Implementation gaps in modifiable risk Factor management among atrial fibrillation patients: a real-world retrospective study from a UK district general hospital

Background

Effective management of atrial fibrillation (AF) requires comprehensive attention to modifiable risk factors, as highlighted in the ESC AF-CARE framework. Despite increasing emphasis on lifestyle optimisation, the extent to which risk factor assessment and management are integrated into routine clinical care remains poorly characterised in real-world practice.

Purpose

To evaluate the identification, documentation, and management of modifiable risk factors among AF patients within a UK district general hospital, and to explore patient-level factors associated with better risk factor optimisation.

Methods

A retrospective observational study was conducted including all patients presenting with a primary diagnosis of AF over a one-month period (July 2023). Data collected included demographic and clinical variables (age, sex, AF subtype, BMI, diabetes, hypertension, sleep apnoea, alcohol intake, and heart failure status). For each factor, documentation of screening, control, and management plans was reviewed. Descriptive statistics and inferential analyses were used to assess associations between clinical variables and risk factor optimisation.

Results

A total of 151 patients were included in the study. The predominant AF subtype was persistent AF (30.7%), followed by newly diagnosed (24.7%), permanent (24.0%), and paroxysmal AF (20.6%). Modifiable risk factor identification and management is detailed in table 1. Obesity (BMI >30 kg/m²) was highly prevalent, affecting 43.3% of the cohort, yet only 21.5% of those with obesity had a documented plan for weight reduction. Diabetes mellitus was identified in 22.7% of patients, with half demonstrating good glycaemic control and one-fifth having documented plans for treatment intensification. Hypertension was present in 47.3% of patients, with 87.3% achieving control and 11.3% of those affected having plans for optimisation.

Alcohol intake history was recorded in only 27.3% of patients, and among those with documented alcohol use, just 26.8% received advice regarding reduction. Screening or acknowledgement of obstructive sleep apnoea (OSA) was infrequently documented (3.3%), with two-thirds of these confirmed through sleep studies and one-third referred for further assessment. Younger age was significantly associated with receiving alcohol reduction advice (p = 0.016), but no other independent predictors of improved risk factor management were identified.

Conclusion

This real-world study highlights substantial implementation gaps in the optimisation of modifiable risk factors among AF patients, particularly concerning weight management, alcohol intake, and sleep apnoea screening. Despite high prevalence of these comorbidities, structured lifestyle interventions remain underutilised in clinical care. These findings underscore the need for integrated risk factor management pathways within AF services to support long-term rhythm control and improve patient outcomes.