workers may improve [59,65–67] [68] [69] China, 26%–44% in Pakistan, 16% in Malaysia, screening, detection and appropriate management of AF that [70] [71] 46.7%–57.8% in Brazil, 36.8% in Mexico, 72.7% in may in turn improve global outcomes. The World Heart [72] [73] Argentina, 33% in South Africa, 34.2% in Camer- Federation is committed to promote this approach in an at- [74] [75] oon, from 11.5% (rural) to 26.5% (urban) in Zimbabwe, tempt to halt the progression of the inevitable endemic. Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com Morillo CA, et al. The current epidemic of AF 201 16 Bruggenjurgen B, Rossnagel K, Roll S, et al. The impact of References atrial fibrillation on the cost of stroke: the berlin acute stroke 1 Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in study. Value Health 2007; 10: 137–143. incidence of atrial fibrillation in Olmsted County, Minnesota, 17 Thrall G, Lane D, Carroll D, Lip GY. Quality of life in pa- 1980 to 2000, and implications on the projections for future tients with atrial fibrillation: a systematic review. Am J Med prevalence. Circulation 2006; 114: 119–125. 2006; 119: 448 e1–19. 2 Krijthe BP, Kunst A, Benjamin EJ, et al. Projections on the 18 Camm AJ, Kirchhof P, Lip GY, et al. Guidelines for the number of individuals with atrial fibrillation in the European management of atrial fibrillation: the task force for the man- Union, from 2000 to 2060. Eur Heart J 2013; 34: 2746–2751. agement of atrial fibrillation of the European Society of Car- 3 Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide diology (ESC). Eur Heart J 2010; 31: 2369–429. epidemiology of atrial fibrillation: a Global Burden of Disease 19 Freedman B, Potpara TS, Lip GY. Stroke prevention in atrial 2010 Study. Circulation 2014; 129: 837–847. fibrillation. Lancet 2016; 388: 806–817. 4 Kim MH, Johnston SS, Chu BC, et al. Estimation of total 20 Chugh SS, Roth GA, Gillum RF, Mensah GA. Global burden incremental health care costs in patients with atrial fibrillation of atrial fibrillation in developed and developing nations. Glob in the United States. Circ Cardiovasc Qual Outcomes 2011; 4: Heart 2014; 9: 113–119. 313–320. 21 Flaker GC, Belew K, Beckman K, et al. Asymptomatic atrial 5 Andersson T, Magnuson A, Bryngelsson IL, et al. All-cause fibrillation: demographic features and prognostic information mortality in 272,186 patients hospitalized with incident atrial from the Atrial Fibrillation Follow-up Investigation of Rhy- fibrillation 1995–2008: a Swedish nationwide long-term case- thm Management (AFFIRM) study. Am Heart J 2005; 149: control study. Eur Heart J 2013; 34: 1061–1067. 657–663. 6 Wattigney WA, Mensah GA, Croft JB. Increased atrial fibril- 22 Healey JS. ASSERT-II Sub-Clinical AF (SCAF) in older lation mortality: United States, 1980–1998. Am J Epidemiol asymptomatic patients. Presented at AHA Late Breaking 2002; 155: 819–826. Clinical Trials Session, New Orleans, LO, USA, November 7 Go AS, Hylek EM, Phillips KA, et al. Prevalence of diag- nosed atrial fibrillation in adults: national implications for 23 Healey JS, Oldgren J, Ezekowitz M, et al. Occurrence of rhythm management and stroke prevention: the AnTicoagula- death and stroke in patients in 47 countries 1 year after pre- tion and Risk Factors in Atrial Fibrillation (ATRIA) Study. senting with atrial fibrillation: a cohort study. Lancet 2016; JAMA 2001; 285: 2370–2375. 388: 1161–1169. 