Primary prevention
Primary prevention strategies are based on reducing risk factors through lifestyle modification.[1][2][3][49] US guidelines now recommend that patients at increased risk of atrial fibrillation (AF) receive comprehensive guideline-directed lifestyle and risk factor modification, which includes maintenance of ideal weight and weight loss if overweight or obese, having a physically active lifestyle, reducing unhealthy alcohol consumption, stopping smoking, controlling diabetes, and controlling blood pressure/hypertension.[1]
Use of ACE inhibitors, statins, and specific dietary lipid components present in certain types of fish have been shown to reduce the incidence of AF.[68][69][70][71][72][73] Preoperative treatment with a beta-blocker or amiodarone reduces postoperative incidence of AF in patients undergoing cardiac surgery or in patients at high risk for AF.[1][5]
[ 
]
[ ]
Nonpharmacologic interventions, including atrial pacing, may also be considered for prevention of postoperative AF in patients undergoing cardiac surgery.[74]
[ ]
In patients with obstructive sleep apnea, optimal management of the condition may reduce AF incidence and recurrences.[1][2]
Moderate physical activity may prevent the development of AF; however, it has been found that strenuous activity can increase the risk of AF.[3][75] It may be appropriate to recommend caution to those who pursue years of regular, high-volume (≥3 hours/day) high-intensity endurance training; observational data exists linking this with increased AF risk in men and similar J-curve risk observed for high or vigorous activity in both men and women in another study.[1][76][77]
The table that follows summarizes recommendations for primary prevention of AF taken from the ACC/AHA/ACCP/HRS (American College of Cardiology/American Heart Association/American College of Clinical Pharmacy/Heart Rhythm Society) guideline for the diagnosis and management of AF.[1]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Adult; with risk factors for AF
Risk factors for AF include (but are not limited to): advancing age; smoking; sedentary lifestyle or elite/extreme exercise; increasing alcohol use; obesity or overweight; increasing height; elevated blood pressure and hypertension; diabetes; presence of cardiovascular disease (e.g., coronary artery disease, heart failure); thyroid disease.
With hypertension
Intervention
Blood pressure control
Optimize blood pressure control using lifestyle interventions with or without antihypertensive medication to reduce blood pressure in line with published clinical guidance on management of hypertension.
Hypertension is the risk factor with the highest attributable risk for AF; intensive BP control lowers the risk of incident AF in observational and randomized data.
Goal
Blood pressure reduction and prevention of AF
Follow recommendations on blood pressure targets for the general population in line with published clinical guidance on management of hypertension.
With overweight or obesity
Intervention
Weight loss
Follow guideline-directed advice on achieving weight loss, which may include lifestyle measures with or without consideration of pharmacotherapy or surgery.
Management of weight is important in the prevention and treatment of AF. Obesity results in direct changes to the atrial myocardium forming the substrate for AF. In addition, obesity is also associated with several comorbidities that have been independently associated with the development of AF.
See Obesity in adults.
Goal
Weight loss and prevention of AF
Follow recommendations on healthy body weight targets for the general population in line with published clinical guidance.
Physically inactive
Intervention
Counseling on maintenance of a physically active lifestyle
Encourage the individual to engage in physical activity. A physically active lifestyle is recommended to reduce the risk of development of AF, particularly if the person is sedentary.
Goal
Increased physical activity and prevention of AF
Physical activity is recommended in line with physical activity targets for the general population.
With alcohol consumption
Intervention
GIve advice on safe drinking levels
Counsel the individual to drink moderately (or abstain from alcohol) and to avoid binge drinking. It may be appropriate to explain that alcohol consumption enhances the risk of AF in a linear fashion, with clear evidence that binge drinking heightens the risk.
One standard alcoholic drink/day is the maximum recommended amount to reduce the risk of AF development, although uncertainty persists regarding harms or benefits of drinking this amount daily.
Goal
Adherence to safe drinking guidance and prevention of AF
Advise patients to limit their alcohol intake to ≤1 standard alcoholic drink/day or to abstain from alcohol.
With suspected or confirmed substance use disorder
Intervention
Consider referral for substance use disorder treatment
Refer the patient with suspected or confirmed substance use disorder for treatment as appropriate. Treatment for substance use disorder may be beneficial in reducing the risk of AF given that there is an association of cannabis, cocaine, methamphetamine, and opioid use with increased incidence of AF.
Goal
Treatment of substance use disorder and prevention of AF
With smoking
Intervention
Smoking cessation counseling and/or medications
Offer guideline-directed management for smoking cessation encompassing behavioral counseling with or without pharmacotherapy.
