Lifestyle Changes Reduce AF: AHA Scientific Statement

March 10, 2020

Healthcare providers need to do more to address lifestyle factors for patients with atrial fibrillation (AF), according to a new scientific statement from the American Heart Association.

The statement notes that although great strides have been made in stroke prevention and rhythm control for patients with AF, lifestyle risk factors for AF are increasing. These include obesity, physical inactivity, sleep apnea, diabetes mellitus, hypertension, cigarette smoking, and excessive alcohol intake.

There is emerging evidence that addressing these modifiable risks may be effective for primary and secondary prevention of AF and that a structured, protocol-driven, multidisciplinary approach to integrating the management of lifestyle and risk factors in AF management may help in the prevention and treatment of AF, according to the statement.

"While established medical treatment protocols remain essential, helping AF patients adopt healthier lifestyle habits whenever possible may further help to reduce episodes of AF," said Mina K. Chung, MD, chair of the writing group for the scientific statement. She is a cardiologist and a professor of medicine at the Cleveland Clinic, in Ohio.

The statement was published online in Circulation on March 9.

Chung told Medscape Medical News that the document was issued at this time because recent studies have demonstrated the benefits of lifestyle changes.

"There is some interesting data now coming out, particularly from Australia, showing that lifestyle changes can reduce AF burden. We have known for a while that AF is associated with several lifestyle stressors, such as obesity and lack of physical activity, and these latest studies have shown that if overweight patients can reduce their weight by 10% and patients can increase their physical activity by 2 METS (expending twice the energy used by the body at rest), then this can reduce their AF," she said.

The authors view lifestyle changes as the fourth pillar of AF care, in addition to anticoagulation and rate and rhythm control, Chung said. "This document could be viewed as a call to action, and to help with that, we wanted to review all the evidence behind the various modifiable risk factors that may contribute to AF," she added.

The statement identifies obesity as a strong risk factor that may be causal for AF. It notes that in one study, individuals who were overweight or obese and who lost at least 10% of their body weight were less likely to develop AF or to have it become persistent. In some cases, persistent AF became intermittent or disappeared entirely. Bariatric surgery for obese patients has been associated with reduced risk for new AF and reduced recurrence after AF ablation.

Physical activity could also help in the battle against AF. The statement notes that regular aerobic exercise is effective in reducing AF burden and improving AF-related symptoms and quality of life. Moderate exercise does not increase the risk for AF and appears to be beneficial, but extreme levels of exercise may be associated with a higher risk for AF.

"Our recommendation is to encourage AF patients to aim for at least the AHA physical activity guidelines for the general population, which advise 150 minutes each week of moderate-intensity exercise," Chung said.

The prevalence of sleep-disordered breathing is high among patients with AF, and observational evidence suggests there is a dose‐response relationship between the severity of sleep-disordered breathing and AF incidence, burden, and response to treatment, according to the statement.

Patients with sleep-disordered breathing who receive therapy with continuous positive airway pressure (CPAP) appear to have a lower risk for AF recurrence after AF ablation. Thus, screening for and treatment of sleep-disordered breathing are important components of lifestyle modification for patients with AF, it adds.

Diabetes mellitus is associated with a higher risk for AF and may predispose to structural, electric, and autonomic changes, the authors report. Good glycemic control has been associated with reduced risk for AF, and blood sugar control may be important for reducing recurrent AF burden, the authors write.

Hypertension is also associated with risk of developing AF. Blood pressure management for AF should follow current guidelines for general cardiovascular health and includes management of contributory lifestyle factors (obesity, physical inactivity, and diet), along with pharmacotherapy, the statement recommends.

Other lifestyle interventions that could help reduce AF burden include smoking cessation, reduction of alcohol intake, and optimization of treatments for heart failure and hyperlipidemia.

Lifestyle modification can be promoted by all healthcare providers, and physicians have a potentially important role in prioritizing clinical lifestyle interventions for patients with AF, according to the statement. Even brief advice from physicians to quit smoking or lose weight is associated with smoking cessation and weight loss, it notes. Optimally, each risk factor should be targeted for a given individual, it adds.

Studies have recommended progressive goals to achieve a target body mass index of ≤25 kg/m2. Initially, low-intensity exercise should be practiced for 20 min three times weekly. The amount should be increased to 200 min/week of moderate-intensity activity. The authors also recommend that patients be referred to a comprehensive weight management program, and they recommend bariatric surgery for those who are eligible.

Because there are many lifestyle factors related to AF management, referral to multidisciplinary teams may facilitate intensive and comprehensive lifestyle counseling. If these programs are not available locally, health systems interested in reducing the burden of AF could invest in such treatment teams, the statement suggests.

Lifestyle risk factors for AF should be considered chronic diseases that require multiple interventions to produce long-term, successful outcomes, it concludes.

"The data emerging support the beneficial effects of lifestyle modification to reduce AF and the development of integrated, multidisciplinary teams and/or structured programs that can facilitate intensive and comprehensive lifestyle counseling for our patients with AF. We encourage healthcare teams to consider lifestyle interventions in addition to medical management for all patients with AF," said Chung.

The statement was written on behalf of the American Heart Association's Electrocardiography and Arrhythmias Committee and the Exercise, Cardiac Rehabilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; the Council on Arteriosclerosis, Thrombosis and Vascular Biology; the Council on Cardiovascular and Stroke Nursing; and the Council on Lifestyle and Cardiometabolic Health.

Circulation. Published online March 9, 2020. Abstract

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