Do you sometimes feel like your heart is beating so fast that it’s going to jump out of your chest? This may last a few minutes, after which your heart rate returns to normal. If this happens often, it could mean that you may have Atrial Fibrillation or Afib, a condition where faulty electrical impulses in the heart make its upper chambers or atria, beat too fast or “quiver”, out of sync with the lower chambers (ventricles).
Atrial Fibrillation (Afib) is the commonest cardiac arrhythmia and affects millions of people across the globe, but continues to remain one of the most neglected and underrated of public health problems, despite it being an enhanced risk factor for stroke and other cardiovascular events.
Understanding Afib
Anyone can develop Afib. Advanced age being an important risk factor, the burden of this condition is set to dramatically increase in the Indian population. Afib can present with symptoms such as palpitations, dyspnea (shortness of breath), chest pain, fatigue and intolerance to exertion . But in approximately 10% to 40% of people, Afib can be asymptomatic, with most remaining undiagnosed until an incidental diagnosis is given during a hospital visit or in the event of an acute stroke.
The abnormal rhythm that Afib causes, stops the heart from pumping as well as it should, disrupting blood flow and allowing it to pool. This increases the risk of clot formation, which is dangerous, because, these clots can travel to the brain and cause a stroke. Untreated Afib can also contribute to heart failure by impairing the heart’s ability to pump blood efficiently. Afib is also associated with significantly increased risk of myocardial infarction, dementia, chronic kidney disease and mortality.
Like many heart conditions, Afib is a progressive disease. People at higher risk of developing Afib include those at an advanced age, those who have high blood pressure, heart disease, diabetes, obesity, sleep apnoea, hyperthyroidism, and a family history of Afib, as well as those who smoke or consume excessive alcohol.
With proper diagnosis and management, including medications to prevent clotting (anticoagulants) and control heart rhythm, most people with Afib can live normal lives. However identifying the condition itself remains the biggest barrier to its management.
Also Read:Heart failure, not stroke, is the common complication of atrial fibrillation
The rise in Afib prevalence
The prevalence of AFib in Southeast Asia is increasing faster than it is globally. Also, there are differences in characteristics and outcomes between Asian and non-Asian patients with Afib: the mortality rate remains high, and major bleeding rates remain a significant concern among Asian Afib patients, note researchers in ‘The burden of atrial fibrillation and unmet needs of its management in Southeast Asia and South Asia’, a comment published in the March 2025 issue of The Lancet Regional-Southeast Asia.
This underscores the need to improve management strategies for patients in Southeast Asia. It also points to the urgent need to implement strategies to improve the standard of care in rural regions.
“Untreated AFib doubles the risk of cardiac deaths and is associated with a heightened risk for stroke. Yet, most people, including some physicians, are unaware that Afib is a serious condition. The detection of Afib in itself is thus our biggest challenge,” says C.G. Bahuleyan, professor of cardiology, Cardiovascular Centre, Ananthapuri Hospitals and Research Institute, Thiruvananthapuram, one of the co-authors of The Lancet article.
The magnitude of Afib is expected to be significant, especially in Kerala where the proportion of the elderly is high, alongside increased longevity, a higher prevalence of cardiovascular risk factors and comorbid conditions
Dr. Bahuleyan, who was one of the lead investigators behind the Kerala AF registry (2016-2021), the largest study on AF patients from India to date, says that the treatment and care offered to these patients is generally perceived to be suboptimal, especially with regard to stroke prevention strategy.
What the Kerala AF study revealed
The Kerala AF registry, instituted under Cardiological Society of India, Kerala Chapter (CSI-K), was initiated to collect systematic hospital-based data on clinical characteristics, risk factors, treatment patterns and outcomes of AF patients . A total of 3,421 patients were recruited from 53 hospitals across Kerala from April 2016 to April 2017. Of these, 51% were women. The median age of the cohort was 65 years. Hypertension, diabetes mellitus and dyslipidaemia were present in 53.8%, 34.5% and 42.2% patients, respectively. Chronic kidney disease was observed in 46.6%, coronary artery disease in 34.8% and heart failure (HF) in 26.5% of the patients.
