The Impact of Diet and Lifestyle on Atrial Fibrillation
Purpose of Review
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in humans, affecting more than 33 million people globally. Its association with complex, resource intensive medical conditions such as stroke, heart failure and dementia have had profound impacts across existing health care structures. The global prevalence of AF has enjoyed significant growth despite significant improvement in our armamentarium for arrhythmia treatment.
Efforts aimed at curtailing the incidence, prevalence, or progression of AF have prompted re-evaluation of traditional frameworks for understanding and managing this debilitating disease. It is in this context that focus has shifted toward lifestyle-associated factors such as obesity, hypertension, sleep apnoea, exercise, alcohol and diet, as mechanistic drivers and putative targets for therapy. Compelling evidence exists for weight loss and management of associated risk factors to improve outcomes of AF treatment.
This review will address the epidemiologic and mechanistic evidence that link lifestyle-associated factors with AF and in light of this analysis evaluate the clinical impacts of their upstream management. Traditional paradigms of AF are shifting in light of emerging evidence, such that risk factor modification has become positioned as the fourth pillar of AF management.
KeywordsAtrial fibrillation Weight loss Risk factor management Diet Exercise Cardio respiratory fitness Alcohol
Compliance with Ethical Standards
Conflict of Interest
C.J. Nalliah and J.M. Kalman declare that they have no conflict of interest.
P. Sanders reports grants, non-financial support and other from Medtronic; grants, non-financial support and other from Abbott; grants, non-financial support and other from Boston-Scientific; other from CathRx; and other from Biosense-Webster. He is also supported by a Practitioner Fellowship from the National Health and Medical Research Council of Australia and also by the National Heart Foundation of Australia.
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.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 4.Mahajan R, Lau DH, Brooks AG, Shipp NJ, Manavis J, Wood JPM, et al. Electrophysiological, electroanatomical, and structural remodeling of the atria as consequences of sustained obesity. J Am Coll Cardiol 7. 2015;66:1–11.Google Scholar
- 8.Kistler PM, Sanders P, Dodic M, Spence SJ, Samuel CS, Zhao C, et al. Atrial electrical and structural abnormalities in an ovine model of chronic blood pressure elevation after prenatal corticosteroid exposure: implications for development of atrial fibrillation. Eur Heart J. 2006;27:3045–56.PubMedGoogle Scholar
- 20.van Rosendael AR, Dimitriu-Leen AC, van Rosendael PJ, et al. Association between posterior left atrial adipose tissue mass and atrial fibrillation. Circ Arrhythm Electrophysiol. 2017;10.Google Scholar
- 23.Pathak RK, Middeldorp ME, Stolcman S, Willoughby SR, Mahajan R, Lau DH, et al. Aggressive Risk factor REduction STudy: implications for the substrate for atrial fibrillation (ARREST-AF substrate study) (abstract). Circulation. Vol 1322015.Google Scholar
- 25.Parkash R, Wells GA, Sapp JL, Healey JS, Tardif JC, Greiss I, et al. Effect of aggressive blood pressure control on the recurrence of atrial fibrillation after catheter ablation: a randomized, open-label clinical trial (SMAC-AF [substrate modification with aggressive blood pressure control]). Circulation. 2017;135:1788–98.PubMedGoogle Scholar
- 30.Wachtell K, Lehto M, Gerdts E, Olsen MH, Hornestam B, Dahlof B, et al. Angiotensin II receptor blockade reduces new-onset atrial fibrillation and subsequent stroke compared to atenolol: the Losartan Intervention For End Point Reduction in Hypertension (LIFE) study. J Am Coll Cardiol. 2005;45:712–9.PubMedGoogle Scholar
- 35.Walters TE, Lee G, Spence S, Larobina M, Atkinson V, Antippa P, et al. Acute atrial stretch results in conduction slowing and complex signals at the pulmonary vein to left atrial junction: insights into the mechanism of pulmonary vein arrhythmogenesis. Circ Arrhythm Electrophysiol. 2014;7:1189–97.PubMedGoogle Scholar
- 39.Anter E, Di Biase L, Contreras-Valdes FM, et al. Atrial substrate and triggers of paroxysmal atrial fibrillation in patients with obstructive sleep apnea. Circ Arrhythm Electrophysiol. 2017;10.Google Scholar
- 41.Shukla A, Aizer A, Holmes D, Fowler S, Park D, Bernstein S, et al. Effect of obstructive sleep apnea treatment on atrial fibrillation recurrence: a meta-analysis. J Am Coll Cardiol. 2015;1:41–51.Google Scholar
- 44.•• Pathak RK, Middeldorp ME, Meredith M, Mehta AB, Mahajan R, Wong CX, et al. Long-term effect of goal directed weight management in an atrial fibrillation cohort: a long-term follow-up study (LEGACY Study). J Am Coll Cardiol. 2015;65:2159. This study provides long-term data of the impact of weight loss on arrhythmia freedom. It also highlights that in addition to weight loss, weight stability was also crucial for long term freedom from arrhythmia.–69.PubMedGoogle Scholar
- 45.Nalliah CJ, Sanders P, Kalman JM. Surgical weight loss to treat atrial fibrillation risk and progression. Curr Cardiovasc Risk Rep. 2017;11:32.Google Scholar
- 46.• Middeldorp ME, Pathak RK, Meredith M, et al. PREVEntion and regReSsive Effect of weight-loss and risk factor modification on atrial fibrillation: the REVERSE-AF study. Europace. 2018. This study observed that sustained weight loss and risk factor modification can reverse AF profile from perisistent to paroxysmal AF. Google Scholar
- 50.• Jamaly S, Carlsson L, Peltonen M, Jacobson P, Sjostrom L, Karason K. Bariatric surgery and the risk of new-onset atrial fibrillation in Swedish obese subjects. J Am Coll Cardiol. 2016;68:2497–504 This study provides data regarding the impact of dramatic surgical weight loss on incident AF. PubMedPubMedCentralGoogle Scholar
- 51.H Y, WR M, F L-J, YM C. The impact of bariatric surgery on incidence of atrial fibrillation. Heart Rhythm. 2014;S151.Google Scholar
- 53.Klatsky AL, Hasan AS, Armstrong MA, Udaltsova N, Morton C. Coffee, caffeine, and risk of hospitalization for arrhythmias. Permanente J Summer. 2011;15:19–25.Google Scholar
- 62.Macchia A, Grancelli H, Varini S, Nul D, Laffaye N, Mariani J, et al. Omega-3 fatty acids for the prevention of recurrent symptomatic atrial fibrillation: results of the FORWARD (randomized trial to assess efficacy of PUFA for the maintenance of sinus rhythm in persistent atrial fibrillation) trial. J Am Coll Cardiol. 2013;61:463–8.PubMedGoogle Scholar
- 66.Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston Miller N, Hubbard VS, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2960–84.Google Scholar
- 67.Larsson SC, Drca N, Wolk A. Alcohol consumption and risk of atrial fibrillation: a prospective study and dose-response meta-analysis. J Am Coll Cardiol. 2014;64:281–9.Google Scholar
- 72.Qiao Y, Shi R, Hou B, Wu L, Zheng L, Ding L, et al. Impact of alcohol consumption on substrate remodeling and ablation outcome of paroxysmal atrial fibrillation. J Am Heart Assoc. 2015;4.Google Scholar
- 82.Azarbal F, Stefanick ML, Salmoirago-Blotcher E, et al. Obesity, physical activity, and their interaction in incident atrial fibrillation in postmenopausal women. J Am Heart Assoc. 2014;3.Google Scholar