Atrial Fibrillation: Risk factors and comorbidities
Atrial fibrillation (AF), the commonest sustained cardiac arrhythmia, is associated with a devastating but largely preventable complication. AF is the leading independent risk factor for stroke and responsible for up to one third of all cases. Stroke related to atrial fibrillation is associated with higher mortality and disability than other strokes (two thirds of patients die within one year of a stroke due to AF5) due to the large clots which embolise from the heart. Comorbidity is common in AF and not only increases the risk of stroke but also the risk of bleeding from anticoagulation treatment. Hypertension, heart failure (which is a common cause and effect of atrial fibrillation), vascular disease, previous TIA /stroke and diabetes significantly increase stroke risk in AF patients1. All patients with AF who have even a single one of these comorbidities or who are aged 65 or over are likely to benefit from anticoagulation treatment1.
The lifetime risk of developing AF from the age of 40 is in the region of 1 in 4 for both men and women2. Sadly, about half of AF strokes occur in patients who were not previously diagnosed with AF3. It is therefore important to opportunistically screen for AF in patients who are at risk of developing AF. Patients over 65 and with diabetes and/or hypertension are at particularly high risk and even higher risk if there is evidence of micro and macro vascular disease e.g. patients with active diabetic foot disease.
Screening for AF can be rapidly and effectively achieved in clinic with a simple pulse check4 and should be an integral part of any diabetic review. If the pulse is regular, persistent AF is effectively ruled out. Those with an irregular pulse, characteristically irregularly irregular, should proceed to electrocardiography (ECG) to confirm or refute the diagnosis of AF. Once AF is confirmed full anticoagulation can be achieved within 3 hours of treatment initiation in the case of the DOACs. Anticoagulation in the setting of AF is one of the most effective treatments in medicine and reduces the risk of stroke by 65-70%.
Portable 1-lead ECG devices, such as the Kardia Alivecor device, are increasingly being used to screen for AF in a clinic setting and offer a high degree of sensitivity and specificity for AF. The device can be paired to a compatible phone or tablet which creates a pdf ECG trace which can be uploaded into the notes.
In summary, it is critically important to screen for and identify the potentially lethal comorbidity of AF in diabetic patients as this confers a more than five fold increase in the risk of stroke. A simple pulse check or use of a portable 1-lead ECG device in clinic can effectively screen for AF and is key to addressing the huge burden of avoidable catastrophic strokes and massive downstream healthcare, social as well as human costs.
Click here to watch Dr Javaid explain why AF detection is crucial and why being proactive in identifying AF can make a great difference and improve both the quantity and quality of a patient’s life.
Eur Heart J (2017) 38 (1): 4-5
Lloyd-Jones D et al. Circulation 2004;110:1042–1046
Cerasuolo J et al. Curr Opin Neurol 2017;30:28–37
SAFE Trial Fitzmaurice BMJ 2007(25 August) 335-383
Lin HJ et al. Stroke 1996;27:1760–1764