Support atrial fibrillation treatment with lifestyle habits

Do you know which lifestyle adjustments help in the treatment of atrial fibrillation (AF) and how? Learn from a leading UK cardiologist and electrophysiologist, Dr Saagar Mahida, about how your medical treatment for atrial fibrillation can be supported by a combination of lifestyle habits.

Firstly, what is atrial fibrillation?

Atrial fibrillation (AF) is a heart rhythm abnormality (also referred to as an arrhythmia). In this condition, the normal organised and regular heart rhythm is replaced by an irregular and often chaotic heart rhythm. Atrial fibrillation is the most common heart rhythm abnormality which leads to referral to a doctor.

What are the symptoms?

Patients with AF might experience various symptoms including heart palpitations (when the heart beats fast with an irregular pattern), fatigue, dizziness and a reduced ability to exercise.

The pattern of atrial fibrillation can be characterised by intermittent episodes of abnormal heart rhythm (clinically called paroxysmal atrial fibrillation) or continuous atrial fibrillation (also known as persistent atrial fibrillation).

How is AF treated?

Treatment for AF includes curative procedures (procedures intended to eliminate symptoms) called catheter ablation procedures, as well as medications. Lifestyle modifications also play an important role in treating atrial fibrillation. In recent years, there has been an increased focus on more holistic approaches to treating AFwith the aim of complimenting lifestyle modifications to complement with curative catheter ablations and/or medications.

What are the risk factors?

The risk factors for developing AF can be divided into two groups: those that can be modified by the patient and those that cannot be modified.

Risk factors that the patient can modify:

• Obesity
• Physical inactivity/poor cardiorespiratory fitness
• High blood pressure (hypertension)
• Diabetes
• Alcohol consumption
• Smoking
• Sleep disorders that affect breathing

Risk factors that the patient cannot modify:

• Age
• Gender
• Ethnic background
• Genetic susceptibility

Lifestyle changes that target the modifiable risk factors can reduce the risk of developing AF. Lifestyle changes can also reduce the progression of the disease and its symptoms in patients who already have a diagnosis of AF. Importantly, a number of lifestyle modifications for AF also have a positive impact on heart health and reduce the risk of other heart diseases.

Exercise

The level of exercise has been shown to influence the risk of developing AF. However, the relationship between exercise and AF is not simple.

Low levels of exercise and poor cardiorespiratory fitness levels are associated with a higher risk of developing AF.^1,2 On the other hand, high-intensity endurance training might also increase the risk of AF. ³ Therefore, the right ‘dose’ of exercise may be important in minimizing the risk of developing AF.

Amongst patients who already have a diagnosis of AF, exercise is a particularly important consideration. While it is common for patients with AF to feel nervous about exercise, the appropriate level of exercise is predicted to have a positive impact on AF and heart health in general. The optimal exercise programmes for patients with AF have not been fully defined but there is evidence to suggest that aerobic interval training improves symptoms, exercise capacity and quality of life in AF patients.⁴

Dietary habits

A healthy diet has a positive impact on AF and heart health in general. In addition to promoting weight loss, a healthy diet reduces the risk of developing diabetes and high blood pressure and promotes better control in people who already have these conditions.

Obesity, diabetes and high blood pressure are associated with an increased risk of developing atrial fibrillation. These conditions also result in poorer outcomes in patients who already have a diagnosis of atrial fibrillation.

The question relating to the optimal diet in patients with AF has not been fully answered. A number of previous studies have demonstrated that the Mediterranean diet, which typically contains fish and plant-based foods, may reduce the risk of AF.⁵ It has been proposed that the presence of natural antioxidants in foods such as olive oil, nuts, fruits and vegetables may reduce AF.^6-8 There is some recent evidence to suggest that a low carbohydrate diet may be associated with an increased risk of developing AF, regardless of the type of protein or fat used to replace carbohydrates.⁹ Overall, however, before specific diets can be recommended in patients with AF, more research studies are necessary. As discussed above, the biggest impact of a healthy diet is likely to be related to weight loss and modification of risk factors for atrial fibrillation such as diabetes and high blood pressure.

