I'm Melissa Brown, I'm a physician assistant working in cardiac electrophysiology at Emory University. I'm going to be presenting today on lifestyle interventions from the Risk Busters Mastering AFib Prevention and Lifestyle Upgrades series. I have no relevant financial disclosures. All of my topics today will center on the 2023 Guideline for Diagnosis and Management of Atrial Fibrillation. The last guideline came out in 2014, so this was quite a big update, nearly double in length, so a lot has happened in the last 10 years. The updated guidelines adopt a more proactive staged model for atrial fibrillation, adding two preclinical categories to help identify and intervene early, before the onset of the arrhythmia. The first stage, at risk for atrial fibrillation, includes people with AFib risk factors but no arrhythmia. The pre-AFib stage includes patients with early markers of electrical or structural atrial dysfunction like frequent PACs, burst of atrial tachycardia, a prior atrial flutter or left atrial enlargement on an echocardiogram. These factors can signal higher risk for atrial fibrillation. In the past, guidelines had primarily focused on stroke prevention and symptom control, but the 2023 update introduces a new section emphasizing the importance of managing comorbidities and modifiable risk factors as foundation to AFib care. This shift reflects a broader move towards upstream holistic care, aiming not just to treat AFib symptoms, but to address underlying causes. One of the key studies in AFib management was a randomized trial from Prosh Sanders Group in Australia, which showed that intensive weight loss significantly reduced AFib symptoms and burden. Based on this and similar data from other studies, such as Reverse AF and Legacy AF, the 2023 guidelines now give a class one recommendation for weight loss in patients with AFib and BMI over 27. Reverse AF showed that aggressive risk factor modification, including weight loss, can not only reduce AFib burden, but also may reverse the progression of AFib stages. Legacy AF demonstrated that sustained weight loss in patients with AFib significantly reduced arrhythmia burden and improved maintenance of sinus rhythm over time. A 10% weight loss over a year is linked with better sinus rhythm maintenance, reduced symptoms, improved ablation outcomes, and even reversal of AFib type. However, rapid weight fluctuations can reduce the benefits of weight loss as demonstrated by the Legacy AF trial. Weight loss in AFib is a bit nuanced. While very high levels of endurance training can increase AFib risk in a small subset of patients, most patients would benefit from moderate to vigorous activity being increased, which has been shown to reduce AFib burden. The recommendations receive a class one recommendation, and the target being 210 minutes a week, which breaks down to 30 minutes a day. Smoking increases AFib risk and recurrence after ablation, including smoking lowers stroke and mortality risk. Despite this, AFib patients often don't receive smoking cessation support. Smoking cessation receives a class one recommendation in the 2023 guidelines for AFib patients, despite no randomized trials due to strong observational data and its broad health impacts. The 2020 New England Journal of Medicine study titled Alcohol Abstinence in Drinkers with Atrial Fibrillation was a small randomized study of about 140 regular consumers of alcohol with AFib that showed that abstinence from alcohol significantly reduced AFib episodes compared to the control group. This evidence supports a class one recommendation for encouraging alcohol abstinence in patients with atrial fibrillation. Sleep apnea is strongly associated with an increased risk of atrial fibrillation. This link is well established. However, whether treating sleep apnea with CPAP reduces the AFib burden is less clear. Small randomized trials have been inconclusive, so the current guidelines give only class two B recommendations for sleep evaluation in atrial fibrillation patients. The rationale is not solely for AFib management, but because sleep apnea is common, affecting 20% of AFib patients, it's often underdiagnosed and treatment may offer broader cardiovascular and health benefits. Although many patients report caffeine as a personal trigger for atrial fibrillation, objective data does not support it consistently. Longitudinal and observational studies have found no increase or decrease of AFib with typical caffeine intake, so the coffee a day. While isolated case reports have associated excessive caffeine, such as energy drink overuse and young, otherwise healthy individuals with AFib, those are more outliers. Overall, the evidence is insufficient to recommend that patients eliminate moderate caffeine consumption like their daily cup of coffee, and we should not be recommending this. Managing all relevant risk factors of atrial fibrillation is a growing priority, now backed by class one recommendation. We should be consistently addressing these in our electrophysiology and cardiology clinics, but given the complexity and time demands, a multidisciplinary approach is often helpful. Nurse or APP-led clinics have shown success in delivering comprehensive AFib risk factor management and reducing AFib burden. While it's still unclear whether multidisciplinary care is superior to a single clinician using evidence-based algorithms, integrated care, including routine AFib checkups and coordinated management, has been shown to reduce all-cause mortality, especially in older adults. And that's all, thank you.

Atrial Fibrillation

Lifestyle Interventions

Risk Factors

2023 Guidelines

Multidisciplinary Approach