The epidemiological burden of atrial fibrillation: a challenge for clinicians and health care systems.

There is increasing awareness that management of atrial fibrillation (AF) and its complications (particularly strokes) constitutes an important burden for health care systems and a major clinical challenge. AF is the most common sustained arrhythmia, and detailed knowledge of its epidemiology is important both for provision of adequate care and for resource allocation. Available epidemiological studies have mainly focused on prevalence of AF. Important frequency variations have been recorded, often linked to different detection procedures. Most of what we know about the incidence of AF in the general population comes from two large North American studies and a single study from Britain mostly regarding hospitalized patients. Thus, the new population-based cohort study by Herringa et al. on the epidemiological profile of AF in Rotterdam is highly relevant. This work, based on almost 8000 inhabitants of (a suburb of) Rotterdam aged at least 55 years at enrollment, provides a valuable picture of the age-specific prevalence and incidence of AF, as well as the lifetime risk of developing this clinically challenging arrhythmia. The Rotterdam study suggests that sex–age-specific incidence increases progressively before peaking at around 80 years. This result fits well with the main available data on incidence of AF, which are summarized in Figure 1. The high reported lifetime risk of developing AF (around 23–25% at the age of 55 years) is broadly in keeping with recent results from the Framingham study. Moreover, the present article as well as all the main available epidemiological studies indicate that in both men and women AF burden, in terms of prevalence of arrhythmia, progressively increases until advanced old age. In general, the findings of the new study suggest that very strong similarities in the epidemiology of AF exist between North America and Europe. Although the authors understandably limit the discussion of their work to comparative epidemiological considerations, their findings prompt broader considerations both from the clinical and public health perspectives. One implication of their findings is that in the light of the progressive ageing of the general population, Europe too seems set to face an ‘epidemic’ of AF in terms of prevalence in the overall population. It also has to be borne in mind that all the available epidemiological studies probably underestimate the true disease burden, as some asymptomatic cases inevitably go undetected (and silent AF can have major clinical consequences). Some clues on the entity of the public health burden of AF in the coming years are provided by a projection study regarding the United States, which suggested an increase in the number of persons with AF from around 2.3 million at present to more than 5.6 million by the year 2050, when over half of the affected individuals will be over 80 years of age. Considering the increase in hospitalization rates because of AF that have already been observed and the overall cost of AF management (estimated to be at present around E3000 per patient/year in France) similar scenarios will imply heavy financial burdens for our health care systems. Timely reflections are required regarding public health strategies and clinical management, as well as research perspectives. Clinically, AF is a multifaceted disease. Clinicians are confronted by a wide spectrum of situations, ranging from cases where AF is the disease itself (e.g. recurrent paroxysmal AF in an otherwise healthy subject) to cases where it is an important manifestation of severe diseases of the heart or other organs (kidney, lung, etc.). The wide heterogeneity of the clinical context in which AF develops (ranging from ‘lone AF’ to AF in the setting of severe heart failure), the varying impact on patients’ lives (from asymptomatic to poorly tolerated), and the different age distribution (from youth to advanced old age) all call for a personalized approach to its management. Such an approach would entail selection, in accordance with the clinical setting and the needs of individual patients, of appropriate rhythm-control or rate-control strategies (involving anticoagulation, antiarrhythmic drugs, cardioversion, substrate ablation, ablate and pace, etc.) for reasonable objectives (increasing life expectancy, improving quality-of-life, relief of symptoms, limiting hospitalizations, stroke prevention, etc.) involving a sustainable consumption of financial resources. A young woman with lone AF clearly requires a completely different approach with respect to an elderly