It may be helpful to explain that smoking is associated with increased risk of AF and smoking cessation is associated with decreased risk of incident AF.
Goal
Smoking abstinence and prevention of AF
With diabetes
Intervention
Optimize glycemic control
Follow guideline-directed management of diabetes according to the subtype of diabetes present, including lifestyle interventions with or without pharmacotherapy.
The presence of either type 1 or type 2 diabetes increases AF risk, with evidence that worse glucose control correlates with a higher probability of developing AF.
There is limited evidence to suggest that taking a sodium-glucose cotransporter-2 (SGLT2) inhibitor may prevent new AF in people with type 2 diabetes, although the evidence is not strong enough to offer a definitive recommendation to support the use of SGLT2 inhibitors for AF prevention.
Goal
Individualized glycemic goal and prevention of AF
Assess glycemic status at appropriate intervals in line with the individual’s personalized diabetes management plan.
Undergoing cardiac surgery
Intervention
Consider short-term prophylactic beta-blocker or amiodarone; consider concomitant posterior left pericardectomy in selected patients
If a patient is undergoing cardiac surgery, it is reasonable for the hospital team to administer short-term prophylactic beta-blockers or amiodarone to reduce the incidence of postoperative AF.
Furthermore, it is reasonable for the surgical team to perform concomitant posterior left pericardiectomy to reduce the incidence of postoperative AF in people undergoing:
A coronary artery bypass graft (CABG)
Aortic valve or ascending aortic aneurysm operations
New-onset AF after cardiac surgery is common and has been associated with increased risks of late mortality and stroke.
Trials of prophylactic amiodarone and beta-blockers have demonstrated effectiveness reducing the occurrence of new AF, but not in all studies.
Goal
Reduced incidence of postoperative AF
Initiated on cancer therapy associated with an increased risk of developing AF
Intervention
Consider cardiology referral for evaluation and optimization of cardiovascular risk factors
If the patient is taking medical cancer therapies that increase the risk of incident AF, consider referral to a cardiologist, as required, for optimization of cardiovascular conditions.
Implicated medical cancer therapies include:
Anthracyclines
Antimetabolites
Alkylating agents
Immunomodulatory drugs
Tyrosine kinase inhibitors (TKIs)
Chimeric antigen receptor (CAR) T-cell therapy
Monoclonal antibodies
Notably, Bruton tyrosine kinase (BTK) inhibitors, such as ibrutinib, which are used to treat chronic lymphocytic leukemia and lymphoproliferative malignancies and often used for an extended period of time, are associated with a higher risk of AF due to off-target cardiac effects.
Patients with cancer and AF are on average older and have higher rates of hypertension, myocardial infarction, and heart failure compared with those who do not develop AF. In general, patients with cancer and cardiovascular disease may be undertreated with guideline-directed medical therapy and infrequently referred to specialists for cardiovascular care.
The presence of raised natriuretic peptides after major thoracic cancer surgery may indicate a higher risk of AF.
Goal
Reduced incidence of AF
With bradycardia requiring cardiac-implanted electronic device (pacemaker); with normal atrioventricular conduction
Intervention
Device selection and programming strategy to maintain atrioventricular synchrony
It is recommended that the specialized healthcare team consider:
using programming strategies that minimize right ventricular pacing to reduce the risk of AF, and
implementing antitachycardia pacing algorithms (where appropriate) to identify and terminate atrial arrhythmias, e.g., in people with organized atrial activation due to reentry.
Goal
Reduced incidence of AF
Secondary prevention
US guidelines now recommend that all patients with AF receive comprehensive guideline-directed lifestyle and risk factor modification, which includes secondary prevention measures: maintenance of ideal weight and weight loss if overweight or obese, having a physically active lifestyle, reducing unhealthy alcohol consumption, stopping smoking, controlling diabetes, and controlling blood pressure/hypertension.[1]
Weight reduction with intensive risk factor management has been shown to reduce AF symptom burden and severity, and result in beneficial cardiac remodeling.[3][220][221][222] Supervised exercise training has been shown to help reduce AF recurrence, improve quality of life, and improve cardiorespiratory fitness and functional capacity.[223][224][225]
Optimal management of obstructive sleep apnea may reduce AF incidence, recurrence, progression, and symptoms.[2][43][226]
Reducing or stopping alcohol intake may reduce arrhythmia recurrences.[3]
Cigarette smoking is associated with poorer outcomes in those with AF, and cessation has been associated with reduced risk of stroke and cardiovascular events.[227][228] Optimal control of blood pressure may reduce AF recurrence and cardiovascular events.[229][230][231]
Use of this content is subject to our disclaimer