An improved public health model targeted at ethnic minorities to recognize and act on symptoms of heart disease and stroke will decrease the burden and complications of AF and lessen the burden on the health system.
Potential research participants should be educated on the mechanisms in place to protect them. Figure 1 summarizes racial differences and disparities in traditional and novel risk factors; genetic studies, AF detection and symptom recognition; and AF-related outcomes. The role of novel risk factors in AF pathogenesis in minorities has had limited investigation. The contributions of traditional risk factors to AF pathogenesis merits further study.
Racial differences in the pattern of AF occurrence may exist but have not been well characterized. Intermittent or paroxysmal AF may be more common in minorities and potentially under diagnosed.
Racial and ethnic minorities are less likely to recognize symptoms of AF. Racial variations in warfarin use and efficacy have had limited study. The effectiveness of novel anticoagulants has not been validated in clinical trials enrolling substantive numbers of racial and ethnic minorities. Limited access to care, barriers to trial recruitment, and long-standing racial disparities may be contributing to higher rates of heart failure, ischemic stroke and overall cardiovascular mortality in minorities.
Quality of life and mortality related to AF have had markedly limited investigations in ethnic and racial minorities. The significant domains, challenges and potential areas for discovery of AF in racial minorities. Michael K. Amponsah and Emelia J. Benjamin declare no conflicts of interest. Human and Animal Rights and Informed Consent.
This article does not contain any studies with human or animal subjects performed by any of the authors. National Center for Biotechnology Information , U. Curr Cardiovasc Risk Rep. Author manuscript; available in PMC Oct 1. Amponsah , MD, 1 Emelia J. Magnani , MD, MSc 2, 3. Emelia J. Jared W. Author information Copyright and License information Disclaimer. Corresponding author: Jared W. Copyright notice. See other articles in PMC that cite the published article. Abstract Atrial fibrillation AF is the most commonly encountered clinical arrhythmia and is associated with adverse outcomes and increased healthcare costs.
Introduction Atrial fibrillation AF is the most commonly encountered clinical arrhythmia and is increasing in prevalence. Future directions Obtaining substantive AF data from developing regions of the world will remain a challenge for the foreseeable future.
AF risk factors in racial and ethnic minorities Traditional risk factors The primary risk factors for AF are advanced age, male sex, smoking, diabetes, hypertension, height, obesity, heart failure, valvular heart disease and myocardial infarction. Novel risk factors Novel risk factors for AF include thyroid disease, alcohol intake, obstructive sleep apnea, P wave indices PWI, electrocardiographic measures of atrial electrical function , and biomarkers.
AF risk prediction AF risk prediction models provide useful insights to the contribution of the risk factors to AF occurrence and may provide targeted pathways for AF prevention. AF Biomarkers Biomarkers have the potential to refine AF risk prediction models and further our understanding of the pathogenesis of AF.
Future directions Identifying novel risk factors in racial and ethnic minorities may reveal differences that will further refine AF risk prediction in racial and ethnic minorities.
Genetics of Atrial Fibrillation The hereditary component of AF in cohorts consisting primarily of individuals of European and Asian ancestry has been described elsewhere.
Future directions Establishing multigenerational cohorts of racial and ethnic minorities will allow for the determination of AF heritability. Future directions Further investigations with enhanced sensitivity for AF ascertainment may provide missing insights into the contribution of AF to stroke in ethnic and racial minorities.
Heart Failure AF and heart failure commonly complicate each other's course. Future directions Significant minority representation in investigations into the causal relations between AF and heart failure will help define the contribution of AF to heart failure in racial and ethnic minorities.
Mortality AF is an independent risk factor for all-cause mortality. Future directions The associations of AF and all-cause mortality and sudden cardiac death merit further investigation in racial minorities. Cognition A cross-sectional study of 6, mostly white individuals, age greater than 55 years showed an age-adjusted odds ratio for dementia in the setting of AF to be 2.
Future directions Individuals with subclinical cognitive impairment may be less likely to adhere to treatment. Symptoms and quality of life The cardinal symptoms of AF are dyspnea and palpitations. Future directions Since symptoms may lead to the diagnosis of AF, and since symptoms are used in AF treatment guidelines, understanding racial variation in AF symptoms will have diagnostic and therapeutic implications. Future Directions Increasing participation of racial and ethnic minorities in anticoagulation trials will allow investigators to identify potential differences in efficacy.
Rate vs. Future Direction The non-inferiority of lenient rate control of AF merits validation across all racial and ethnic groups. Future directions Data are needed to determine rates of utilization and outcomes of RFA among various ethnic and racial groups.
The persistent problem of racial disparities in healthcare The National Healthcare and Quality Disparities report highlights persistent racial differences in healthcare access, quality, and outcomes.
Conclusion Table 1 outlines the significant domains, challenges and potential areas for discovery of AF in racial minorities. Open in a separate window. Figure 1. Table 1 The significant domains, challenges and potential areas for discovery of AF in racial minorities. Domain Challenge Example of Challenge Areas for potential discovery, scientific advancement or improvement Epidemiology AF global burden Absent cardiovascular surveillance systems and limited studies from resource-poor settings.
Investigations in racial and ethnic minorities to validate novel risk factors and AF biomarkers. Current GWAS limited to largely white cohorts. AF outcomes Adverse outcomes Higher ischemic stroke death rate and heart failure hospitalization rates in racial minorities.
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CNS Drugs. Use and effectiveness of warfarin in Medicare beneficiaries with atrial fibrillation. These four randomized trials demonstrated that a rate control strategy is an acceptable alternative to rhythm control in patients with recurrent atrial fibrillation. For those with severely symptomatic atrial fibrillation, continued rhythm control is unavoidable.
For these patients, safer and more effective methods of maintaining sinus rhythm are needed to reduce morbidity related to palpitations and atrial fibrillation-induced heart failure. Furthermore, the randomized studies showed that rhythm control therapy does not prevent stroke. It was observed from RACE that 21 of the 35 thromboembolic complications occurred under rhythm control, the majority while receiving inadequate anticoagulation therapy.
Therefore, one of the main lesson learned from the randomized studies is that anticoagulation must be continued if stroke risk factors are present even if patients maintain sinus rhythm. Abstract Atrial fibrillation is the most common sustained cardiac arrhythmia. Gov't Review. Substances Anti-Arrhythmia Agents.
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