Most Paroxysmal AF Patients Report 'Triggers' Like Alcohol, Caffeine Intake

February 28, 2019

Three-fourths of patients with symptomatic paroxysmal atrial fibrillation (AF) in a survey-based study identified at least one acute experience they believed was a trigger of individual episodes of their arrhythmia. The most commonly reported possible triggers were consumption of alcohol, caffeine intake, a bout of exercise, and a lack of sleep.

Among the nearly 1300 survey respondents, women and those with a family history of AF were the likeliest to report that they had such triggers and that they had multiple triggers. Those with heart failure in addition to symptomatic paroxysmal AF were among the least likely to report that their atrial arrhythmia had triggers.

One goal of the analysis was to identify potential AF triggers that are modifiable and could contribute to patient discussions and, in the case of family AF history, clarify interactions between genetic predisposition and environmental promoters, observed senior author Gregory M. Marcus, MD, MAS, University of California, San Francisco.

"It's a little unsatisfying," he told theheart.org | Medscape Cardiology, that "there appears to be quite a bit of heterogeneity regarding the perceived triggers, suggesting that, for example, a catch-all recommendation may not be appropriate."

For example, he noted, avoidance of caffeine seems to be an almost universal recommendation for patients with known paroxysmal AF.

"But the reality is, yes, there may be some people for whom caffeine is a trigger, but almost certainly many others for whom it is not. Same thing for exercise. We don't want to discourage exercise, but certain types of exercise may be an important trigger for some people," Marcus said.

"We need to better understand these more idiosyncratic relationships that may be most relevant to any one given individual."

The analysis was published February 14 in Heart Rhythm, with lead author Christopher A. Groh, MD, University of California, San Francisco.

Of the 1295 patients with symptomatic paroxysmal AF who responded to the survey, 74% reported experiencing at least one of the triggers on a provided list. Among that group, the most prevalent perceived triggers that were experienced "all or some of the time" were:

Respondents also were invited to "write in" perceived triggers not on the provided list. By far the most common write-in trigger, at 20% of respondents, was stress or anxiety.

The remaining triggers on the provided list, cited less often, included not exercising, drinking cold beverages, eating cold foods, eating a large meal, a high-sodium diet, dehydration, and lying on the left side.

March said the provided list of possible triggers to which the patients responded were based on expert consensus or collected via online survey and by social media.

"There are almost no data to show that most of these things in fact trigger afib, so at this point the best evidence we have is what the patients are telling us."

The survey participants had been identified by being part of the Health eHeart Study or subscribers to the patient advocacy organization StopAfib.org.

Those who did and did not report having triggers for their AF episodes were statistically similar for demographics and cardiovascular comorbidities, except those reporting triggers were twice as likely to have a family AF history (P = .008) and 71% less likely to have heart failure (= .001) in adjusted analysis.

Collectively, the respondents reported a median of two separate triggers. Groups most likely to report multiple triggers included women, younger patients, and those with Hispanic ethnicity, a family history of AF, or obstructive sleep apnea.

The findings are consistent with different mechanisms thought to be underlying AF in a broad range of patients, Marcus said. They include chronic, structural changes such as myocardial fibrosis or atrial enlargement, which track with advanced age and may be less associated with acute triggers.

Or they can include more dynamic and functional properties, such as ion-channel disturbance, that can be present in the absence of structural changes and may be more likely to react to environmental and behavioral triggers, he said.

In other words, triggers seem to be associated more with lone AF than AF with structural heart disease.

"It would make sense if you have an important environmental trigger that it would more likely influence something dynamic that could have an acute and transient effect on the electrical properties of the heart, as opposed to a kind of fixed structural issue that doesn't care whether alcohol is present or they didn't get enough sleep."

Marcus said the current analysis was part of preparation for the Individualized Studies of Triggers of Paroxysmal Atrial Fibrillation (I-STOP-AFib) randomized trial, the primary end point of which is based on the Atrial Fibrillation Effect on Quality of Life survey (AFEQT).

The trial plans to enter an estimated 478 smartphone-equipped patients with symptomatic paroxysmal AF, randomly assigning them to an intervention group or a control groups, both of which call for regular use of the Kardia Mobile (AliveCor) electrocardiographic monitor.

The intervention group, but not the control group, will make personalized lifestyle changes on the basis of a preceding period in which they tracked AF frequency, symptoms, and exposure to possible triggers. They'll conduct further monitoring to determine whether avoiding identified possible triggers has an effect on AF episodes.

"The goal is to be able to provide patients with their own information regarding the probability that a perceived trigger is in fact a trigger or not," Marcus said.

Marcus discloses research funding from Medtronic and Jawbone; consulting for Johnson & Johnson and InCarda Therapeutics; and holding equity in InCarda. Groh reported no conflicts. Disclosures for the other authors are in the report.

Heart Rhythm. Published online February 14, 2019. Abstract

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