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NVAF: Reducing Disparities
Reducing Disparities to Improve Identification of Nonvalvular Atrial Fibrillation: Let’s Start With Awareness

Released: February 23, 2023

Expiration: February 22, 2024

Larry R. Jackson II
Larry R. Jackson II, MD, MHSc
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Key Takeaways
  • The lower incidence and prevalence of atrial fibrillation despite the higher prevalence of traditional risk factors in Black individuals compared with White individuals is known as the atrial fibrillation paradox.
  • One key component to improving atrial fibrillation diagnosis and management in underrepresented racial and ethnic populations is improving patients’ understanding of their own health, including knowledge about the disease process and associated outcomes.
  • Atrial fibrillation management works best as a team-based, integrated approach with the patient as the focal point.

Atrial fibrillation (AF) is the most common abnormal heart rhythm. It causes approximately 20% to 25% of ischemic strokes in the United States, but it often has minimal or no symptoms, making diagnosis challenging. Unfortunately, in some cases AF is not diagnosed until a stroke occurs. In addition, healthcare disparities exist in the management of AF, including rhythm control strategies and stroke reduction therapies. The incidence and prevalence of AF is higher in White patients compared with Black and Hispanic patients, but adverse outcomes are higher in underrepresented racial and ethnic groups. What accounts for this difference?

The AF Paradox 
The lower incidence and prevalence of AF despite the higher prevalence of traditional risk factors in Black patients compared with White patients is known as the AF paradox. This paradox has been documented in numerous observational cohorts. We do not know why this paradox exists, but it is important to review the possible reasons. 

Could the reason for the AF paradox be that Black patients have more paroxysmal AF? Their AF is more likely to come and go, so it is harder to identify and diagnose. I believe another reason could be access to healthcare. Black individuals and those in other underrepresented racial and ethnic groups tend to be more economically, socially, and environmentally marginalized. These patients may have issues with transportation, lack of neighborhood access to healthcare, financial concerns, or additional comorbidities. It is impossible to capture AF if the patient does not go to a clinic or facility to have an ECG to record the abnormal rhythm. 

In addition, survival bias may contribute to the AF paradox. Underrepresented racial and ethnic groups tend to have a lower life expectancy than their White counterparts, and a diagnosis of AF is more prevalent as the patient ages. Therefore, the life expectancy average and the age of diagnosis may be another reason for the differences in prevalence between racial and ethnic groups. 

The Double AF Paradox 
Undiagnosed AF in underrepresented racial and ethnic groups also is a double paradox. The first paradox is that, although Black patients have more risk factors associated with AF—higher rates of diabetes, hypertension, chronic kidney disease, and obesity—this group is less likely to have AF, or at least be diagnosed with AF   . The second paradox is regarding outcomes: When Black patients are diagnosed with AF, their outcomes associated with AF are significantly worse than those of White patients, including more strokes, more fatal strokes, more heart failure, and higher mortality.  

Although current data on prevalence of undiagnosed AF may not be available, the AF paradox and the double paradox need to be appreciated. 

Challenges to Care and Cost 
AF often goes undiagnosed despite the many screening tools available to healthcare professionals, such as the implantable loop recorder. These tools may be covered by insurance, but if the patient is not in specialty care or the health system to begin with, they cannot benefit from their use. Only when a patient is in the system can the conversation about screening begin. 

Targeting Social Determinants of Health With AF 
To help increase the diagnosis of AF in Black patients and other underrepresented racial and ethnic groups, I believe more clinical investigation on and attention to social determinants of health with AF are needed. Health literacy in AF should be a focus area. It is important to improve patients’ knowledge through education about their disease state. One key component to improving AF diagnosis and management in underrepresented racial and ethnic groups is improving patients’ understanding of their own health. Patients must have knowledge about their disease state and treatment strategies to make informed decisions. 

Literature has shown that underrepresented racial and ethnic groups with AF have lower awareness about the disease. Some patients may not even understand that AF causes strokes or the role of blood thinners in reducing the risk of strokes. 

Once a patient is diagnosed, much of the work I do is about optimizing preference-based decision-making in AF, such as choosing an oral anticoagulant that fits the patient’s values, preferences, and lifestyle. If a patient is not empowered to make this type of decision based on knowledge around what AF is, why it is important, and why various stroke reduction therapies are important, then they cannot make an informed, values-based decision.

Steps Moving Forward
Healthcare professionals need to get ready—AF is an epidemic of epic proportions, and underrepresented racial and ethnic groups must be a priority for screening and early diagnosis. Primary care providers are the first line of defense and need education on the core concepts around AF. Stroke reduction therapy cannot be delayed for weeks or months until a specialist appointment is available; therefore, it may be up to primary care providers to initiate and assist in the management of oral anticoagulant therapy for AF. AF management works best as a team approach with the patient included. Ideally, specialists and primary care providers should build and organize workflow around AF education and knowledge about the various stroke reduction therapies that are available and meet the patients’ needs. More patients can be reached through a streamlined and integrated approach of primary care providers interacting and integrating with electrophysiologists and general cardiologists. As this epidemic continues, this team approach will help to identify, manage, and educate the influx of patients with AF. 

To learn more about the effects of social determinants of health and disparities in care on AF outcomes and strategies to mitigate those effects, register for the live webinar on Thursday, March 23, 2023, titled, “Reducing the Burden of NVAF Through Improved Screening and Management.”

Your Thoughts?
Do you think improving patients’ health literacy will improve their health outcomes? Join the conversation by answering the polling question and leaving a comment in the discussion box below.   

 

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