8 Stefansdottir H, Aspelund T, Gudnason V, Arnar DO. Trends 24 Oldgren J, Healey JS, Ezekowitz M, et al. Variations in cause in the incidence and prevalence of atrial fibrillation in Iceland and management of atrial fibrillation in a prospective registry and future projections. Europace 2011; 13: 1110–1117. of 15,400 emergency department patients in 46 countries: the 9 Frost L, Vestergaard P, Mosekilde L, Mortensen LS. Trends RE-LY Atrial Fibrillation Registry. Circulation 2014; 129: in incidence and mortality in the hospital diagnosis of atrial 1568–1576. fibrillation or flutter in Denmark, 1980–1999. Int J Cardiol 25 Marcus GM, Alonso A, Peralta CA, et al. European ancestry 2005; 103: 78–84. as a risk factor for atrial fibrillation in African Americans. 10 Piccini JP, Hammill BG, Sinner MF, et al. Incidence and Circulation 2010; 122: 2009–2015. prevalence of atrial fibrillation and associated mortality among 26 Lau CP, Gbadebo TD, Connolly SJ, et al. Ethnic differences Medicare beneficiaries, 1993–2007. Circ Cardiovasc Qual in atrial fibrillation identified using implanted cardiac devices. Outcomes 2012; 5: 85–93. J Cardiovasc Electrophysiol 2013; 24: 381–387. 11 Colilla S, Crow A, Petkun W, et al. Estimates of current and 27 Benjamin EJ, Levy D, Vaziri SM, et al. Independent risk factors for atrial fibrillation in a population-based cohort. The future incidence and prevalence of atrial fibrillation in the U.S. Framingham Heart Study. JAMA 1994; 271: 840-844. adult population. Am J Cardiol 2013; 112: 1142–1174. 28 Heeringa J, Kors JA, Hofman A, et al. Cigarette smoking and 12 Murphy A, Banerjee A, Breidthart G, et al. World Heart Fed- risk of atrial fibrillation: the Rotterdam Study. Am Heart J eration Global Atrial Fibrillation Roadmap, 2017; Http://www. 2008; 156: 1163–1169. world-heart-federation.org/what-we-do/whf-roadmaps/atrial-fi 29 Conen D, Tedrow UB, Cook NR, et al. Alcohol consumption brillation-roadmap/ (accessed on Jan 10, 2017). and risk of incident atrial fibrillation in women. JAMA 2008; 13 The Global Burden of Disease Study 2013. Http://www. 300: 2489–2496. healthdata.org/gbd (accessed on Jan 7, 2017). 30 Frost L, Vestergaard P. Alcohol and risk of atrial fibrillation 14 Stewart S, Murphy NF, Walker A, et al. Cost of an emerging or flutter: a cohort study. Arch Intern Med 2004; 164: epidemic: an economic analysis of atrial fibrillation in the UK. 1993–1998. Heart 2004; 90: 286–292. 31 Kodama S, Saito K, Tanaka S, et al. Alcohol consumption and 15 Blomstrom Lundqvist C, Lip GY, Kirchhof P. What are the risk of atrial fibrillation: a meta-analysis. J Am Coll Cardiol costs of atrial fibrillation? Europace 2011; 13 (Suppl 2): 2011; 57: 427–436. S9–S12 http://www.jgc301.com; jgc@mail.sciencep.com | Journal of Geriatric Cardiology 202 Morillo CA, et al. The current epidemic of AF 32 Frost L, Hune LJ, Vestergaard P. Overweight and obesity as rillation Project. Int J Cardiol 2013; 167: 2682–2687. risk factors for atrial fibrillation or flutter: the Danish Diet, 47 Jabaudon D, Sztajzel J, Sievert K, et al. Usefulness of ambu- Cancer, and Health Study. Am J Med 2005; 118: 489–495. latory 7-day ECG monitoring for the detection of atrial fibril- 33 Gami AS, Hodge DO, Herges RM, et al. Obstructive sleep lation and flutter after acute stroke and transient ischemic at- apnea, obesity, and the risk of incident atrial fibrillation. J Am tack. Stroke 2004; 35: 1647–1651. Coll Cardiol 2007; 49: 565–571. 