The one-year clinical outcome of patients with non-valvular Afib from the Kerala AF Registry reported that despite the high risk profile of patients in this registry, the use of oral anticoagulants (OAC) was suboptimal at 38.6%, whereas antiplatelets were used in nearly half of patients. One-year all-cause mortality was 16.48 and hospitalization 20.65 per 100 person years, which is relatively high.
The Kerala registry findings are not indicative of the pattern in the rest of the country because of the wide socio-economic disparities between States. However, the barriers to the comprehensive and guidelines-based management of Afib are the same across India, say experts.
Lack of comprehensive, guidelines-based treatment
The use of new oral anticoagulants (NOACS) or Non-vitamin K Antagonist Oral Anticoagulants has drastically changed the treatment of Afib in patients with non-valvular atrial fibrillation, as it offers a safe, convenient alternative compared to traditional vitamin K antagonists (VKAs) like warfarin, which pose some bleeding complications.
Although NOAC is the preferred drug for stroke prevention in Afib as per guideline recommendations, the cost considerations and wide difference in prescription practices among physicians perhaps contribute to their lower use, say doctors.
“Given that almost all of our patients have non valvular Afib, physician inertia [in using NOACS] is one reason why the management of Afib remains suboptimal. A one-year clinical follow-up of Kerala AF Registry patients showed that just 7.1% were receiving NOACS. The price of NOACS could be one inhibiting factor but now that generic drugs are available, the cost-effectiveness of the therapy should not be in question,” Dr. Bahuleyan says.
Deepak Padmanabhan, senior consultant, cardiac electrophysiology at Narayana Health, Bangalore concurs that there is great variance in the manner in which Afib is managed, partly because of the lack of proper protocols and the shortage of skilled specialists or electrophysiologists to manage the condition.
“The new guidelines in 2023 by the American College of Cardiology, and in 2024 by the European Society of Cardiology, which point to the importance of maintaining a normal heart rhythm in preventing death and heart failure, are now making physicians, as well as people sit up and take note that Afib is a serious condition and that it has to be managed well,” Dr. Padmanabhan says.
People with persistent Afib may need surgical procedures to restore their normal heart rhythm. Small implantable devices like Implantable Cardioverter Defibrillators (ICDs) and pacemakers aside, selected patients who do not respond well to medical therapy are offered radiofrequency ablation or cardiac catheter ablation treatment. These treatments are expensive, performed only in select centres in the country, and hence inaccessible to most
Need for awareness
The need to enhance awareness and patient education of Afib, its symptoms, risk factors, the need to modify lifestyle factors to prevent the onset of Afib and the significance of seeking timely medical attention is acute, says Dr. Bahuleyan. “If untreated, Afib increases mortality risk in the elderly. It affects one’s physical well being, cognitive potential, worsens existing comorbidities and even makes the body less responsive to standard drugs for these conditions,” he adds.
K.K. Narayanan Namboodiri, professor of cardiology and head of cardiac electrophysiology division, SCTIMST points out that while an Afib diagnosis is difficult without a clinical evaluation or an ECG, smart watches with built-in ECG capability — like the Apple watch — can pick up Afib. It has been reported that in May 2024, the U.S. Food and Drug Administration (FDA) qualified Apple’s Atrial Fibrillation (AFib) History Feature as a Medical Device Development Tool (MDDT). This qualification allows the feature to be used as a non-invasive method to assess Afib burden estimates within clinical studies. This is the first time a digital health technology has been qualified under the FDA’s MDDT program for such purposes. Other brands have followed suit.
This is being seen as a new and convenient way to broadly screen for Afib and to monitor the condition long-term.
Professional bodies of cardiologists recommend a comprehensive care approach based on the ‘Atrial Fibrillation Better Care’ (ABC) pathway as a strategy to manage atrial fibrillation (Afib) that focuses on three key areas: Avoiding stroke (with anticoagulation), Better symptom management (through patient-centered rate or rhythm control), and Cardiovascular risk factor and comorbidity optimisation.
(With inputs by Athira Elssa Johnson)
Published – March 19, 2025 06:09 pm IST