Atrial Fibrillation in

India

Introduction

Atrial fibrillation is the commonest arrhythmia

Globally, its burden is increasing
Worsens symptoms, quality of life
Increases hospitalization
Has higher mortality rate

Dorian P et al,
J. Am Coll Cardiol 200:36

Few interesting facts

AF increases risk of stroke 5 times
Increases risk of heart failure 3 times
Use of CHADS2VASc score helps to
plan better antithrombotic
management
But rate vs rhythm control is still a
debatable issue
Fuster V et al. J Am
Coll Cardiol 2006

AF in India: How
common?
Virtually no epidemiological data available
Recently Some knowledge is available from
Indian patient cohort in REALIZE & RELY studies
Ongoing IHRS AF registry is probably the largest
study on Indian AF patients

Narasimhan C et al 2012

Incidence & Prevalence

Prevalence in West 1.5-2 % in general
population
Average age is between 75-85 years
Remarkable increase in incidence after 80
than below 65 years

Piccini JP et al, Circ Cardovasc

Qual Outcomes 2012

First Indian population based

study
Reported in 1995
Included 984 Himalayan village residents
Prevalence only 0.1%
Causes Healthy participants
Received only a single ECG
Only 6% <65 years
Kaushal
SS et al JAPI 1995

Other Studies
West Birmingham atrial fibrillation project revealed
0.6% prevalence of AF in India*
PANARM study showed AF as the commonest
arrhythmia# (66% of all)
Average age more than a decade younger in Indians
- in REALIZE-AF 60 years
- in IHRS-AF 54 years
Lower age is due to high prevalence of Rheumatic heart
disease
*Lip GYH et al Int J Cardiol 1998
#PANARM 2011 presented in ISE meeting
Mumbai

RVHD & AF in India

The CRRAFT study on rheumatic valvular
heart disease & AF had mean age of 38years*
Gender distribution Almost equal in RELY &
REALIZE-AF Indian cohort (55% men)
IHRS AF registry had 51% women likely
because of more RVHD
Vora A et al
Indian Heart J. 2004

Type of AF
Paroxysmal AF was more often seen in Indian subset of
RELY (38%) & REALIZE (43%) trials
but in IHRS-AF it was only 19.5%
Permanent AF was similar in REALIZE (34.3%) & IHRSAF (33.7%)
but in RELY only 18.6%
Possible cause of discrepancy
In RELY more private hospitals were included
In IHRS AF distribution of public & private hospitals were
similar
RVHD & permanent AF are more common in public
hospitals

Comorbid conditions
Plenty of data on AF are available in western
world which is predominantly Non valvular
In India, in a significant proportion of patients,
RVHD is the prevailing cause
In a study done in rural area in North India has
shown 61% of patients with AF having RVHD*
In REALIZE AF global study valvular heart disease
was found in 26.7% of patients
but
In Indian sub-study it was found in 40.7% patients
* Bharadwaj R
India Heart J 2012

RVHD in AF
In RELY study global vs Indian valvular heart
disease burden was 21.8% & 25.4% respctively
In REALIZE & RELY patients RVHD data is not
available in those with VHD
In IHRS AF, burden of RVHD was 42% in AF patients
Patients with RVHD & AF have very high risk of
thromboembolic risk 17-18%/year*
Alpert JS Annu Rev
Med 1988

Hypertension
Commonest comorbidity in Non valvular AF
Over last two decades prevalence of hypertension
in AF patients increased from 53% to 83%
In recent studies(RELY, ROCKET, ARISTOTLE) it was
found to be 70-80%
In REALIZE study global vs Indian data revealed
burden of hypertension 72.2% vs 50.8%
It is similar in China & Japan i.e. 42-52%
Hypertensive patients with LVH (proven by echo &
ECG) had higher prevalence of AF*
* Kannel WB et
al Am J Cardiol 1998

Other Comorbidities
In REALIZE AF Indian sub study
a) Coronary Artery Disease 32%
b) Heart failure 26%
c) Diabetes 20%
d) Dyslipidemia 16%
In severe HF, almost 50% develops AF*
DM is independent predictor of AF, RR 1.8
Comparative global data shows higher
prevalence of HT & HF as opposed to VHD in India
*Maisen WH, Stevenson LW Am J
Cardiol, 2003

Other Comorbidities
(contd.)
Other risk factors for AF
Obesity - sleep apnoea
Hyperthyroidism
Alcoholism
Chronic obstructive lung disease
Data available in Western literature but
unfortunately not studied in Indian
population

Risk of Stroke
REALIZE AF (Indian sub study)
- CHADS2 score 2 in 36.6%of
patients
IHRS AF
- CHADS2VASc 2 in 49% patients
Actual risk may be much higher
in Indians due to presence of
RVHD in 40% patients
Availability of follow up data from IHRS AF will

Conclusion
Indian AF patients are different
compared to their Western
counterparts
They are younger by more than a
decade
RVHD is seen in almost 40% of them
Persistent & permanent AF is more
Stroke risk is higher requiring more
anticoagulation

Conclusion (contd.)
Contemporary large population data not available
True incidence & prevalence not known
1 year follow up data of IHRS AF registry will be
highly important to reveal different aspects of AF
in Indian context
A model like Framingham can be developed to
address epidemiological characteristics of
different cardiovascular diseases In india