Atrial fibrillation in the Indigenous populations of Australia, Canada, New Zealand, and the United States: a systematic scoping review

Quality of care among patients diagnosed with atrial fibrillation in Greenland

This cross-sectional study sought to assess the prevalence of atrial fibrillation (AF) diagnosis in Greenland among various age groups and examine the corresponding quality of care. We collected data from Greenland's electronic medical records and evaluated the quality of care using six internationally recommended indicators, which are: percentage of AF patients with an assessment of smoking status within the previous year, an assessment of body mass index within the previous year, assessment of blood pressure within the previous year, measurement of thyroid stimulating hormone (TSH), treatment with an anticoagulant and percentage of patients with a measurement of serum-creatinine. We found the prevalence of AF among patients aged 20 years or older in Greenland to be 1.75% (95% CI 1.62-1.88). We found an increasing prevalence of AF with age and a greater proportion of men than women until the age of 74 years. Our study suggests that the associated quality of care could be higher as the requirement of only one of the six quality indicators was met. A lack of registration may partly explain this, and initiatives to improve the quality of care are recommended.

Arrhythmias and ion channelopathies causing sudden cardiac death in Hispanic/Latino and Indigenous populations

The limited literature and increasing interest in studies on cardiac electrophysiology, explicitly focusing on cardiac ion channelopathies and sudden cardiac death in diverse populations, has prompted a comprehensive examination of existing research. Our review specifically targets Hispanic/Latino and Indigenous populations, which are often underrepresented in healthcare studies. This review encompasses investigations into genetic variants, epidemiology, etiologies, and clinical risk factors associated with arrhythmias in these demographic groups. The review explores the Hispanic paradox, a phenomenon linking healthcare outcomes to socioeconomic factors within Hispanic communities in the United States. Furthermore, it discusses studies exemplifying this observation in the context of arrhythmias and ion channelopathies in Hispanic populations. Current research also sheds light on disparities in overall healthcare quality in Indigenous populations. The available yet limited literature underscores the pressing need for more extensive and comprehensive research on cardiac ion channelopathies in Hispanic/Latino and Indigenous populations. Specifically, additional studies are essential to fully characterize pathogenic genetic variants, identify population-specific risk factors, and address health disparities to enhance the detection, prevention, and management of arrhythmias and sudden cardiac death in these demographic groups.

Is the Pattern Changing? Atrial Fibrillation and Screening with Holter Electrocardiograms among Ischemic Stroke Patients in Greenland from 2016 to 2021

A standardized examination regime for ischemic stroke (IS) patients was implemented in Greenland in 2010. Prevalence of atrial fibrillation (AF) of 32% was found among discharged IS patients from 2011 to 2012, and our study aims to estimate the use of Holter ECGs for AF diagnostics and the current prevalence of AF among IS patients in Greenland. Patients discharged from Queen Ingrid's Hospital in Nuuk between 2016 and 2021 with an ICD-10 diagnosis of IS or stroke without specification were included. Data on Holter recordings, age, gender, medical treatment with rivaroxaban or warfarin, and ICD-10 and ICPC codes for AF were extracted for each patient. The overall incidence of IS from 2016 to 2021 was 133/100,000 and unchanged since 2012. Sixty-eight of the study's IS patients (14.5%) had AF, and 46% of IS patients with Holter data accessible had a recording according to international recommendations. Our results indicate that fewer IS patients in Greenland have AF than previously. However, the insufficient use of Holter as a diagnostic tool may explain part of the drop, as well as improved preventive treatment with rivaroxaban among AF patients in Greenland. Regardless, IS remains common, and a focus on diagnostics and preventable risk factors should be maintained.

Atrial fibrillation incidence and outcomes in two cohorts of octogenarians: LiLACS NZ

BACKGROUND

Atrial fibrillation (AF), the most common cardiac arrhythmia in the general population, has significant healthcare burden. Little is known about AF in octogenarians.

OBJECTIVE

To describe the prevalence and incidence rate of AF in New Zealand (NZ) octogenarians and the risk of stroke and mortality at 5-year follow-up.

DESIGN

Longitudinal Cohort Study.

SETTING

Bay of Plenty and Lakes health regions of New Zealand.

SUBJECTS

Eight-hundred-seventy-seven (379 indigenous Māori, 498 non-Māori) were included in the analysis.

METHODS

AF, stroke/TIA events and relevant co-variates were established annually using self-report and hospital records (and ECG for AF). Cox proportional-hazards regression models were used to determine the time dependent AF risk of stroke/TIA.

