Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia with increasing incidence worldwide. Much focus has been directed towards AF prevention, given the morbidity and mortality from stroke, heart failure, and dementia. There are a number of common conditions associated with the onset of AF including, but not limited to, increased alcohol consumption, body weight, exercise, and stress. To reduce the incidence of AF, public health campaigns and targeted patient interventions may be warranted to promote balanced alcohol intake, appropriate exercise, and stress management to prevent AF and associated comorbidity. In this narrative review, we consider the evidence linking these risk factors with AF, putative mechanisms underlying the association, and whether risk factor modification may reduce AF burden.

Hypertension On a population-wide basis, hypertension is the most common predisposing factor for AF. The relationship between AF and blood pressure (BP) was first convincingly demonstrated by the Framingham Heart Study (FHS), in which hypertensive patients (defined as a systolic BP [SBP] of 160 mm Hg or higher, diastolic BP [DBP] of 95 mm Hg or higher, or use of antihypertensive medications) were significantly more likely to develop AF (odds ratio, 1.5 for men and 1.4 for women) over a 38-year follow-up. Similarly, the Manitoba study demonstrated a 1.42-fold increased risk of AF in hypertensive individuals over a 44-year follow-up. 9 The association between higher SBP and AF has also been noted within a shorter follow-up time of 3 years. 9,10 The association between incremental SBP and DBP and risk of AF has been shown in a prospective, population-based study of 2014 Norwegian men who were nondiabetic and nonhypertensive at baseline. Over a 35-year follow-up, the risk of AF onset was increased 1.60-fold (95% CI, 1.15-2.21) with an SBP of 140 mm Hg or higher and 1.50-fold (95% CI, 1.10-2.03) with an SBP of 128 to 138 mm Hg, as compared with an SBP

Implantable loop recorders (ILR) are devices that are implanted subcutaneously on the chest, which enables the continuous monitoring of arrhythmias for up to three years. These devices have an important role in helping to make a diagnosis and supporting decisions about the best patient management. There are currently three companies that produce ILRs. The Reveal DX and XT device is produced by Medtronic. The Confirm device is produced by Abbott. The Biomonitor III device is produced by Biotronik. The established indications for ILR include the management of transient loss of consciousness and the diagnosis of undocumented palpitations; however, they are also used for less established applications, including atrial fibrillation (AF) monitoring and risk stratification in patients with previous myocardial infarction or inherited cardiomyopathies. There is also diverse literature exploring the use of these devices in other populations, including patients with conditions such as congenital heart disease, amyloidosis, stroke, obstructive sleep apnea, renal transplant and patients who undergo procedures such as AF ablation and coronary artery bypass graft. In this review, we describe how the use of ILR has been applied in different settings, including patients with cardiac and non-cardiac conditions as well as post-cardiac procedures. We then discuss the potential issues related to using ILR in these other indications.

BackgroundAtrial fibrillation (AF) represents a growing healthcare challenge, mainly driven by acute hospitalisations. Virtual wards could be the way forward to manage acute AF patients through remote monitoring, especially with the rise in global access to digital telecommunication and the growing acceptance of telemedicine post-COVID-19.MethodsAn AF virtual ward was implemented as a proof-of-concept care model. Patients presenting acutely with AF or atrial flutter and rapid ventricular response to the hospital were onboarded to the virtual ward and managed at home through remote ECG-monitoring and ‘virtual’ ward rounds, after being given access to a single-lead ECG device, a blood pressure monitor and pulse oximeter with instructions to record daily ECGs, blood pressure, oxygen saturations and to complete an online AF symptom questionnaire. Data were uploaded to a digital platform for daily review by the clinical team. Primary outcomes included admission avoidance, readmission avoidance and patient satisfaction. Safety outcomes included unplanned discharge from the virtual ward, cardiovascular mortality and all-cause mortality.ResultsThere were 50 admissions to the virtual ward between January and August 2022. Twenty-four of them avoided initial hospital admission as patients were directly enrolled to the virtual ward from outpatient settings. A further 25 readmissions were appropriately prevented during virtual surveillance. Patient satisfaction questionnaires yielded 100% positive responses among participants. There were three unplanned discharges from the virtual ward requiring hospitalisation. Mean heart rate on admission to the virtual ward and discharge was 122±26 and 82±27 bpm respectively. A rhythm control strategy was pursued in 82% (n=41) and 20% (n=10) required 3 or more remote pharmacological interventions.ConclusionThis is a first real-world experience of an AF virtual ward that heralds a potential means for reducing AF hospitalisations and the associated financial burden, without compromising on patients’ care or safety.

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