Atrial fibrillation in low- and middle-income countries: a narrative review

Abstract

Preventing premature non-communicable disease mortality necessitates a thorough review of one of the most important risk factors for stroke, which is atrial fibrillation (AF). The latter and AF-related stroke are still considered to be problems of high-income countries and are frequently overlooked in low- and middle-income countries (LMICs). In this narrative review, we provide an overview of studies that evaluated at least one of the following determinants of AF burden in LMICs: current epidemiology and trends, stroke prevention, health outcomes, and economic burden. Studies focusing on samples close to the general population (including community- and primary care-based samples) indicate sex-specific prevalence rates up to 7.4% in LMICs. Although AF prevalence is still higher in high-income countries than LMICs, the gap in AF burden between these two groups has been reducing in the past three decades. Oral anticoagulant (OAC) therapy for stroke prevention is underused in LMICs, and there are little data on OAC therapy in relation to stroke risk scores, such as CHA2DS2-VASc. Available data also points to higher morbidity and mortality for patient with AF in LMICs than their counterparts in high-income countries. Data on the consequent economic burden in LMICs is scarce, but it is reasonable to consider it will follow the same trend as that observed for health outcomes. Raising the visibility of AF as a public health problem in LMICs is necessary as a first step to providing adequate care for patients with this condition.

The prevalence of atrial fibrillation in Greenland: a register-based cross-sectional study based on disease classifications and prescriptions of oral anticoagulants

“…Thus, as our study is based on disease classification codes and medication, it is more likely to include patients with all AF types, although our study setup only allows us to include patients already diagnosed or treated for AF and therefore misses undiagnosed patients. However, our findings are in line with studies from other parts of the world, as the worldwide prevalence of AF in adults is estimated to be between two and four per cent [ 22 ], between one and two per cent in the Canadian and the general US population [ 10 , 23 ] and between 0.5% and three per cent in most low- and middle-income countries [ 24 ].…”

Clinical Profile of Patients with Atrial Fibrillation According to EHRA (Evaluated Heart Valves, Rheumatic or Artificial) Categorization in A Middle-Income Country

“…The underutilization of oral anticoagulation is still a current fact. In low-and middle-income countries, the oral anticoagulation rate ranges from 11% to 85%, and in Latin America the average rate is 43.3% [19]. With regard to the use of warfarin, this occurs mainly in elderly people aged at least 75 years, with higher CHA2DS2-VASc score, even in developed countries, with a prescription rate of 50.8%, and anemia is one of the associated independent factors [20].…”

Environmental Fe, Ti, Al, Cu, Hg, Bi, and Si Nanoparticles in the Atrioventricular Conduction Axis and the Associated Ultrastructural Damage in Young Urbanites: Cardiac Arrhythmias Caused by Anthropogenic, Industrial, E-Waste, and Indoor Nanoparticles

“…Ambient air pollution across the globe is strongly associated with cardiovascular morbidity and mortality. , Exposure to high ambient air pollutants, particularly concentrations of fine particulate matter (PM 2.5 ) above current standards, has been linked with abnormal cardiac rhythms through oxidative stress, autonomic and coagulation dysfunction, and inflammation. , Unpredictable and lethal and nonlethal arrhythmias are associated with structural heart diseases, cardiac remodeling, common diseases such as diabetes mellitus, autonomic nervous system alterations, and genetic channelopathies. − Atrioventricular node reentrant tachycardia (AVNRT) is the most common mechanism of supraventricular tachycardia, and atrioventricular asynchrony is strongly associated with atrial fibrillation (AF), which is the most common cardiac tachyarrhythmia, with an estimated 6–12 million people in the USA being affected by 2050. − AF is a major global problem affecting millions of people, with varying prevalence in North America, Europe, China, and Southeast Asia versus Africa and the Middle East, and is associated with air pollution exposures. − …”

“…We have reported in clinically healthy Metropolitan Mexico City (MMC) 6y olds supraventricular arrhythmias. In forensic autopsy cohorts (19.97 ± 6.8 years) without cardiac diseases, extensive myocardial oxidative and endoplasmic reticulum (ER) stress, upregulation of inflammatory genes and inflammasomes, (including nucleotide oligomerization domain (NOD) factors (NOD-like receptors (NLRs) are intracellular proteins that play a critical role in examining the intracellular environment for the presence of infection, noxious substances, and metabolic perturbations) and caspases, and magnetite/maghemite nanoparticles (NPs) with rounded crystal morphologies and fused surface textures as described in combustion- and friction-derived nanoparticles. − The amount of magnetic, iron-rich NPs was up to ∼22 billion per gram of ventricular tissue and was more abundant in exposed vs low air pollution controls; it was present in ventricular cardiomyocytes, mitochondria, endoplasmic reticulum (ER), at mitochondria-ER contact sites (MERCs), intercalated disks, and endothelial and mast cells. , The increasing number of patients with atrial fibrillation and patients with embolic stroke of undetermined source with potentially undiagnosed AF in Latin America and Mexico is a major concern. , …”

“…Although the multiple potential mechanisms underlying the association between AV node pathology and typical and unusual accessory pathways and the development of cardiac arrhythmias and each type of AV nodal reentrant tachycardia , is under intensive study, exploration of the ultramicroscopic pathology and the composition of NPs in the AV node is paramount because air pollution is a robust risk factor for arrythmias. ,,,,, …”