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. 2025 May 6;47:101110. doi: 10.1016/j.lana.2025.101110

Atrial fibrillation in the Americas

Jason G Andrade a,i,∗, Larry R Jackson II b, Juan Carlos Diaz c, Mina Chung d, Jody Hurwitz e, Carlos A Morillo f,j, Gregory YH Lip g,k,l, Nestor Lopez-Cabanillas h
PMCID: PMC12143173  PMID: 40486987

Summary

Atrial Fibrillation is the most common sustained cardiac arrhythmia, and is associated with significant impairments in quality of life. Regional variations and challenges in the management of atrial fibrillation are present throughout the Americas. Atrial fibrillation incidence and prevalence varies widely, with significant regional differences in the consequences of atrial fibrillation (disability adjusted life years, and mortality). While the contemporary goals are similar, the management of atrial fibrillation is highly variable across the Americas, driven by regional differences in access to medical services, diagnostics, treatments and technologies, as well as country-specific differences in health-care expenditures. Healthcare policies to address these within and between country barriers will lead to improved care and a reduction in the economic burden of atrial fibrillation. Failure to remediate health inequities will exacerbate the burden of healthcare resources attributed toward the management of this disease.

Keywords: Atrial fibrillation, Guidelines, Stroke, Anticoagulation, Hypertension, Rate-control, Rhythm-control, Ablation

Introduction

Atrial Fibrillation is the most common sustained cardiac arrhythmia, and is associated with significant impairments in health-related quality of life.1 While arrhythmia suppression is desirable, the contemporary goals of atrial fibrillation management are centered on improvement in quality of life, a reduction in the morbidity and mortality associated with atrial fibrillation (particularly the prevention of atrial fibrillation-associated ventricular dysfunction/cardiomyopathy, and stroke/systemic thromboembolism), and reduction in atrial fibrillation-related healthcare utilization. The creation of policies aimed at the comprehensive management of patients with atrial fibrillation is expected to have a significant impact on patient outcomes as well as a reduction in atrial fibrillation-related healthcare costs, and as such regional and national variations should be explored. This may ultimately lead to identification of gaps in the treatment, as well as the creation of healthcare policies oriented towards improving outcomes. The purpose of the current article is to examine the regional variations and challenges in the management of atrial fibrillation within the Americas.

Epidemiology

Incidence and prevalence

Historically atrial fibrillation has been reported to affect 1% of the population, with a prevalence that increases with age (e.g. <1.0% of the population younger than 50 years of age, to 4% at 65 years, and 12% of those ≥80 years).1,2 After adjusting for age and predisposing conditions male sex is associated with a 1.5-fold risk of developing atrial fibrillation.3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 Despite the higher incidence, prevalence, and lifetime risk of atrial fibrillation in men, the absolute number of women with atrial fibrillation exceeds the number of men with atrial fibrillation due to the significant differences in overall longevity. Worldwide, the absolute prevalence of atrial fibrillation has more than doubled (+137%) over the last 3 decades, rising from 22.2 million prevalent cases in 1990 to 52.5 million prevalent cases in 2021.15

Importantly, the distribution of atrial fibrillation is heterogenous. While high-income countries report a relatively greater prevalence of atrial fibrillation (age-standardized rate 788/100,000); most patients with atrial fibrillation are found in middle-income countries (33.1 million or 63% of all atrial fibrillation cases worldwide) where the incidence of atrial fibrillation is increasing (estimated annual percentage change +0.1 to +0.13 vs. −0.07 in high-income countries). In addition, the age and sex distribution differs across socio-demographic index countries, whereby atrial fibrillation occurs relatively more often in younger individuals and women in middle- and low-income countries, and mainly affects older individuals and men in high-income countries.16

The United States of America (USA) has remained one of the top five countries in terms of absolute atrial fibrillation prevalence (second worldwide in 1990, 2.9 million cases, and 2021, 6.4 million cases), and experienced the greatest change in atrial fibrillation incidence and prevalence between 1990 and 2021 (estimated annual percentage change 0.54 and 0.57, respectively).15 After correcting for age and demographic factors the prevalence of atrial fibrillation was higher in Canada in 1990 (second worldwide), however, in contrast to the USA, the incidence and prevalence of atrial fibrillation decreased between 1990 and 2021 (−0.67%/year and −0.53%/year, respectively). Thereafter, in the Americas, Brazil experienced the highest age-standardised incidence and prevalence, ranking 17th worldwide, while Argentina had the lowest (Fig. 1). Although the prevalence of atrial fibrillation is relatively lower in Latin American countries (which may at least in part explained by a lower use of screening strategies), it remains the leading arrhythmia in many jurisdictions (Supplemental Tables S1 and S2).

