Opinion
Video
Long-Term Consequences of Arrhythmias
Experts discuss the complex clinical and economic challenges of atrial fibrillation, emphasizing the need for personalized care that balances symptom management, stroke prevention, and risk factor control—while recent evidence on subclinical atrial fibrillation highlights the limitations of widespread anticoagulation, reinforcing the importance of targeted, value-based strategies for optimal outcomes.
Atrial fibrillation (AFib) presents significant short- and long-term clinical challenges. In the short term, symptoms such as palpitations, dizziness, syncope, and hemodynamic instability can lead to hospitalizations, especially in individuals with undiagnosed heart failure. Over the long term, the condition is associated with more serious outcomes, including increased risks of ischemic stroke, heart failure progression, cognitive decline—even in the absence of stroke—and a higher risk of mortality. Given its potential to cause both symptomatic and silent complications, the goals of care must include symptom management, stroke prevention through anticoagulation, and addressing underlying risk factors to prevent disease progression.
From a broader, population-level perspective, atrial fibrillation also poses a significant economic burden, particularly depending on the stage at which it's diagnosed. Screening high-risk populations can uncover subclinical AFib in up to one-third of patients. However, evidence from recent clinical trials suggests that treating these brief, asymptomatic episodes of AFib with anticoagulation does not meaningfully reduce stroke risk. In fact, any small benefit in stroke reduction is often offset by an increased risk of bleeding, as seen in some studies that were halted early due to futility or harm. This highlights the complexity of determining cost-effectiveness when managing patients without clear, symptomatic AFib.
In contrast, patients who present with symptomatic AFib benefit more clearly from interventions such as anticoagulation or, in specific cases, catheter ablation—particularly those with reduced ejection fraction, where it can reduce hospitalizations and mortality. However, in populations with preserved ejection fraction, the benefit is less clear. These nuances underscore the need for a personalized approach to care and a deeper understanding of which populations will benefit most from early detection and aggressive treatment. More research is needed to refine strategies and ensure value-based care.
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