RESULTS

AF was present in 21% at baseline (Māori 26%, non-Māori 18%), the prevalence doubled over 5-years (Māori 50%, non-Māori 33%). 5-year AF incidence was 82.6 /1000-person years and at all times AF incidence for Māori was twice that of non-Māori. Five-year stroke/TIA prevalence was 23% (22% in Māori and 24% non- Māori), higher in those with AF than without. AF was not independently associated with 5-year new stroke/TIA; baseline systolic blood pressure was. Mortality was higher for Māori, men, those with AF and CHF and statin use was protective. In summary, AF is more prevalent in indigenous octogenarians and should have an increased focus in health care management. Further research could examine treatment in more detail to facilitate ethnic specific impact and risks and benefits of treating AF in octogenarians.

Mind The Gap, Aboriginal and Torres Strait Islander Cardiovascular Health: A Narrative Review

Australia's First Nations Peoples, Aboriginal and Torres Strait Islanders, have reduced life expectancy compared to the wider community. Cardiovascular diseases, mainly driven by ischaemic heart disease, are the leading contributors to this disparity. Despite over a third of First Nations Peoples living in New South Wales, the bulk of the peer-reviewed literature is from Central Australia and Far North Queensland. Regardless of the site of publication, First Nations Peoples are significantly younger at disease onset and have higher rates of comorbidities, in turn driving adverse health events. On top of this, very few First Nations Peoples specific cardiovascular interventions or programs have been shown to improve outcomes. The traditional biomedical model of care is less efficacious and non-traditional models of communication such as clinical yarning may benefit both clinicians and patients. The key purpose of this review is to highlight the deficiencies of our knowledge of cardiovascular burden of disease for First Nations Peoples; and to serve as a catalyst for more dedicated research. We need to have relationships with communities and concentrate on community improvement and partnerships. By involving First Nations Peoples researchers in collaboration with local communities in all levels of health care design and intervention will improve outcomes.

American Indians and atrial fibrillation

The American Indian population is known to experience high rates of cardiovascular disease and have a heightened vulnerability to severe outcomes driven by an overall poor health status and lower access to quality health care. Our group has previously published an analysis demonstrating that American Indians have the highest risk of atrial fibrillation (AF), as well as of AF-related stroke, when compared with other races and ethnicities. Despite this, AF in this population has not been extensively studied and additional publications are scarce. Our review article provides an up-to-date summary of the relevant literature addressing the relationship between race, ethnicity, and AF by focusing on American Indians.

The prevalence of atrial fibrillation in Greenland: a register-based cross-sectional study based on disease classifications and prescriptions of oral anticoagulants

   Previous studies of the prevalence of atrial fibrillation (AF) in Greenland are based on either single-point electrocardiograms (ECGs) or patients admitted with stroke. This study estimates the prevalence of AF based on disease classifications in the electronic medical record system (EMR) and prescriptions of oral anticoagulants (OACs). Patients given a diagnose classification code for AF or atrial flutter or prescribed the vitamin K antagonist Warfarin or the direct-acting oral anticoagulant Rivaroxaban were identified in the EMR. Descriptive data and selected laboratory values were extracted, and a minimum CHA₂DS₂-VASc score was calculated for the 790 patients identified in the EMR (66% men). A total prevalence of AF of 1.4% was found in the general population (1.8% among men and 1.0% among women), with a significantly lower prevalence among women younger than 70 years. There was a significant increase in AF-prevalence with advancing age (p<0.001) for both men and women. A minimum CHA₂DS₂-VASc was estimated and app. 10% of the patients may be undertreated with OACs. The prevalence of AF found in this study is higher than that found in previous studies in Greenland and comparable to the prevalence found in other Western countries, indicating that AF is common in Greenland.

Racial and Ethnic Considerations in Patients With Atrial Fibrillation: JACC Focus Seminar 5/9

Atrial fibrillation (AF) affects at least 60 million individuals globally and is associated with substantial impacts on morbidity, mortality, and health care expenditures. This review focuses on how race and ethnicity influence AF epidemiology, risk prediction, treatment, and outcomes; knowledge gaps in these areas are identified. Most AF studies have predominantly included White populations, with an underrepresentation of racial and ethnic groups, including but not limited to Black, Hispanic, and Indigenous individuals. Enhancement and implementation of AF risk prediction, prevention, and management call for studies that will gather accurate race-based epidemiologic data and evaluate social determinants and genetic factors in the context of multiple races and ethnicities. Available studies highlight inequities in access to treatment as well as outcomes between White individuals and persons of other races/ethnicities. These inequities will need to be addressed by a renewed emphasis on structural and social determinants of health that contribute to AF.

Can the CHA2 DS2 -VA schema be used to decide on anticoagulant therapy in Aboriginal and other Australians with non-valvular atrial fibrillation?