Fig. 1.

Fig. 1

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Age Standardized Rate for atrial fibrillation prevalence, disability-adjusted life years, and death in the Americas.

It is important to recognise that the true prevalence of atrial fibrillation is likely to be substantially higher, as these the majority of these estimates did not account for short episodes of paroxysmal (i.e., short enough as to impede diagnosis, as the arrhythmia may self-terminate before a diagnostic ECG is performed) or asymptomatic AF.17 For example, Noubiab et al., estimated the atrial fibrillation prevalence in the US to be at least 10.55 million in 2019 using healthcare databases from California's Department of Health Access and Information, which was 36% higher than the 2019 estimate from the Global Burden of Disease.17,18 During recent years, the increasing availability of wearables capable of detecting atrial fibrillation may ultimately lead to a greater incidence and prevalence of AF. Whether or not this increase in the detection of previously undiagnosed atrial fibrillation will lead to a reduction in AF-related adverse events is yet to be determined.

Death and disability

Globally, the age standardized death rate has risen from 1990 to 2019, with rates in male and female patients.19 Regionally, the Americas have observed the greatest increase in disability-adjusted life years (DALYs) between 1990 and 2021 (estimated annual percentage change 0.28), increasing from 117.14 (2nd worldwide) to 120.68 per 100,000 (1st worldwide). Likewise, the Americas has observed the greatest increase in age-standardised death rates between 1990 and 2021 (estimated annual percentage change 0.47), rising from an age-standardized rate of 4.18 [3rd worldwide] to 4.84 per 100,000 (2nd worldwide behind Europe).15 These rates may reflect changing demographic and risk factor profiles within the regions, as the contribution for both AF-associated deaths and DALYs were observed with hypertension, obesity (increased body-mass index), alcohol and tobacco consumption, and a high sodium diet. Within the Americas, there have been significant differences in the change in the estimated annual death rate and DALYs attributable to AF, with North America having the highest and central America the lowest change (Supplemental Tables S3 and S4).19

Healthcare resource utilisation

The economic burden of atrial fibrillation on global health systems is substantial. Previous studies have estimated that the direct costs of managing atrial fibrillation approximate 2.5% of annual healthcare expenditures, though these expenditures are increasing significantly as the global prevalence of disease and associated healthcare utilisation increases.20, 21, 22, 23, 24

From 2007 to 2014 the annual number of US emergency department visits for atrial fibrillation increased from 411,406 to 537,801 (31% increase), with hospitalisations similarly increasing from 288,225 to 333,570 (plus an additional 3,466,556 hospitalisations with atrial fibrillation as a secondary diagnosis).25 Concurrently, the cost of AF-associated care in the US has increased from $7.4 to $10.1 billion over the same period, with 43.6% of these costs attributed to hospital charges and procedures for which atrial fibrillation was the principal diagnosis, 29.3% attributed to the incremental inpatient costs due to atrial fibrillation as a comorbid diagnosis, 23.1% attributed to the ambulatory management of AF, and 4.0% representing prescription drug costs.25,26 In Canada, atrial fibrillation resulted in 8815 same-day procedures, 76,964 emergency room visits, and 64,214 acute care admissions (25,892 with atrial fibrillation as the principal diagnosis and 38,222 with atrial fibrillation as a comorbid diagnosis) in the 2007–2008 fiscal year, costing $956 million adjusted 2020 CAD (86.7% attributed to AF-associated hospitalisation, 9.0% attributed to AF-associated emergency department visits, and 3.3% attributed to AF-associated day-procedures).27