48 Binici Z, Intzilakis T, Nielsen OW, et al. Excessive supraven- 34 Wang TJ, Parise H, Levy D, et al. Obesity and the risk of tricular ectopic activity and increased risk of atrial fibrillation new-onset atrial fibrillation. JAMA 2004; 292: 2471–2477. and stroke. Circulation 2010; 121: 1904–1911. 35 Otero L, Hidalgo P, González R, Morillo CA. Association of 49 Haeusler KG, Kirchhof P, Heuschmann PU, et al. Impact of cardiovascular disease and sleep apnea at different altitudes. standardized monitoring for detection of atrial fibrillation in High Alt Med Biol 2016; 17: 336–341. ischemic stroke (MonDAFIS): rationale and design of a pro- 36 Alonso A, Krijthe BP, Aspelund T, et al. Simple risk model spective randomized multicenter study. Am Heart J 2016; 172: predicts incidence of atrial fibrillation in a racially and geo- 19–25. graphically diverse population: the CHARGE-AF consortium. 50 World Health Organization. Global action plan for the pre- J Am Heart Assoc 2013; 2: e000102. vention and control of noncommunicable diseases. Geneva: 37 Pathak RK, Elliott A, Middeldorp ME, et al. Impact of cardio- WHO, 2013. respiratory fitness on arrhythmia recurrence in obese indi- 51 World Health Organization. The WHO Essential Medicines viduals with atrial fibrillation: The CARDIO-FIT Study. J Am List. Http://www.who.int/medicines/publications/essentialmedi- Coll Cardiol 2015; 66: 985–996. cines/en/ (accessed on February 15, 2016). 38 Rahman F, Kwan GF, Benjamin EJ. Global epidemiology of 52 Ben Freedman S, Gersh BJ, Lip GY. Misperceptions of aspi- atrial fibrillation. Nat Rev Cardiol 2014; 11: 639–654. rin efficacy and safety may perpetuate anticoagulant underuti- 39 Davis M, Rodgers S, Rudolf M, et al. Guideline Development lization in atrial fibrillation. Eur Heart J 2015; 36: 653–656. Group for the Nice clinical guideline for the management of 53 Investigators A, Connolly SJ, Pogue J, et al. Effect of clopi- atrial fibrillation. Patient care pathway, implementation and dogrel added to aspirin in patients with atrial fibrillation. N audit criteria for patients with atrial fibrillation. Heart 2007; Engl J Med 2009; 360: 2066–2078. 93: 48–52. 54 Connolly SJ, Eikelboom JW, Ng J, et al. Net clinical benefit 40 Fitzmaurice DA, Hobbs FD, Jowett S, et al. Screening versus of adding clopidogrel to aspirin therapy in patients with atrial routine practice in detection of atrial fibrillation in patients fibrillation for whom vitamin K antagonists are unsuitable. aged 65 or over: cluster randomized controlled trial. BMJ Ann Intern Med 2011; 155: 579–586. 2007; 335: 383. 55 Pisters R, Lane DA, Nieuwlaat R, et al. A novel user-friendly 41 Taggar JS, Coleman T, Lewis S, et al. Accuracy of methods score (HAS-BLED) to assess 1-year risk of major bleeding in for detecting an irregular pulse and suspected atrial fibrillation: patients with atrial fibrillation: the Euro Heart Survey. Chest A systematic review and meta-analysis. Eur J Prev Cardiol 2010; 138: 1093–1100. 2016; 23: 1330–1338. 