The Australasian guidelines recommend use of the CHA₂ DS₂ -VA schema to stratify ischaemic stroke risk in patients with non-valvular atrial fibrillation (N-VAF) and determine risk thresholds for recommending oral anticoagulant (OAC) therapy. However, the CHA₂ DS₂ -VA score has not been validated in a representative Australian population cohort with N-VAF, including in Aboriginal people who are known to have a higher age-adjusted stroke risk than other Australians. In a retrospective data-linkage study of 49 114 patients aged 24-84 years with N-VAF, 40.0% women and 2.5% Aboriginal, we found that patients with a CHA₂ DS₂ -VA score >2 had high annual stroke rates (>2%) that would justify OAC therapy. This occurred regardless of Aboriginal status. Non-Aboriginal patients with a CHA₂ DS₂ -VA score of 0 had a mean annual stroke rate of 0.4%, and hence were not likely to benefit from antithrombotic therapy. However, Aboriginal patients with a zero CHA₂ DS₂ -VA score had a significantly higher annual stroke rate of 0.9%, and could potentially obtain net clinical benefit from anticoagulation, primarily with the safer non-vitamin K antagonist OAC. We conclude that clinicians can confidently use the CHA₂ DS₂ -VA score to make decisions regarding anticoagulation in accordance with stroke risk in patients with N-VAF, except in Aboriginal people in whom the risk score was unable to identify those at truly low risk of stroke.

Atrial Fibrillation in Remote Indigenous and Non-Indigenous Individuals Hospitalised in Central Australia

BACKGROUND

The epidemiology of atrial fibrillation (AF) amongst Indigenous populations remains poorly characterised. We studied hospitalisations for AF in Central Australia, the most populous Indigenous region in the country.

METHODS

Patients with a diagnosis of AF admitted to Alice Springs Hospital, the only secondary health care facility and provider of cardiac care in remote Central Australia, were identified from 2006 to 2016. Age and gender-specific hospitalised AF prevalence, comorbidities, and CHA₂DS₂-VASc scores were ascertained.

RESULTS

Of 57,056 admitted patients over the study period, 1,210 (2.1%; 46% Indigenous) had a diagnosis of AF. For Indigenous and non-Indigenous individuals <45 years, hospitalised AF prevalence per 10,000 population was 105 (CI 84-131) and 50 (CI 36-68) in males (ratio=2.10), and 98 (CI 77-123) and 12 (CI 6-23) in females (ratio=7.92), respectively. For Indigenous and non-Indigenous individuals ≥65 years, hospitalised AF prevalence per 10,000 was 1,577 (CI 1,194-2,026) and 2,326 (CI 2,047-2,623) in males (ratio=0.68), and 1,713 (CI 1,395-2,069) and 1,897 (1,623-2,195) in females (ratio=0.90). Indigenous individuals had higher rates of cardiometabolic comorbidities, particularly at younger ages. CHA₂DS₂-VASc scores were greater in Indigenous individuals, particularly those <45 years (2.5±1.5 versus 0.7±1.1, p<0.001).

CONCLUSIONS

The prevalence of hospitalised AF amongst Indigenous people in remote Central Australia was significantly higher than in non-Indigenous individuals, particularly in younger age groups and females. Indigenous individuals with hospitalised AF also had a markedly greater prevalence of cardiometabolic comorbidities and elevated stroke risk. These data suggest that AF may be contributing to the gap in morbidity and mortality experienced by Indigenous Australians.

Predictors of Anticoagulation Use in Indigenous and Non-Indigenous Australians With Atrial Fibrillation

OBJECTIVE

Prior studies have demonstrated that anticoagulation underutilisation for atrial fibrillation (AF) and elevated stroke risk is common. However, there is little data on factors associated with appropriate anticoagulation, particularly in Indigenous Australians who face a disproportionate burden of AF and stroke. We thus sought to determine factors associated with anticoagulation use in Australians with AF.

DESIGN

Administrative, clinical, prescriptive and laboratory data were linked and aggregated over a 12-year period.

SETTING

Single tertiary teaching hospital.

PARTICIPANTS

19,305 (98%) and 308 (2%) consecutive non-Indigenous and Indigenous Australians with AF identified from administrative databases.

MAIN OUTCOME MEASURES

Associations of anticoagulation use according to ethnicity.

RESULTS

Significant independent predictors of anticoagulation use included hypertension (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.17-1.34; p<0.001), diabetes (OR 1.14, 95% CI 1.05-1.24; p=0.002), heart failure (OR 1.54 95% CI 1.43-1.66; p<0.001) and prior stroke or transient ischaemic attack (OR 2.07, 95% CI 1.84-2.33; p<0.001). In contrast, increasing age (OR 0.99, 95% CI 0.98-0.99; p<0.001), female gender (OR 0.88, 95% CI 0.82-0.93; p<0.001), and vascular disease (OR 0.72, 95% CI 0.64-0.80; p<0.001) were significant predictors of no anticoagulation. Hypertension was associated with less anticoagulation use in Indigenous compared to non-Indigenous Australians (p=0.02).