On a per-patient basis, the direct annual cost of atrial fibrillation in the US has been estimated to be $22,462 (2020 USD) per patient with atrial fibrillation compared with $5518 (adjusted 2020 USD) for those without AF, leading to an excess annual direct cost of $16,944–19,529 (adjusted 2020 USD) due to an approximately 2- and 4-fold increased rate of outpatient and inpatient healthcare utilization (adjusted rate ratio 2.14 and 3.94, respectively).28, 29, 30 For those with incident atrial fibrillation the excess direct healthcare cost has been estimated at $27,896 USD annually.31 In Canada, the direct annual cost of atrial fibrillation has been estimated to be $11,866 USD, with incident diagnosis being associated with an annual cost of $34,782 USD (vs. $63,031 in the US).31,32

In addition to these direct costs, the annual indirect costs (e.g. lost productivity due to days of work missed due to illness) have been estimated to be $3082 (adjusted 2020 USD) higher for patients with atrial fibrillation when compared those without atrial fibrillation ($4111 vs. $1029, respectively).33

Impact of atrial fibrillation on indigenous populations

The Indigenous peoples of the Americas comprise a culturally and ethnically diverse group, encompassing hundreds of distinct Indigenous populations based on cultural traits, linguistics, and habitation within 10 North and 14 Central and South American geographic regions.34, 35, 36, 37

United States and Canada

The Indigenous populations of the United States and Canada comprise a minority of the contemporary populations. Indigenous populations in the United States include Native Americans (contiguous United States), Alaska Natives, and Pacific Islander Americans, who collectively comprise 2.9% of the US population. Aboriginal populations in Canada, including the First Nations, Inuit, and Métis peoples, comprise approximately 4.3% of Canada's population. In the US and Canada, the Indigenous populations have experienced long-standing health disparities, suffering from disproportionately higher prevalence of chronic health conditions (such as diabetes and hypertension), nutritional problems (including obesity), mental health concerns, and substance abuse, leading to increased morbidity and significantly reduced life expectancy.38 Native Americans and Alaska Natives have a life expectancy that is 3–10 years less than the U.S. population (71.8 years vs. 81.9 years for Hispanic, 78.8 years for Non-Hispanic white, 74.8 years for Non-Hispanic Black).39 In Canada the life expectancy for First Nations, Inuit, and Métis peoples is estimated to be 9.5, 4.5, and 11 years shorter than the non-Indigenous population.40

In the US and Canada, atrial fibrillation is observed more commonly in Indigenous populations. Native Americans have been observed to have a higher risk of atrial fibrillation compared with all other racial and ethnic groups.41,42 In Canada, Aboriginal persons experience a 200% increased incidence and 150% higher prevalence of AF, which occurs at a younger age compared to the non-aboriginal population.43 While there are no AF-specific data regarding Canadian First Nations or Inuit peoples, at 1 year following index presentation the mortality rate for atrial fibrillation has been reported to be 3.3 times higher for Métis people (standardized rate 31.0% vs. 9.4% for non-Métis; P = 0.01). In addition, Native American and First Nations populations are known to be at relatively high risk for stroke, a risk that is particularly striking for younger First Nations peoples.44,45 Specifically, Native American individuals experienced the highest risk of non-hemorrhagic stroke, irrespective of the presence or absence of AF.46

Unfortunately, there are no data regarding risk factor intervention, pharmacological and invasive rhythm management, stroke prevention assessment and oral anticoagulation usage available for the Indigenous populations in Canada and the US.

Latin America

In contrast to Canada and the US, the Indigenous populations of Latin America are more populous, representing approximately 8% of the population according to the United Nations Development Program, and constituting majorities (Bolivia), pluralities (Guatemala, Belize, Peru, Ecuador, Mexico, Panama), or large minorities (Guyana, Chile). In many cases Mestizos/Mestiços (mixed Indigenous and non-Indigenous ancestry) comprise the largest ethnic group (Paraguay, Colombia, Venezuela, Brazil, Ecuador) or second largest ethnic group (Peru, Chile, Bolivia, and Argentina).47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57 Unfortunately, there are little data regarding atrial fibrillation epidemiology in Latin American Indigenous population as well as atrial fibrillation interventions. In a small observational study from Ecuador, the prevalence of atrial fibrillation in an indigenous population was 2.3%, which is lower than reported in other regions.58 Overall, access to healthcare for these indigenous and rural populations in Latin America is severely limited, and there is a significant knowledge gap which should be addressed by government agencies.

