Analysis: AF Treatment Should Go Beyond Stoke Prevention

A meta-analysis of 104 cohort studies involving more than 9.5 million patients concludes that atrial fibrillation (AF) is associated with elevated rates of cardiovascular disease, renal disease and early death.

Its authors conclude the treatment of AF should expand its focus beyond stroke prevention.

Investigators looked for all cohort studies that reported which patients had AF and at least 1 of the following outcomes: cardiovascular disease, renal disease or death. A pair of reviewers then independently extracted information on study characteristics and on the relative risk of AF and control patients for a wide variety of negative outcomes.

AF was associated with an increased risk of all-cause mortality, cardiovascular mortality, major cardiovascular events, stroke, ischemic stroke, ischemic heart, sudden cardiac death, heart failure, chronic kidney disease, and peripheral arterial disease, but not hemorrhagic stroke (RR, 2.00; 95% CI, 0.67-5.96).

The investigators also found that associations between AF and the included outcomes were broadly consistent across subgroups and in various sensitivity analyses.

“Our assessment of the consistency of relative risk estimates across demographic and clinical subgroups of participants is an important expansion on previous studies, many of which have limited their analysis to a single patient subgroup, such as those with ischemic heart disease and congestive heart failure,” they wrote in the British Medical Journal. “We observed that the association between atrial fibrillation and cardiovascular disease and death was generally consistent, irrespective of baseline history of ischemic heart disease, baseline history of stroke, mean participant age, and baseline risk.”

Not all of the studies focused specifically on patients with AF. Several of the largest were general population studies that included some patients who happen to have AF. As a result, “just” 587,867 of the 9,686,513 patients had AF. However, even that smaller number of patients is by far the largest to be included in the meta-study of this kind.

The size of the effect estimates, moreover, and their consistency among various subpopulations of patients led the authors of the new study to conclude that their work justifies a rethinking of AF treatment regimens that focus almost exclusively on preventing the strokes that are a relatively minor cause of death among AF patients.

“Our study could have implications for the prioritization of public health resources and the development of novel interventions for adults with atrial fibrillation. The development and testing of novel oral anticoagulants has been the principal focus of clinical care in atrial fibrillation, but recent studies have shown that these drugs reduce mortality related to stroke, with little reduction in mortality related to congestive heart failure and sudden cardiac death. Similarly, pharmacological control of atrial fibrillation and the restoration of sinus rhythm has shown no benefit over rate control for sudden cardiac death, worsening heart failure, or mortality,” the study authors wrote.

“Reduction of non-stroke events in adults with atrial fibrillation would benefit from a focus on primary prevention and management of cardiovascular risk factors. Evidence based strategies in this regard include discussion of the concept of predicted cardiovascular risk with patients and calculation of their cardiovascular age. Regular updates should also be provided to patients after lifestyle changes and/or pharmacotherapy have begun as a way to encourage further progress.”

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