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When an irregular heartbeat is something more: the WHF Roadmap on Atrial Fibrillation

27 May 2021

The heart’s two upper chambers (atria), and two lower chambers (ventricles), beat in coordinated motion to carry oxygen-rich blood and other nutrients around the whole body. In people with cardiac arrythmia, this coordination is disrupted and can become life-threatening.

The most common form of arrythmia is Atrial Fibrillation (AF), also called AFiB, affecting more than 33 million people worldwide. With AF, the beating motion of the atria is more like a quivering, reducing the heart’s ability to pump blood efficiently. As a result, blood can pool in the heart’s atria, forming clots. When blood clots in the left atrium break free they travel in the circulation and block arteries. This commonly affects the brain arteries, causing a severe stroke.

Because AF does not always manifest symptomatically, it can remain undiagnosed. Not only are many people unaware of AF, surveys suggest that more than 50 per cent of AF patients were minimally aware of the risk of stroke, heart failure and death from AF or did not know the name of their condition.

The newly updated WHF Roadmap on Atrial Fibrillation reflects important updates since its first iteration in 2017 – welcome news, given the rising incidence of AF and associated health, social and well-being costs.  It is part of a series of WHF Roadmaps on Cardiovascular Disease (CVD) that offer an integrated approach to care by drawing on the expertise of clinicians, researchers, allied health professionals, health systems experts and patient groups. The Roadmaps identify obstacles to better global health and outline a guide for overcoming them that can be adapted to national contexts.

The WHF Roadmap on Atrial Fibrillation also emphasises the issues and opportunities for care in low- and middle-income countries (LMICs). Some of these same issues apply to areas of higher-income countries where populations experience socioeconomic pressures, health inequalities and inadequate access to affordable care. Indeed, many of the challenges involved in AF testing and treatment mirror those across the spectrum of heart and circulatory diseases that claim more than 18 million lives annually. These challenges encompass geographical access to clinics especially for those in rural areas, affordable services and medication, shortage of trained health professionals, and care that does not factor in a patient’s full case history.

The AF Roadmap therefore identifies priorities for reducing death and disability. It emphasises advocacy to widen awareness of the issue of AF relating to heart disease, physician education and patient literacy, and focuses on the digital interventions that can facilitate screening, diagnosing and management.

Seven strategic areas make up a nexus for care delivery and are worth strong consideration, especially with regard to LMICs.  For example, a “hub and spoke” model, especially in rural and semi-urban zones, involves a specialist physician at the hub while caregivers such as community health workers and general practitioners aid in initiation of therapy, case detection and follow-up. Indeed, all have a role to play in addressing complementary strategies: promoting medication adherence, boosting health literacy, filling patient knowledge gaps, and enhancing the quality of educational resources and access to them.

One important impetus for the updated Roadmap has been the addition of treatments to the World Health Organization’s Model List of Essential Medicines vetted for their safety and effectiveness in meeting global health needs.  Non-vitamin K antagonist oral anticoagulants are crucial for stroke prevention and for the management of AF and are now included on the WHO List, following relevant efforts by the WHF Emerging Leaders team.

From wearable devices, smartphone-ready apparatus and implantable monitors, the digital horizon is expanding rapidly to allow for identifying and monitoring AF. Some hand-held or chest-applied electrocardiogram (ECG) devices attached to smartphones work as event recorders, creating a “rhythm strip” that is able to relay information gathered over a 30-second period to diagnose AF. Investigational work is underway to use artificial intelligence (AI) for mapping clinical information to create a tool that can identify those at risk. The Roadmap cites data from 11 LMICs in four different regions of the world showing that 53 per cent of adults have smartphones to connect to internet and run applications. Connectivity will be a critical opportunity for ensuring access to care via digital means.

The updated WHF Roadmap on Atrial Fibrillation is a key reference document for anyone involved in the planning, organization, patient management and implementation of approaches to reduce the burden of AF. The World Heart Federation supports the global implementation of this Roadmap through our National Roundtables, CVD scorecards, the Emerging Leaders Programme, and World Heart Day.