The Burden of Atrial Fibrillation in India

The true burden of atrial fibrillation in the Indian population remains poorly defined. Some studies have reported that the prevalence of atrial fibrillation is lower among Indians than among Western populations. In the Global Burden of Disease study, atrial fibrillation and flutter represented only a small percentage of the total cardiovascular disease burden in India. The percentage of DALYs due to atrial fibrillation under the umbrella of cardiovascular disease was estimated to be 0.13% in Indian males and 0.15% in Indian females. Another screening study among 4,077 urban adults in Nagpur found the prevalence of AF to be 0.2% after 12-lead ECGs were performed, which was comparable to global AF prevalence estimates. 

It is important to point out that many of the current studies that estimated AF prevalence performed AF screening at single time-points. Although feasible from a study design perspective, it may miss patients with paroxysmal AF. Many of these studies also suffer from selection bias and lack of external validity of the results. Hence, the true burden of AF in India is likely to be underestimated. 

The SMART-India cross-sectional study screened 2,074 adults from rural Gujarat for AF multiple times and found that 1.6% of the study participants had undiagnosed AF. This was triple the prevalence of AF previously reported in India and comparable to the prevalence found in research from North America and Western Europe. If only single time-point AF screening was performed, the prevalence would have been 1.1%. Another study in a smaller sample population (234 participants) from rural Gujarat found the sample AF prevalence to be 5.1% (95% CI: 2.7-8.7%), once again markedly higher than estimates reported in other Indian and Western research. 

Although the literature reports conflicting information about the prevalence of AF in India, it well establishes the burden of stroke in India. Stroke was one of the two adverse cardiovascular events responsible for about 83% of cardiovascular disease-related mortality in 2016. There are a lack of studies about the contribution of AF to the ongoing stroke epidemic in India. But given the increasing number of Indians affected by AF risk factors like diabetes mellitus and hypertension, AF is likely to be behind a large proportion of the stroke cases in India, both now and in the near future.  

Routine AF screening is needed to ensure timely detection and treatment commencement; especially because a third of AF patients remain asymptomatic. Novel technology-based tools can be employed for this purpose. An interesting aspect of both the studies in rural Gujarat reporting higher AF prevalence was the use of the AliveCor KardiaMobile device in their screening protocols. AF screening using this FDA-approved, smartphone-operated ECG device enabled the researchers to record ECGs multiple times during the study period and hence, helped detect paroxysmal AF. Participants conveniently placed their index fingers on the single-lead electrodes and their real-time ECGs were displayed on the smartphone screens. Thus, pocket-friendly ECG devices like the AliveCor KardiaMobile can be used by a range of clinicians (from specialist cardiologists to primary care nurses) to screen patients in both urban and remote rural areas.

In conclusion, the hidden burden of AF in India calls for innovative ways to diagnose AF in asymptomatic and high-risk patients. Smartphone-enabled ECG devices like the AliveCor KardiaMobile can pave the way towards timely AF management and in turn, help India overcome its current stroke epidemic.

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#1. Which disease generally occurs as a result of AFib?