Prevention and Treatment of Atrial Fibrillation via Risk Factor Modification Evan L. O’Keefe, MD a , Jessica E. Sturgess, MD b , James H. O’Keefe, MD b,c, *, Sanjaya Gupta, MD b,c , and Carl J. Lavie, MD d Atrial fibrillation (AF) is the most common clinically significant arrhythmia, and it increases stroke risk. A preventive approach to AF is needed because virtually all treat- ments such as cardioversion, antiarrhythmic drugs, ablation, and anticoagulation are associated with high cost and carry significant risk. A systematic review was performed to identify effective lifestyle-based strategies for reducing primary and secondary AF. A PubMed search was performed using articles up to March 1, 2021. Search terms included atrial fibrillation, atrial flutter, exercise, diet, metabolic syndrome, type 2 diabetes melli- tus, obesity, hypertension, stress, tobacco smoking, alcohol, Mediterranean diet, sodium, and omega-3 fatty acids. Additional articles were identified from the bibliographies of retrieved articles. The control of hypertension, ideally with a renin-angiotensin-aldoste- rone system inhibitor, is effective for preventing primary AF and recurrence. Obstructive sleep apnea is a common cause of AF, and treating it effectively reduces AF episodes. Alco- hol increases the risk of AF in a dose-dependent manner, and abstinence reduces risk of recurrence. Sedentary behavior and chronic high-intensity endurance exercise are both risk factors for AF; however, moderate physical activity is associated with lower risk of AF. Recently, sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 ago- nists have been associated with reduced risk of AF. Among overweight/obese patients, weight loss of ≥10% is associated with reduced AF risk. Lifestyle changes and risk factor modification are highly effective for preventing AF. © 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/) (Am J Cardiol 2021;160:46-52) An analysis of the Framingham Heart Study revealed a fourfold increase in the age-adjusted prevalence of atrial fibrillation (AF) over the past 50 years. 1 Today, the lifetime risk of AF in the United States is 1 in 4 in individuals older than 40 years, 2,3 and AF accounts for 1 in 3 ischemic strokes. 4 In addition to increasing the risk of stroke fivefold and the risk of premature death by 1.5- to twofold, this arrhythmia adversely affects quality of life and increases health care costs. 1,4-7 Targeting modifiable risk factors could avert a substantial proportion of AF cases, reduce the need for antiarrhythmic drugs and/or catheter ablation/pul- monary vein isolation (PVI), and improve success rates of these rhythm control strategies. 8 Indeed, optimal control of AF risk factors enabled 40% of patients in the LEGACY study to maintain sinus rhythm without the need for other rhythm control strategies. 9 This review will provide an overview of the modifiable risk factors that predispose to AF, including sleep, alcohol, tobacco, weight, diet, exer- cise, diabetes mellitus (DM), hypertension, and stress. Strategies to optimally manage these risk factors will also be discussed. Methods A PubMed search was performed using articles pub- lished up to March 1, 2021. Search terms included atrial fibrillation, atrial flutter, exercise, diet, metabolic syn- drome, diabetes mellitus, obesity, hypertension, stress, tobacco smoking, sleep apnea, alcohol, Mediterranean diet, sodium, and omega-3 fatty acids. Additional articles were identified from the bibliographies of retrieved articles. The literature review revealed strong evidence to support associ- ations for risk of AF with sleep apnea, obesity/overweight, hypertension, DM, alcohol, psychosocial stress, tobacco smoking, extreme exercise, sedentary lifestyle, and some dietary factors. Results Sleep apnea markedly increases the risk of both AF and stroke, and those with obstructive sleep apnea (OSA) are 5 times more likely to develop AF than those without sleep apnea. 10 . Furthermore, the risk of AF is directly correlated with the severity of sleep apnea. 10 OSA stimulates excess vagal tone, while triggering activation of the sympathetic nervous system. 11 Upper airway obstruction during inhala- tion leads to substantial negative intrathoracic pressure, which sucks blood into the atria, causing them to become distended. In the setting of untreated OSA, the constellation a Tulane Medical Center, New Orleans, Louisiana; b University of Mis- souri-Kansas City, Kansas City, Missouri; c Saint Luke’s Mid America Heart Institute, Kansas City, Missouri; and d John Ochsner Heart and Vas- cular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana. Manuscript received July 27, 2021; revised manuscript received and accepted August 20, 2021. Dr. Gupta receives research support from Medtronic, Minneapolis, MN; Abbott Laboratories, Chicago, IL and Bristol-Meyers Squibb, New York, NY. See page 51 for disclosure information. *Corresponding author: Tel: (816) 751-8480; fax: (816) 751-8665. E-mail address: [email protected] (J.H. O’Keefe). www.ajconline.org 0002-9149/© 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) https://doi.org/10.1016/j.amjcard.2021.08.042
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