CONCLUSIONS

Anticoagulation for AF was suboptimal in both Indigenous and non-Indigenous Australians. Older age, female gender, and comorbid vascular disease were found to be negatively associated with anticoagulation. Importantly, hypertension may also be under-recognised as a stroke risk factor in Indigenous Australians. Future efforts to encourage anticoagulation use in accordance with guideline recommendations is likely to reduce the burden of AF-related stroke in both Indigenous and non-Indigenous populations.

Rheumatic heart disease: infectious disease origin, chronic care approach

BACKGROUND

Rheumatic heart disease (RHD) is a chronic cardiac condition with an infectious aetiology, causing high disease burden in low-income settings. Affected individuals are young and associated morbidity is high. However, RHD is relatively neglected due to the populations involved and its lower incidence relative to other heart diseases.

METHODS AND RESULTS

In this narrative review, we describe how RHD care can be informed by and integrated with models of care developed for priority non-communicable diseases (coronary heart disease), and high-burden communicable diseases (tuberculosis). Examining the four-level prevention model (primordial through tertiary prevention) suggests primordial and primary prevention of RHD can leverage off existing tuberculosis control efforts, given shared risk factors. Successes in coronary heart disease control provide inspiration for similarly bold initiatives for RHD. Further, we illustrate how the Chronic Care Model (CCM), developed for use in non-communicable diseases, offers a relevant framework to approach RHD care. Systems strengthening through greater integration of services can improve RHD programs.

CONCLUSION

Strengthening of systems through integration/linkages with other well-performing and resourced services in conjunction with policies to adopt the CCM framework for the secondary and tertiary prevention of RHD in settings with limited resources, has the potential to significantly reduce the burden of RHD globally. More research is required to provide evidence-based recommendations for policy and service design.

Epidemiology of Atrial Fibrillation: The Australian and Asia-Pacific Perspective

The epidemic of atrial fibrillation (AF) is increasingly recognised as a growing health problem worldwide. Although epidemiological studies on AF in the Asia-Pacific region are scarce, given the increasing age and size of populations in this region, the burden of AF is expected to be far greater than in North America and Europe. This is not only due to the growing, ageing population but also an increased incidence of risk factors for AF, such as hypertension, obesity, metabolic syndrome and diabetes, in the Asia-Pacific region. While further, high quality data on such aspects as risk factors, racial disparities and clinical implications is urgently required, there is an immediate need for increased focus on appropriate stroke prophylaxis and risk factor management to minimise the clinical complications and societal burden of AF.

Screening for Atrial Fibrillation

Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country- and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.

Opportunistic screening to detect atrial fibrillation in Aboriginal adults in Australia

INTRODUCTION

There is a 10-year gap in life expectancy between Aboriginal and non-Aboriginal Australians. The leading cause of death for Aboriginal Australians is cardiovascular disease, including myocardial infarction and stroke. Although atrial fibrillation (AF) is a known precursor to stroke there are no published studies about the prevalence of AF for Aboriginal people and limited evidence about AF in indigenous populations globally.

METHODS AND ANALYSIS

This mixed methods study will recruit and train Aboriginal health workers to use an iECG device attached to a smartphone to consecutively screen 1500 Aboriginal people aged 45 years and older. The study will quantify the proportion of people who presented for follow-up assessment and/or treatment following a non-normal screening and then estimate the prevalence and age distribution of AF of the Australian Aboriginal population. The study includes semistructured interviews with the Aboriginal health workers about the effectiveness of the iECG device in their practice as well as their perceptions of the acceptability of the device for their patients. Thematic analysis will be undertaken on the qualitative data collected in the study. If the device and approach are acceptable to the Aboriginal people and widely adopted, it may help prevent the effects of untreated AF including ischaemic stroke and early deaths or impairment in Aboriginal people.

ETHICS AND DISSEMINATION

This mixed methods study received ethics approval from the Aboriginal Health and Medical Research Council (1135/15) and the Australian Health Council of Western Australia (HREC706). Ethics approval is being sought in the Northern Territory. The findings of this study will be shared with Aboriginal communities, in peer reviewed publications and at conferences. There are Aboriginal investigators in each state/territory where the study is being conducted who have been actively involved in the study. They will also be involved in data analysis, dissemination and research translation.

TRIAL REGISTRATION NUMBER

ACTRN12616000459426.