56 Macle L, Cairns J, Leblanc K, et al. 2016 Focused update of 42 Willits I, Keltie K, Craig J, Sims A. WatchBP Home A for the Canadian Cardiovascular Society guidelines for the manage- opportunistically detecting atrial fibrillation during diagnosis ment of atrial fibrillation. Can J Cardiol 2016; 32: 1170–1185. and monitoring of hypertension: a NICE Medical Technology 57 Adler AJ, Prabhakaran D, Bovet P, et al. Reducing cardio- Guidance. Appl Health Econ Health Policy 2014; 12: 255–265. vascular mortality through prevention and management of 43 Camm AJ, Lip GY, De Caterina R, et al. 2012 focused update raised blood pressure: a world heart federation roadmap. of the ESC Guidelines for the management of atrial fibrilla- Global Heart 2015; 10: 111–122. tion: an update of the 2010 ESC Guidelines for the manage- 58 Perel P, Avezum A, Huffman M, et al. Reducing premature ment of atrial fibrillation. Developed with the special contri- cardiovascular morbidity and mortality in people with athero- bution of the European Heart Rhythm Association. Eur Heart sclerotic vascular disease: The World Heart Federation road- J 2012; 33: 2719–2747. map for secondary prevention of cardiovascular disease. 44 Akeroyd JM, Chan WJ, Kamal AK, et al. Adherence to car- Global Heart 2015; 10: 99–110. diovascular medications in the South Asian population: A 59 Nguyen TN, Hilmer SN, Cumming RG. Review of epidemi- systematic review of current evidence and future directions. ology and management of atrial fibrillation in developing World J Cardiol 2015; 7: 938–947. countries. Int J Cardiol 2013; 167: 2412–2420. 45 Ganesan AN, Chew DP, Hartshorne T, et al. The impact of 60 Wen-Hang QI, Society of Cardiology CMA. Retrospective atrial fibrillation type on the risk of thromboembolism, mor- investigation of hospitalized patients with atrial fibrillation in tality, and bleeding: a systematic review and meta-analysis. mainland China. Int J Cardiol 2005; 105: 283–287. Eur Heart J 2016; 37: 1591–1602 61 Kakkar AK, Mueller I, Bassand JP, et al. Risk profiles and 46 Banerjee A, Taillandier S, Olesen JB, et al. Pattern of atrial antithrombotic treatment of patients newly diagnosed with fibrillation and risk of outcomes: the Loire Valley Atrial Fib- atrial fibrillation at risk of stroke: perspectives from the inter- Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com Morillo CA, et al. The current epidemic of AF 203 national, observational, prospective GARFIELD registry. 73 Ntep-Gweth M, Zimmermann M, Meiltz A, et al. Atrial fib- PloS one 2013; 8: e63479. rillation in Africa: clinical characteristics, prognosis, and ad- 62 Hsu J, Maddox T, Kennedy K, et al. Oral anticoagulant ther- herence to guidelines in Cameroon. Europace 2010; 12: apy prescription in patients with atrial fibrillation across the 482–487. spectrum of stroke risk: insights from the NCDR PINNACLE 74 Bhagat K, Tisocki K. Prescribing patterns for the use of anti- registry. JAMA 2016; 1: 55–62. thrombotics in the management of atrial fibrillation in Zim- 63 Lip GY, Laroche C, Ioachim PM, et al. Prognosis and treat- babwe. Cent Afr J Med 1999; 45: 287–290. ment of atrial fibrillation patients by European cardiologists: 75 Mbaye A, Pessinaba S, Bodian M, Mouhamadou BN, Mbaye one year follow-up of the eurobservational research programme- F, Kane A, et al. [Atrial fibrillation, frequency, etiologic fac- atrial fibrillation general registry pilot phase (EORP-AF pilot tors, evolution and treatment in a cardiology department in registry). Eur Heart J 2014; 35: 3365–3376. Dakar, Senegal]. Pan Afr Med J 2010; 6: 16. [Article in 64 Lang K, Bozkaya D, Patel AA, et al. Anticoagulant use for the French]. prevention of stroke in patients with atrial fibrillation: findings 76 Karacaglar E, Atar I, Yetis B, Corut H, Ersoy B, Yilmaz K, et from a multi-payer analysis. BMC Health Serv Res 2014; 14: al. [The frequency of embolic risk factors and adequacy of an- 329. ti-embolic treatment in patients with atrial fibrillation: a single 65 Zhou Z, Hu D. An epidemiological study on the prevalence of tertiary center experience]. Anadolu Kardiyol Derg 2012; 12: atrial fibrillation in the Chinese population of mainland China. 