Bridging the gap: addressing modifiable risk factors in atrial fibrillation patients following percutaneous coronary intervention

This invited commentary refers to ‘Modifiable risk factors and self-reported health after percutaneous coronary intervention: with and without a history of atrial fibrillation’, by A.J. Kjølseth et al., https://doi.org/10.1093/eurjcn/zvae114. Atrial fibrillation (AF) is the most common cardiac arrhythmia, with prevalence increasing with age and affecting an estimated 2–4% of adults worldwide.1 Cardiac remodelling is the primary underlying cause of AF, although the aetiology of remodelling may vary.2 The most serious consequence of AF is cardiac-related stroke. Patients with AF commonly have comorbidities such as hypertension, hyperlipidaemia, and coronary artery disease (CAD). Between 10 and 15% of patients with AF undergo percutaneous coronary intervention (PCI) for obstructive CAD.3 Generally, patients with AF who undergo PCI have more comorbidities than those without AF, presenting unique challenges in their post-procedural care and recovery.4 Kjølseth et al.5 provide valuable insights into the modifiable risk factors and self-reported health of patients with and without AF undergoing PCI. Their findings reveal important differences between patient groups and highlight areas for improvement in post-PCI care. Similar to prior studies, the patients with AF were older and had more comorbidities than patients without AF in the CONCARDPCI study.6 Patients without AF had higher smoking rates at baseline but lower rates of comorbidities, including hypertension, hypercholesterolaemia, coronary heart disease, myocardial infarction, and prior coronary revascularization. Some of these differences in comorbidities may be partially due to patients with AF already engaging with the healthcare system and initiating preventive measures, including smoking cessation and risk factor optimization. Conversely, patients without AF, who exhibited lower rates of pre-existing coronary heart disease and associated risk factors, started with higher smoking rates but quickly decreased to levels noted in AF patients across the study period. The study revealed that patients with AF consistently reported poorer general health compared with those without AF, despite both groups showing improvements in physical and mental health scores over time.5 This finding underscores the need for more comprehensive support and interventions for AF patients after PCI. Several mechanisms might contribute to this disparity. The physiological stress of managing both AF and CAD could lead to elevated levels of inflammatory markers and oxidative stress, potentially impacting overall health perception.7 It is also possible that complex medication regimens required for AF patients following PCI, including anticoagulants and antiarrhythmic drugs, may contribute to the side effects that affect the quality of life as well and lead to concerns over adverse bleeding events that may further create a perception of poor health.8 The psychological burden of managing multiple chronic conditions could significantly impact self-reported health. Trends in adherence to physical activity recommendations were less consistent but suggested lower adherence among patients with AF. While this study cannot provide detailed insight into causality, the higher rate of heart failure in the AF group raises the possibility that disabling symptoms may have been a contributing factor to lower physical activity. This highlights an opportunity for further enhancing patient care and outcomes in this higher-risk sector of the AF population particularly in terms of promoting physical activity. These results have significant clinical implications and highlight the need for long-term support in lifestyle modifications. While there is encouraging news regarding the decrease in smoking among patients without AF, more work is needed in smoking cessation and adherence to physical activity recommendations for all PCI patients, regardless of AF status. The persistent gap in self-reported health measures between AF patients and patients without AF suggests that current post-PCI care may not adequately address the unique needs of AF patients. The increase in smoking rates from 2 to 12 months after PCI in patients with AF is particularly concerning and suggests that lifestyle recommendations following PCI may be insufficient and not result in sustained behaviour change. To bridge this gap, tailored interventions for patients with AF following PCI are crucial. Comprehensive cardiac rehabilitation programmes that address both the cardiovascular and AF-specific needs of these patients could be beneficial. Such programmes should include targeted education on AF management, stroke prevention, and strategies to improve quality of life alongside traditional cardiac rehabilitation components.9 Moreover, the integration of AF-specific modules within cardiac rehabilitation, focusing on rhythm control strategies and anticoagulation management, could provide additional benefits for this population. Additionally, this study highlights the need for long-term support in lifestyle modifications even beyond the confines of traditional cardiac rehabilitation. Implementing extended follow-up protocols particularly in nurse-led clinics and leveraging telehealth technologies could help motivate and increase adherence to lifestyle modification.10 Future research should focus on interventional studies specifically targeting modifiable risk factors among patients with AF before and after PCI to identify the most effective strategies to sustain permanent lifestyle modifications. One potential intervention is the use of community health workers to provide additional support to these patients in fostering and maintaining lifestyle modifications.11,12 Barriers to adherence to recommended physical activity in particular for patients with AF should also be investigated to inform the development of tailored exercise programmes that are both acceptable and sustainable for patients with AF. Interventions using mobile health applications should also be studied, as utilization of these applications could provide remote monitoring for patients with AF following PCI but could also support risk reduction and lifestyle changes. This study by Kjølseth et al. sheds light on the disparities in risk factor management and self-reported health between patients with and without AF following PCI. While progress has been made in some areas, significant opportunities remain to improve care for this complex patient population. A multidisciplinary approach, involving nurses, cardiologists, mental health professionals, and primary care providers in conjunction with the cardiac rehabilitation team could result in creating comprehensive, patient-centred care for this complex population. A multifaceted approach involving tailored interventions, comprehensive rehabilitation programmes, and extended follow-up is needed to bridge the gap and optimize outcomes for all patients undergoing PCI, particularly those with AF. As we move forward, it is imperative that we continue to investigate and implement strategies that address the unique needs of AF patients in the post-PCI setting, ultimately improving their quality of life and long-term health outcomes. Aderonke Kareem, BSN (Conceptualization [supporting], Writing—original draft [equal], Writing—review & editing [equal]); Kurt G. Barringhaus, MD (Writing—original draft [equal], Writing—review & editing [equal]); and Sarah Slone, PhD, DNP (Conceptualization [lead], Writing—original draft [equal], Writing—review & editing [equal]) No funding was obtained for this commentary. Not applicable. No new data were used for this commentary.