The Gaps in Management of Women with Atrial Fibrillation

The following article was written by Dr. Alaa Diab as a CardioNerds Conference Scholar for

Women’s Cardiometabolic Health and Wellness Retreat

Atrial fibrillation (AF) is the most prevalent type of arrhythmia in the United States affecting at least 2.3 million people.¹ Although AF is equally prevalent in men and women, women have a higher risk of stroke- a more disabling stroke- and death than men as delineated by a review article presented at the Cardiometabolic Health Women’s Master Class.² Even more concerning is that women have longer duration of symptoms, higher functional impairment, higher limitations of activities of daily living, and worse quality of life scores when compared to their male counterparts.² Given the burden of symptomatic atrial fibrillation in women there should be an even greater emphasis on early management and prevention of AF. At this time however, this may not be the case.

Management of AF consists of rate and rhythm control, along with the use of anticoagulation for stroke prevention.³ To decide on whether to start anticoagulation or not, CHADS-VASc score is used to assess stroke risk. One of the score factors is Sex category Female (1 point). A score of 1 point and above would make an AF patient qualify for anticoagulation. Yet, a study of 2.3 million women and men with a new diagnosis of AF and CHA2DS2-VASc ≥2 from 2008 to 2015 found women were not anticoagulated as frequently as men, where 50.0% women versus 43.9% men did not received anticoagulation.²

Rhythm control strategies utilize either oral medications or catheter ablation but women are less likely to undergo AF ablations.³ Dr. Ulrika Birgersdotter-Green, Professor of Medicine at the Division of Cardiology and Electrophysiology at the University of California San Diego Health explains that “Women are less often referred for catheter ablation from the first place, and they develop more procedural complications with catheter ablation and higher recurrence rates.” Furthermore, Dr. Green highlighted that women may have larger left atrial sizes with more adverse electrical and structural remodeling that may be responsible for lower ablation success rates. In terms of medical rhythm control, women are more likely to be treated with glycosides which are associated with increased risk of breast cancer.²

“An ounce of prevention is worth a pound in cure, and that’s absolutely true for atrial fibrillation” said Dr. Green. Thus, to start with, we should focus on prevention by targeting the risk factors that affect women the most- diabetes and hypertension- in regard to lifestyle modification. Dr. Green explained that the risk factors of atrial fibrillation are all modifiable except for age. “As important and simple it is to target the modifiable risk factors, yet it hasn’t even been discussed in the papers that talk about women with atrial fibrillation”.

From primary prevention, stroke prophylaxis, and symptom control, there is indeed much room for improvement to help narrow the gaps in women’s AF management.

Dr. Ulrika Birgersdotter-Green points out that in good papers of #afib there is no discussion of #lifestyle & #riskfactor modification m:
Most risk factors for AFib are modifiable. @CMHC_CME pic.twitter.com/1njYpKddca

— Dr. Martha Gulati ♥️🫀❤️‍🩹🇨🇦 (@DrMarthaGulati) September 10, 2022

Risk for #stroke and disabling stroke in AF is higher in women vs. men and women are less likely than men to receive oral anticoagulation therapy in the U.S., Ulrika Birgersdotter-Green, MD, of @UCSDHealth, said during #CMHCWomensMC @CMHC_CME @ErinMichos @PamTaubMD pic.twitter.com/Nfhcj2HDp5

— Cardiology Today (@CardiologyToday) September 10, 2022

The impressive line-up continues!

Dr. Ulrika Birgersdotter-Green of @UCSDHealth on Arrhythmias in Women – starting with "the final common pathway – #AtrialFibrillation

What risk factors drive AFib in women > men? #WomenInEP #WIC @CMHC_CME #CMHCWomensMC @CardioNerds

— Jessie Holtzman (@jholtzman3) September 10, 2022

In this Healio video exclusive, Ulrika Birgersdotter-Green, MD, discusses the “unique differences” between men and women with #AFib #CMHCWomensMC @CMHC_CME #CardioTwitter @healiowomen https://t.co/2FEjtp6uf4

— Cardiology Today (@CardiologyToday) September 12, 2022

References.

1. Khurshid S, Choi SH, Weng LC, et al. Frequency of Cardiac Rhythm Abnormalities in a Half Million Adults. Circ Arrhythm Electrophysiol. 2018;11(7):e006273. doi:10.1161/CIRCEP.118.006273
2. Volgman AS, Benjamin EJ, Curtis AB, et al. Women and atrial fibrillation. J Cardiovasc Electrophysiol. 2021;32(10):2793-2807. doi:10.1111/jce.14838
3. Knapp E, Watson K. Medication management of atrial fibrillation: emerging therapies for rhythm control and stroke prevention. P T. 2011;36(8):518-528.