384–390. [Article in Turkish]. J Epidemiol 2008; 18: 209–216. 77 Potpara TS, Stankovic GR, Beleslin BD, et al. A 12-year 66 QI WH; Society of Cardiology, Chinese Medical Association. follow-up study of patients with newly diagnosed lone atrial fi Retrospective investigation of hospitalized patients with atrial brillation: implications of arrhythmia progression on progno- fibrillation in mainland China. Int J Cardiol 2005; 105: 283–287. sis: the Belgrade atrial fibrillation study. Chest 2012; 141: 67 Rasool S, Haq Z. Anticoagulation therapy in high risk patients 339–347. with atrial fi brillation: retrospective study in a regional hos- 78 Elezi S, Qerkini G, Bujupi L, et al. Management and comor- pital. J Liaquat Uni Med Health Sci 2009; 8: 136–138. bidities of atrial fibrillation in patients admitted in cardiology 68 Freestone B, Rajaratnam R, Hussain N, Lip GY. Admissions service in Kosovo: a single-center study. Anadolu Kardiyol with atrial fibrillation in a multiracial population in Kuala Derg 2010; 10: 36–40. Lumpur, Malaysia. Int J Cardiol 2003; 91: 233–238. 79 Diaconu N, Grosu A, Gratii C, Pavlic G. Stroke prevention in 69 Fornari LS, Calderaro D, Nassar IB, et al. Misuse of anti- atrial fibrillation—a major problem in the Republic of Mol- thrombotic therapy in atrial fi brillation patients: frequent, per- dova. Eur J Neurol 2011; 18. vasive and persistent. J Thromb Thrombolysis 2007; 23: 65–71. 80 Apostolakis S, Zubaid M, Rashed WA, et al. Assessment of 70 Cortes-Ramirez J, Cortes-De La Torre J, Cortes-De La Torre stroke risk in Middle Eastern patients with atrial fibrillation: R, et al. Atrial fibrillation in a general hospital. Rev Mex Car- the Gulf SAFE registry. Int J Cardiol 2013; 168: 1644–1646. diol 2011; 22: 145–8. 81 Murray S, Lazure P, Pullen C, et al. Atrial fibrillation care: 71 Fitz Maurice M, Di Tommaso F, Zgaig M, et al. Thrombo- challenges in clinical practice and educational needs assess- prophylaxis of atrial fibrillation. Analysis of the argetinean ment. Can J Cardiol 2011; 27: 98–104. national register of atrial fibrillation and atrial flutter (RE- 82 Gaziano TA, Abrahams-Gessel S, Denman CA, et al. An NAFA). 2011; 22: S102. assessment of community health workers’ ability to screen for 72 Sliwa K, Carrington MJ, Klug E, et al. Predisposing factors cardiovascular disease risk with a simple, non-invasive risk and incidence of newly diagnosed atrial fibrillation in an ur- assessment instrument in Bangladesh, Guatemala, Mexico, ban African community: insights from the Heart of Soweto and South Africa: an observational study. Lancet Glob Health Study. Heart 2010; 96: 1878–1882. 2015; 3: e556–e563. This article is part of a Special Issue “Atrial fibrillation in the elderly”. Guest Editors: Manuel Martínez-Sellés & Antoni Bayés de Luna http://www.jgc301.com; jgc@mail.sciencep.com | Journal of Geriatric Cardiology

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Journal of Geriatric Cardiology : JGCPubmed Central

Published: Mar 1, 2017

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