The Impact of Modifiable Risk Factors and Lifestyle Management on Atrial Fibrillation with Dr. Prash Sanders

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Dr. Kelly Arps, Dr. Naima Maqsood, and Dr. Sahi Allam focus on modifiable danger elements and way of life administration of atrial fibrillation with Dr. Prash Sanders. Atrial fibrillation is turning into extra prevalent the world over as individuals are dwelling longer with heart problems. While a lot of our present focus lies on the pharmacological and procedural administration of atrial fibrillation, a number of research have proven that focused discount of danger elements, comparable to weight problems, sleep apnea, hypertension, and alcohol use, also can considerably scale back atrial fibrillation burden and signs. Today, we focus on the information behind way of life administration and why it’s thought-about the “4th pillar” of atrial fibrillation therapy. We additionally discover methods to include prevention methods into our basic cardiology and electrophysiology clinics to raised serve the rising atrial fibrillation inhabitants. Audio modifying for this episode was carried out by CardioNerds Intern, Julia Marques Fernandes. 

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

Pearls

1. More folks have atrial fibrillation as a result of it’s being detected earlier utilizing wearable expertise, and sufferers are dwelling longer with subclinical or scientific heart problems 

2. There are 3 parts of atrial fibrillation: {an electrical} “trigger” + a vulnerable substrate (as a result of age, intercourse, genetics) + “perpetuators” that trigger the set off to proceed stimulating the substrate (way of life danger elements comparable to weight problems, smoking, diabetes, and so forth.) 

3. Obesity is the highest attributable danger issue for atrial fibrillation. Treating weight problems typically helps to deal with different danger elements, comparable to hypertension and sleep apnea. 

4. Counseling is patient-dependent. Most sufferers are unable to make main behavioral adjustments cold-turkey and might want to make small, incremental adjustments. 

5. Dr. Sanders’ tip: He tells his personal sufferers that “atrial fibrillation is the body’s response to stress.” The key to treating atrial fibrillation is to manage your underlying stressors – procedures and medicines are merely band-aids that don’t repair the basis of the issue. 

Notes

Notes drafted by Dr. Allam.

1. How widespread is atrial fibrillation? 

• Atrial fibrillation is the most typical sustained arrhythmia. Currently, an estimated 50-60 million people worldwide are estimated to have atrial fibrillation, or roughly 1 in 4 people over the age of 45.¹ 

• The rising world prevalence of atrial fibrillation might be attributed to the getting old of the inhabitants, elevated charges of weight problems, and larger accumulation of cardiovascular danger elements and survival with scientific heart problems.² Atrial fibrillation can be being detected earlier by means of digital and wearable gadgets.² 

• Annually, we spend roughly $5,312 per grownup on the administration of atrial fibrillation within the United States.³ 

2. What is the underlying pathophysiology of atrial fibrillation? How do danger elements like sleep apnea or weight problems “trigger” atrial fibrillation? 

• For atrial fibrillation to happen, there’s {an electrical} “trigger”, a vulnerable substrate (as a result of age, intercourse, genetics), and “perpetuators” that enable the set off to proceed stimulating the substrate.² 

1. 90% {of electrical} “triggers” come from the pulmonary veins 

2. “Perpetuators” affect how the autonomic nervous system interacts with the triggers and substrate to perpetuate atrial fibrillation. Sleep apnea, weight problems, and different danger elements are the “perpetuators” 

3. Over time, as atrial fibrillation recurs, the substrate remodels to lead to persistent atrial fibrillation. 

3. What are a number of the danger elements for atrial fibrillation and what are the potential advantages of controlling them? 

• Reference 4 gives a wonderful overview of the person danger elements 

4. Nicotine patches/gums and counseling are related to profitable nicotine cessation in RCTs.  

5. In the long run, nicotine itself may cause atrial fibrosis. However, it’s protected to make use of patches and gums within the brief time period to abet cessation. 

1. The highest attributable danger issue for atrial fibrillation. Treating weight problems typically helps to deal with different danger elements, comparable to hypertension and sleep apnea 

2. In addition to common train, lowering caloric consumption may help fight weight problems. Eating extra fiber-laden meals comparable to greens as a substitute of carbohydrates, limiting parts, sugary drinks, and alcohol, and growing fasting intervals can all assist lower weight. 

3. GLP-1 agonists can considerably scale back weight problems and enhance each signs and mortality for sufferers with comorbid situations, comparable to HFpEF. 

• Obstructive sleep apnea 

1. This is an evolving space of analysis with upcoming randomized trial knowledge 

2. Sleep apnea might be not a static situation. Our chance of getting sleep apnea adjustments with how rested we’re, how a lot we’ve exercised, or whether or not we’ve consumed alcohol, and so forth. The testing and therapy of the long run will replicate the changeable nature of sleep apnea. 

3. Current knowledge: 

1. In the atrial fibrillation ablation inhabitants, therapy of sleep apnea was related to an enchancment in time to arrhythmia recurrence.  

