Elsevier

International Journal of Cardiology

Volume 167, Issue 6, 10 September 2013, Pages 2412-2420
International Journal of Cardiology

Review
Review of epidemiology and management of atrial fibrillation in developing countries

https://doi.org/10.1016/j.ijcard.2013.01.184Get rights and content

Abstract

Background

Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia. In developing countries, AF is a growing public health problem with the epidemiologic transition from communicable to non-communicable diseases. However, relatively little is known about AF in the developing world. The aim of this review is to examine in developing countries the prevalence, associated medical conditions and management of AF.

Methods

A literature search was conducted via MEDLINE and EMBASE (1990–2012).

Results

Seventy studies were included in the review. The prevalence of AF in the general population ranged from 0.03% to 1.25%, while the prevalence of AF in hospital-based studies varied from 0.7% to 55.7%. Prevalence of AF in Africa was lower than in other regions. The most common conditions associated with AF were hypertension (10.3%–71.9%) and valvular heart disease (5.6%–66.3%). The prevalence of stroke in patients with AF ranged from 6.7% to 27%. The utilization of anticoagulants was highly variable (2.7%–72.7%). Approximately half of the patients with AF using warfarin had therapeutic International Normalized Ratios (INR). There was a high prevalence of use of rate control therapies (55.3%–87.3%).

Conclusions

The limited studies available suggest that in the developing world there is a significant prevalence of AF, which is predominantly associated with hypertension and valvular heart disease, and carries a risk of stroke. Highly variable use of anticoagulants may be related to different health care and socioeconomic settings. More studies are needed to improve understanding of the epidemiology and management of AF in developing countries.

Introduction

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. There have been many studies in Western countries reporting the prevalence of AF. Approximately 2.3 million American people and six million Europeans are affected by AF [1], [2]. The prevalence of AF in the general population in some Western countries ranges from 0.5% to 2% [3], [4], [5]. According to the Framingham study, the incidence of AF increases significantly with age. The incidence doubles with each decade after the age of 50 and reaches around 10% at the age of 80 years [6]. According to the Cardiovascular Health study, the prevalence of AF in patients older than 65 years old is 6.2% in men and 4.8% in women [7]. People with AF have an increased risk of stroke [8].

Risk factors for AF include old age, male sex, hypertension, heart failure, ischemic heart disease, valvular heart diseases, diabetes, obesity, hyperthyroidism, alcohol abuse, smoking, and pulmonary disease. Mainstay therapy for AF includes assessment of thromboembolic risk and stroke prevention, applying appropriate rate-control or rhythm-control strategies, and management of associated diseases [8], [9].

In developing countries, AF is a growing public health problem in the context of the epidemiologic transition from communicable to non-communicable diseases [10], [11], [12], [13], [14]. The effect of AF on mortality and morbidity is likely to be substantial. In addition, AF puts a great burden on the socioeconomic system in these countries. The estimated annual costs of AF are high in these countries [15]. Anticoagulant use and monitoring are major challenges for health system in developing countries. Accessibility to the monitoring tests for anticoagulants, unreliability of test results, lack of compliance of patients, and interactions with diet and complementary medicines are all substantial issues in developing countries [16], [17], [18].

However, there have been few published studies about AF in developing world. Therefore, the aim of this review is to examine the prevalence of AF, the associated medical conditions, the impacts of AF on stroke rate and the management of AF (antithrombotic therapy and rate or rhythm control strategy) in developing countries.

Section snippets

Methods

A literature search was conducted via MEDLINE and EMBASE (from 1990 to May 2012). Keywords used for searching included “atrial fibrillation”, “epidemiology”, “prevalence”, “risk factors”, “associated medical conditions”, “associated diseases”, “stroke”, “antithrombotic”, “anticoagulant”, “INR”, “rate control”, “rhythm control”, “developing country”, “developing world”, and the names of developing countries according to the classification of the World Bank [19]. The articles attained by this

Results

A total of 70 articles were included in the review. There were 16 articles from East Asia and the Pacific, 17 from Europe and Central Asia, 12 from Latin America and the Caribbean, 3 from the Middle East and North Africa, 9 from South Asia and 11 from sub-Saharan Africa. China had the leading number of articles (13 articles), followed by Brazil (7 articles), Pakistan (6 articles), Turkey (4 articles), and Bosnia and Herzegovina (3 articles). Russia Federation, Thailand, Romania, Serbia,

Discussion

The prevalence of AF in the general population in community based studies in this review ranged from 0.03% to 1.25%, which is similar to that reported in some developed countries such as North America, the United Kingdom and Iceland (from 0.5% to 1%) [3], [4], [90] but lower than the prevalence reported in Australia (4%) [91]. The low prevalence of AF in both studies in India (0.03% and 0.1%) may be related to the populations studied: one study was in people living high altitude in a tribal

Conclusion

The limited studies available suggest that in the developing world there is a significant prevalence of AF, which is predominantly associated with hypertension and rheumatic heart disease, and carries a high risk of stroke. Highly variable use of anticoagulants may be related to different health care and socioeconomic settings. Large studies of representative populations are needed to improve understanding of the epidemiology and management of AF in developing countries.

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