Care, outcomes remain uneven amid growing atrial fibrillation burden in US
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Key takeaways:
- September is National Atrial Fibrillation Awareness Month, and AF burden in the U.S. is growing.
- Large disparities in AF care and outcomes persist based on race, sex, geography and other factors.
Atrial fibrillation affects 2.7 million to 6.1 million people in the U.S., according to the American Heart Association, and that burden is expected to rise substantially in the coming years.
With AF comes risk for other CV conditions, including a fivefold elevated risk for stroke compared with the general population, yet many people remain undiagnosed and some people are at much higher risk for AF than others. There is likely a complex web of factors that explains the uneven burden of AF in the U.S., including social determinants of health such as access to care and transportation, according to Larry R. Jackson II, MD, MHSc, cardiac electrophysiologist and associate professor of medicine at Duke Health and an American Heart Association volunteer.
Healio spoke with Jackson about the burden of AF in the United States, how to reduce racial and ethnic disparities in care and outcomes, and initiatives aimed at educating clinicians and the public about AF. September is National Atrial Fibrillation Awareness Month.
Healio: What is the estimated prevalence of AF in the U.S. today, and what does that mean for CV risk?
Jackson: Contemporary literature suggests there are 6 million people with AF in the United States. That is likely a conservative, woefully underrepresented number, given the paroxysmal nature of AF. Meaning, AF can come and go and be asymptomatic. Whatever the number is, we can expect that number to double or even triple by 2025.
AF is associated with significant morbidity and mortality. It can increase risk for HF, stroke, cognitive decline presumably due to stroke, or other vascular phenomena.
Healio: Who is most at risk for AF and why?
Jackson: In the United States, at least, there are clear racial and ethnic differences in the incidence and prevalence of AF. This is paradoxical in the sense that Black adults tend to cluster a higher burden of risk factors associated with AF, such as HF, hypertension and diabetes. Yet, study after study suggests Black adults have a lower incidence and prevalence of AF compared with white people. We call that the AF paradox. In fact, it is a double paradox: Black individuals cluster more traditional risk factors associated with AF but have a lower incidence and prevalence. Yet, they are more likely to have strokes and die when they do have AF.
We have some theories about what might be behind that double paradox, but nothing concrete. One of the reasons may be a survivorship bias. Non-Hispanic white people tend to live longer than Black people and therefore have more detected AF during a longer life span. Some of it may be access-related. There are a whole host of social determinants of health that are preventing racial and ethnic minoritized populations from getting to medical care, specialized cardiac care and electrophysiology care to get a diagnosis. There may be a genetic component; some allele that is protective in racial and ethnic groups and deleterious in white patients, or structural or anatomical issues.
Healio: You mention access-related issues. Can you talk about how the built environment impacts health?
Jackson: We are working under the assumption that social determinants, whether that be neighborhood, distance from medical centers, transportation, green space, all play a role with respect to outcomes in AF like any other medical condition. If you have distance or a neighborhood preventing you from getting to a health center, your ability to be diagnosed and treated or even have a conversation about AF is severely limited. We are trying to analyze that from a research perspective. We make the strongest assumption that this is playing out in other disease processes that are linked to AF.
Healio: What is the AHA doing to improve education and awareness around AF?
Jackson: Get With the Guidelines is a quality improvement initiative that is aimed at improving uptake and utilization of the latest evidence-based guidelines. We do that through research and speaking to a broader audience about rhythm control strategies and risk factors associated with AF. Each of us who are members of the guidelines take this seriously because this is such a prevalent issue.
Unfortunately, the burden of AF is so large that primary care physicians must understand some baseline knowledge of AF to at least start the discussion. Cardiologists simply cannot keep up with the number of people with AF in this country. Primary care physicians are busy people seeing many different patients with different disease conditions. For us as researchers, what is the right type of tools to provide them, how often and in what space? We know, given the AF burden, that this has to start further upstream than cardiologists and certainly further upstream than cardiac electrophysiologists.
Healio: What further research is needed to better understand AF and improve AF outcomes?
Jackson: We live in a very geographically diverse country. When I speak about health equity, it is not only racial and ethnic groups. It is people living in rural and urban regions. It is our older populations. It is women, men and LGBTQ+ populations. It is people who may not be citizens of our country. We have not done a good job understanding AF and AF treatments and how they are utilized across the spectrum. How are those over age 80 years treated, when AF is most prevalent? We know minoritized patients are less likely to receive an ablation or oral anticoagulation therapy. Women, who have a disproportionately higher burden of morbidity and mortality than men, how are they treated? Much more work is needed around health equity.
It is incumbent upon patients to be their own advocate, but our clinician body is going to have to learn a little more about AF. We have to identify potential risks, have some basic knowledge about treatment options, and understand that the approach to AF should include a multidisciplinary team: Advanced practice providers, clinicians, patients, patient advocates and social support structures. If we can do that, across the board, we can begin to effect some change.
References:
- AFib Month Toolkit Resources. Available at: https://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-afib/afib-awareness-month-23/afib-month-toolkit-resources. Accessed Sept. 11, 2023.
- Get With the Guidelines AFib. Available at: https://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-afib. Accessed Sept. 11, 2023.
For more information:
Larry R. Jackson II, MD, MHSc, can be reached at larry.jackson@duke.edu; X (Twitter): @larryrjacksonII.
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