2. Another observational examine from Norway, which included varied sufferers who used dental sleep home equipment, discovered no important distinction in atrial fibrillation between those that have been handled for sleep apnea and those that weren’t. It was severely underpowered to detect a distinction. 

1. There isn’t any proof to assist cessation of caffeine in sufferers with atrial fibrillation 

2. For sufferers with bothersome palpitations, caffeine cessation might be tried if it improves their signs 

1. Per knowledge from the UK Biobank, a single drink of alcohol every day doesn’t enhance your danger for creating atrial fibrillation. However, a number of drinks per day will enhance your danger. 

2. A proof-of-concept examine confirmed that sufferers who abstained from alcohol for at the very least 6 months had full decision of atrial fibrillation. However, the dropout charge was very excessive as most sufferers couldn’t fully abstain from alcohol 

3. Dr. Sanders recommends alcohol consumption of ≤ 3 drinks/week, which is the cutoff utilized in way of life administration research.  

1. For sufferers with coronary heart failure, the 4 pillars of coronary heart failure administration are additionally essential to treating atrial fibrillation. SGLT2 inhibitors particularly are more likely to confer advantages. 40-50% of sufferers within the SGLT2 inhibitor scientific trials had co-morbid atrial fibrillation. 

2. About half of sufferers present process atrial fibrillation ablation seem to have HFpEF based mostly on their hemodynamics. 

4. Can atrial fibrillation be handled with solely way of life modifications? 

• Potentially. This is an evolving space of analysis with out a lot revealed knowledge. Empirically, Dr. Sanders has observed that in sufferers referred for atrial fibrillation ablation, aggressive way of life modifications lead to 40% of them not requiring ablation. After a 10-year follow-up, 20% nonetheless don’t require ablation. 

• However, ablation remains to be an efficient modality to attain rhythm management. It can be turning into a safer process owing to novel strategies, comparable to pulse subject ablation.  

• In the long run, we foresee most sufferers using a mixture of way of life modification and rhythm management methods (ablation and/or medicines) to manage their atrial fibrillation. 

5. What are the advantages of train in sufferers with atrial fibrillation? How a lot train do you suggest to your sufferers? Also, on the opposite finish of the spectrum, does participation in endurance sports activities paradoxically promote atrial fibrillation? 

• The ACTIVE-AF examine examined whether or not an intensive cardio train routine, as much as 210 minutes per day, is protected and efficient in controlling atrial fibrillation. Intensive train was related to a major discount in atrial fibrillation burden and signs in addition to a rise in high quality of life and upkeep of sinus rhythm.⁵  

• Endurance athletes do have an roughly 5-fold greater danger of atrial fibrillation in comparison with sedentary folks.⁶ However, this happens at very excessive ranges of train, exceeding 4 hours per day. Low to average ranges of train have been proven to cut back charges of atrial fibrillation.^4,5 

6. How ought to we counsel sufferers about way of life administration? Are there any good sources to make use of? 

• Dr. Sanders’ tip: Counseling is patient-dependent. For the vast majority of sufferers, the important thing to behavioral change is to make incremental changes over time, accompanied by encouragement. Some sufferers reply nicely to steady suggestions from digital gadgets. We also can complement pharmacological therapies, comparable to medicines to help with weight reduction or tobacco/alcohol cessation, to behavioral counseling. 

• Risk issue modification ought to be the central pillar of atrial fibrillation administration and reviewed early on with sufferers of their atrial fibrillation course. It could also be useful to have clinic classes particularly devoted to way of life counseling, which might be run by a multidisciplinary group of electrophysiologists, basic cardiologists, and nurse educators. 

7. How ought to we clarify what atrial fibrillation is to our sufferers? 

• Dr. Sanders’ tip: He tells his personal sufferers that “atrial fibrillation is the body’s response to stress. It occurs because the heart is not coping well with increased stress. Procedures and medications for atrial fibrillation are simply band-aids that do not fix the root of the problem, but controlling the risk factors contributing to increased stress will.”  

• He additionally emphasizes the elevated stroke danger of atrial fibrillation. 

References

1. Linz D, Gawalko M, Betz Ok, Hendriks J, Lip G, Vinter N. Atrial fibrillation: epidemiology, screening and digital well being. The Lancet Regional Health – Europe. 2024;37(100786). 

2. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Jan 02 2024;149(1):e1-e156. 

3. Serpa F, Tale A, Zimetbaum P, Kramer D. Trends in well being care expenditures and incremental well being care price in adults with atrial fibrillation within the United States. Heart Rhythm O2. 2025;6(1). 

4. Chung MK, Eckhardt LL, Chen LY, et al. Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation: A Scientific Statement From the American Heart Association. Circulation. Apr 21 2020;141(16):e750-e772. doi:10.1161/CIR.0000000000000748 

5. Elliott AD, Verdicchio CV, Mahajan R, et al. An train and bodily exercise program in sufferers with atrial fibrillation. JACC: Clinical Electrophysiology. 2023;9(4):455-465. doi:10.1016/j.jacep.2022.12.002 

6. Atrial fibrillation in aggressive athletes. American College of Cardiology. Accessed February 22, 2025.