Regional varaibility in access and care

Canada

At almost 10 million square kilometers, Canada is the second largest country in the world, however, at 41 million inhabitants it is the 36th most populous (2021 population density of 4.2/km2 ranking 239/250).59 The distribution of Canada's population is heterogeneous, with over 80% of the population living within 150 km of the southern border, and nearly 50% of the population residing in the Windsor-Quebec City Corridor (population density 82.2/km2 over a region that comprises 2.3% of Canada's geography). As a result, the vast majority of Canada's land mass is sparsely populated (e.g. population density 0.05/km2).

Canada's Northern and remote communities are disproportionately comprised of aging populations owing to limited economic opportunity (e.g. fewer businesses and lack of industry), leading to a relatively greater prevalence of unemployment and poverty. In addition, many northern and remote communities lack basic healthcare and social services, including primary and emergency care. Specifically, medical services (e.g. hospitals and specialized clinics, including dedicated atrial fibrillation clinics and cardiac ablation centres) are localised in urban centres predominantly near the southern border, rendering them largely inaccessible to the residents living in Canada's northern and remote areas. While telemedicine and videoconferencing has helped to expand access to specialist services many northern and remote communities have limited or no internet access. As a result, there exists significant place-based healthcare disparities, which disproportionately impact older, poorer, and Indigenous peoples.

In the case of the Indigenous populations, these disparities have been attributed to the legacy of colonialism, which has directly and indirectly resulted in social, economic, cultural, and political marginalization.60 Forced displacement to remote communities has resulted in social isolation, disconnection from traditional lands, culture, resources, and practices (including degradation of the systems of Indigenous health knowledge), economic deprivation (e.g. colonial policies focused development on unseated lands), food insecurity, barriers to housing and education, and lack of access to necessities including health care. Moreover, Indigenous persons may experience discrimination when accessing the health care system, including a lack of cultural safety and acceptance of Indigenous health and healing models, further exacerbating a lack of trust in Western Healthcare and a perception of the health care system as being unsafe.

It is important to consider that while the Canadian Healthcare System provides universal healthcare coverage, the administration is provincial. As a result, the access, services, care delivery, and outcomes vary significantly from province to province. For example, a recent analysis examining atrial fibrillation outcomes demonstrated that the annual rates of stroke, major bleeding, and heart failure varied by 170% (2.3% vs. 3.9%), 180% (1.1% vs. 2.0%), and 130% (7.8% vs. 10.2%), respectively.61 Likewise, funding, access, and wait times for specialist services (e.g. atrial fibrillation clinics and ablation) demonstrate significant interprovincial variation.

United States

The USA, with a population of over 336 million individuals, is the 3rd most populous country in the world. However, as the 4th largest country in the world (with a geography spanning over 9.5 million square kilometers) the population density is 34.8/Km2, thus ranking 186/250.62 Moreover, there exhibits significant regional variation in population density as the majority of the US population resides east of the Mississippi River. The most densely populated geographic region in the US is the Northeast (133.4/km2; comprised of Mid-Atlantic 160.8/km2 and New England 90/km2), and the least densely population regions are Alaska (0.5/km2), the Mountain West region (10.3/km2), and West North Central region (15.9/km2).62 Specific to AF, there exists substantial regional variability in epidemiology, management, and outcomes. Oltman et al. demonstrated that Midwestern, Southern, and Northeastern regions had a higher prevalence of atrial fibrillation compared to the Mountain and Pacific regions.63 Atwater and colleagues observed that patients in the southern region of the US had the highest clinical risk scores, which corresponded with the highest incidence rates of stroke and systemic embolism and bleeding; however, they observed that this region had the lowest rates of oral anticoagulation (OAC) treatment.64 In addition, there exists significant differences when outcomes are considered within regions, whereby in-hospital mortality has been noted to be higher for atrial fibrillation patients from rural settings when compared to urban settings.65

