Unhealthy lifestyles raise risk of cardiac events in low-risk AF patients

Having an unhealthy lifestyle, such as smoking, drinking, and being sedentary, can increase the risk of clinical events in patients with atrial fibrillation (AF) who are at low risk of stroke, reports a study.

“Sedentary lifestyle, alcohol consumption, and cigarette smoking may synergistically affect poor clinical outcomes,” the researchers said. “Maintaining healthy lifestyles is essential for a holistic care approach to AF management, even in those deemed to be at low risk of stroke.”

Using the National Health Insurance Service of the Republic of Korea database, the researchers identified 52,451 AF patients (mean age 51.6 years) with a low risk of stroke between 2009 and 2016. They used the survey on health habits to calculate the unhealthy lifestyle score (ULS) by adding one point each if a respondent had a sedentary lifestyle, drinking, or smoking.

The composite of myocardial infarction, ischaemic stroke, heart failure, and all-cause death was the primary outcome. The risk of this outcome according to the ULS was estimated using multivariable Cox regression analysis.

Of the low-risk AF patients, 12,792 (24.4 percent) had 0 points, 24,785 (47.3 percent) had 1 point, 11,602 (22.1 percent) had 2 points, and 3,272 (6.2 percent) had 3 points of the ULS.

Over a median follow-up of 4.1 years, the healthiest lifestyle group (ULS 0) had the lowest risk of the primary outcome compared with the other groups, which were at significantly greater risk with a gradually increasing trend based on the ULS: ULS 1 (adjusted hazard ratio [aHR], 1.17, 95 percent confidence interval [CI], 1.05‒1.31), ULS 2 (aHR, 1.37, 95 percent CI, 1.21‒1.56), and ULS 3 (aHR, 1.82, 95 percent CI, 1.53‒2.17). [Am J Med 2024;137:37-46.E6]

In an earlier study, aggressive risk factor management such as alcohol abstinence and smoking cessation resulted in reduced recurrence following AF ablation. [J Am Coll Cardiol 2014;64:2222-2231]

Physical activity, on the other hand, had differing effects on AF. Studies suggested that excessive or endurance activity could increase the risk of incident AF, while moderate activity could provide some benefits. [Int J Cardiol 2006;107:67-72; Sci Rep 2019;9:13270]

“Due to the lack of randomized controlled trials, recommendations on physical activity among AF patients are largely based on observational studies or expert consensus,” the researchers said. [Eur Heart J 2016;37:2893-2962]

“However, there has been increasing evidence that a sedentary lifestyle may lead to poorer clinical outcomes in AF patients, similar to that seen in the general population,” they added. [J Clin Med 2021;10:3126; PLoS Med 2021;18e1003659]

Notably, the addition of obesity to the ULS fell short of improving risk stratification for the higher-risk population. A possible explanation for this was the heterogeneity of obesity and its modest impact on the risk of cardiovascular outcomes.

“Only metabolically unhealthy obesity might be associated with a significant risk of cardiovascular events, while metabolically healthy obesity is not,” the researchers said. “Therefore, we concluded that incorporating obesity into the ULS did not offer better clinical utility.” [BMJ Open 2021;11e049063]