Review
Atrial fibrillation: Profile and burden of an evolving epidemic in the 21st century

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Abstract

Background

Atrial fibrillation (AF) represents an increasing public health challenge with profound social and economic implications.

Methods

A comprehensive synthesis and review of the AF literature was performed. Overall, key findings from 182 studies were used to describe the indicative scope and impact of AF from an individual to population perspective.

Results

There are many pathways to AF including advancing age, cardiovascular disease and increased levels of obesity/metabolic disorders. The reported population prevalence of AF ranges from 2.3%–3.4% and historical trends reflect increased AF incidence. Estimated life-time risk of AF is around 1 in 4. Primary care contacts reflect whole population trends: AF-related case-presentations increase from less than 0.5% in those aged 40 years or less to 6–12% for those aged 85 years or more. Globally, AF-related hospitalisations (primary or secondary diagnosis) showed an upward trend (from ~ 35 to over 100 admissions/10,000 persons) during 1996 to 2006. The estimated cost of AF is greater than 1% of health care expenditure and rising with hospitalisations the largest contributor. For affected individuals, quality of life indices are poor and AF confers an independent 1.5 to 2.0-fold probability of death in the longer-term. AF is also closely linked to ischaemic stroke (3- to 5-fold risk), chronic heart failure (up to 50% develop AF) and acute coronary syndromes (up to 25% develop AF) with consistently worse outcomes reported with concurrent AF. Future projections predict at least a doubling of AF cases by 2050.

Summary

AF represents an evolving, global epidemic providing considerable challenges to minimise its impact from an individual to whole society perspective.

Introduction

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia and one of the most common cardiovascular conditions overall, is a “spectrum disorder” that spans isolated and benign episodes of electrical disturbance to a chronic condition that results in cardiac remodelling and functional impairment. AF is undoubtedly a progressive disorder with paroxysmal episodes becoming more frequent and persistent and persistent episodes often becoming permanent. Classification of AF sub-types reflects this natural history comprising “first diagnosed” AF, self-terminating paroxysmal episodes (transient to persistent) and the long-standing and permanent form of AF that defies attempts to achieve sinus rhythm [1]. However, much of the literature describing its epidemiology does not differentiate between paroxysmal versus persistent forms of AF: the minimum common standard for its detection being an episode of AF captured on ECG.

Advances have been made over recent decades to — a) improve our understanding of the evolving burden of AF, b) increase surveillance for its presence, c) accurately diagnose and characterise the sub-type of AF presentation (i.e. “first diagnosed”, paroxysmal, persistent or permanent) and d) improve its therapeutic management through the combination of pharmacological [2], [3], interventional [4], [5] and surgical [6], strategies. However, AF continues to have a significant impact on quality of life [7], morbidity and mortality [8]. In high income countries, the number of affected individuals is projected to increase exponentially over the next four decades [9]. Parallel increases in low-to-middle income countries due to epidemiological transition and an overall rise in non-communicable forms of heart disease are also likely [10]. Overall, therefore, AF exerts a major but evolving public health, social and economic burden worldwide. Notwithstanding the caveats and limitations to providing a succinct review of a large and heterogeneous literature base, the overall aim of this report is to provide an accurate, valid and comprehensive description of the evolving burden of AF by collating and synthesising data from the largest and most robust scientific reports.

Section snippets

Search strategy

Initially, all relevant publications and research reports on the epidemiology and global burden of AF were identified using specific search terms (refer to Appendix 1) via PubMed (incorporating literature that would be identified from many other bibliographic databases such as MEDLINE [11]). Searches were limited to English-language material published up to May, 2012. No restriction on earliest publication date was imposed. Therefore, manuscripts from as early as 1985 were included.

Antecedents

There are numerous reports of modifiable and non-modifiable risk factors that contribute to the development of AF. Table 1 provides a summary of the most commonly reported contributors to AF. These include socio-demographic factors, adverse lifestyle choices, cardiovascular conditions and other co-morbid conditions [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33]. The population prevalence of each of the common

Discussion

With a clear understanding of the caveats around trying to categorise and describe a nebulous body of studies and reports focussing on AF, this report provides a contemporary picture of the evolving impact of AF, predominantly from a high-income country perspective. As expected, all relevant data indicate that the current clinical and financial burden of AF is profound and shows no signs of slowing in the foreseeable future. Paradoxically, this phenomenon largely reflects improved longevity

Author declaration

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

Acknowledgements

The SAFETY study is funded by a National Health and Medical Research Council of Australia Program Grant (519823). In addition, JB, MC and SS are supported by the National Health and Medical Research Council of Australia. This study is supported in part by the Victorian Government's Operational Infrastructure Support Program.

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