Optimisation of weight

Overweight and obese patients have a significantly higher risk of developing atrial fibrillation .¹⁰

Once they have a diagnosis of AF, overweight patients may also progress faster from having sporadic episodes of AF to more prolonged AF episodes and eventually continuous AF .^11,12 Overweight patients also have a higher risk of a catheter ablation procedure failing.¹³

Weight loss has the potential to reduce symptoms, positively influence other risk factors for AF (such as high blood pressure and diabetes) and promote heart health in general.¹⁴ Patients who lose weight have been proven to have a significantly higher chance of their catheter ablation procedure being successful.¹⁵ Importantly, even relatively small amounts of weight loss could reduce AF episodes.

Alcohol

The association between excessive alcohol and AF is well recognised. The phrase ‘holiday heart syndrome’ is commonly used to describe AF caused by binge drinking.

Moderate levels of alcohol consumption in people who drink regularly could also increase the risk of developing AF. Essentially, as the ‘dose’ of alcohol increases, so too does the risk of AF. Not surprisingly, amongst people who are already diagnosed with AF, increased alcohol intake can trigger episodes of AF and result in a higher burden of symptoms overall. Increased alcohol intake is also associated with faster progression from transient intermittent (paroxysmal) AF to continuous (persistent) AF.¹⁶ Higher levels of alcohol consumption are also associated with higher failure rates after catheter ablation procedures. ¹⁷

Aside from triggering episodes of AF and increasing symptoms, alcohol can increase blood pressure and weight. Alcohol intake is also associated with an increased risk of sleep apnoea (sleep-disordered breathing), which in turn also influences the risk of AF.

Aside from triggering episodes of AF and increasing symptoms, alcohol can increase blood pressure and weight. It could be associated with an increased risk of and sleep apnoea (sleep-disordered breathing), which in turn also influences the risk of AF.

Caffeine and other stimulants

The link between drinking coffee and stimulant drinks with AF is not clearly defined.

Research studies on caffeine and AF have reported inconsistent results and the overall effect of caffeine is not well understood.¹⁸ While there are some reports of patients developing AF episodes after consuming stimulant drinks, once again, there is not enough research evidence on the subject.

Overall, avoidance of caffeine and stimulants would be recommended in patients in whom these drinks are known to trigger AF episodes. But there is not enough evidence to recommend avoidance of these drinks in all AF patients.

Management of stress

There is relatively limited information on whether anxiety/stress is a trigger for AF but several previous research studies have reported a potential mutual relationship between AF and anxiety.

It is often difficult to determine whether anxiety is a cause or a consequence of AF or if psychological stress is a potential trigger for AF.

Previous studies have reported an association between negative emotion and AF. The higher the number of ‘happy days’, the lower the burden of AF.¹⁹ Activities that have been associated with lower stress levels (such as yoga) have been linked to a reduced number of symptomatic AF episodes.²⁰ There is also some evidence indicating that patients with higher levels of anxiety have more recurrences of AF after ablation procedures.²¹

Patient-specific lifestyle changes

The discussion above has focused on general lifestyle modifications for atrial fibrillation patients. However, a ‘one size fits all’ approach is often not effective when treating patients with atrial fibrillation. Individual patients may benefit from tailoring their lifestyle changes based on their specific risk profile and triggers for atrial fibrillation. For instance, for some patients, removal of alcohol altogether may not be necessary but rather, defining the threshold that results in arrhythmia suppression might be more effective. By doing so, patients can balance quality of life with atrial fibrillation control. For other patients, specific alternative triggers may be identified and lifestyle modifications put into place to avoid these triggers.

Conclusions

It is important to emphasize that the lifestyle measures discussed in this article are aimed as complementary measures to curative catheter ablation procedures and/or medical therapy. An integrated and holistic approach to the management of AF is likely to have a more positive long-term outcome in terms of management of AF. In isolation, lifestyle measures are likely to be only moderately effective in suppressing the arrhythmia. The lifestyle modifications discussed here are closely interrelated and modification of one aspect is likely to have a positive impact on multiple different risk factors. However, these measures require a sustained and dedicated long-term strategy. The overall aim is to balance the reduction of arrhythmia burden and improve quality of life.

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References

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