Beyond geography, the United States encompasses a wide range of social, economic, structural, and environmental diversity, which fuel health inequities based on sex, race, ethnicity, geography, and socio-economic status. These inequities extend to the management of abnormal heart rhythm conditions including AF. It is well-known that females, non-urban residents, individuals from racialized communities, and older individuals are less likely to receive therapeutic anticoagulation or be treated with direct-acting oral anticoagulants (DOACs), less likely to be referred to specialist services (clinical cardiac electrophysiologists and atrial fibrillation centers), and consequently less likely to undergo invasive cardiovascular procedures (procedural rhythm control [catheter ablation] and stroke reduction therapies [LAAO]), though efforts to improve these inequities are ongoing.66, 67, 68, 69, 70, 71, 72 Reasons for these differences are incompletely understood, and are likely multifactorial based on a combination and interplay of the patient, the physician, and the health care system, as well as the intersection between these factors. Remediating inequities in access to cardiovascular care for historically underserved groups will require an in-depth understanding of the factors that impede access to primary and specialty care, including dedicated arrhythmia clinics and cardiac electrophysiologists. Targeted interventions to improve outcomes may include quality improvement initiatives aimed at enhancing delivery of cardiovascular care, efforts to expand Medicaid, particularly in Medicaid non-expansion states, and public policy directives aimed at remediating inequities to access to atrial fibrillation care, particularly among marginalized populations.

Latin America

Latin America is a vast region, stretching from Mexico to the southern tip of Argentina, with an estimated population of more than 652 million.73 Given this vast geography there exists significant cultural and economic differences between member countries. In addition to differences in income status, and percentage of the gross domestic product invested in each country's health system, the design of the health systems varies from country to country. Publicly funded healthcare, while present in most Latin American countries, varies substantially in terms of universality (i.e., not every citizen is part of the plan), coverage (i.e., not all services are provided as part of the plan), infrastructure and resources. In many countries there exists parallel or integrated private healthcare options, with out-of-pocket expenditure differing significantly between countries.

As a result of these differences in healthcare policies there are substantial differences in access to care, with secondary effects on screening, diagnosis, and treatment of arrhythmias.74 Specifically, patients with atrial fibrillation in Latin America are older, more frequently have permanent atrial fibrillation compared to other regions, and are more likely to suffer an AF-associated complication (e.g. higher rates of mortality and stroke/systemic embolism), reflecting significant delays in diagnosis and treatment initiation.75

In addition, there are significant issues related to rural and remote populations, which present geographical barriers to access and introduce substantial language barriers, as many languages are spoken across the different indigenous groups. In addition, the rural and remote regions suffer from digital inequity (e.g. lack of Internet connectivity and technological infrastructure), further impacting the ability to provide outreach care, further delaying diagnosis and subsequent management.

Regional differences in the management of AF

Goals of care and guidance

The contemporary goal of atrial fibrillation management is an improvement of arrhythmia-related symptoms and reduction in the morbidity associated with atrial fibrillation through management strategies that meaningfully reduce the AF-associated healthcare utilization. International guidelines affirm the importance of providing a structured, integrated, multidisciplinary, and patient-focused approach to the management of AF, focusing on a collaboration that enables individuals living with atrial fibrillation to guide the care of their heart rhythm disorder in partnership with their healthcare provider(s). While fundamentally similar, notable differences exist in the guidance provided by the American College of Cardiology/American Heart Association (ACC/AHA), the Canadian Cardiovascular Society/Canadian Heart Rhythm Society (CCS/CHRS), and the European Society of Cardiology (ESC) recommendations, which many Latin American countries follow in the absence of regional guidance.76, 77, 78

Regional variation in stroke prevention therapies

Despite unequivocal evidence for the efficacy of stroke prevention therapies, oral anticoagulation is commonly over-prescribed in patients with a low stroke risk (e.g. nearly half of CHA2DS2-VASc [clinical estimation of the risk of stroke in patients with atrial fibrillation, where congestive heart failure, hypertension, age ≥65, diabetes, vascular disease and female sex are given 1 point and age ≥75 and stroke or transient ischemic attack are given 2 points] score 0–1 patients are prescribed OAC) and under-prescribed in patients at high stroke risk (CHA2DS2-VASc ≥2). Appropriate OAC prescription has been observed to be better in the Americas than that observed in Asia but despite clear guidance, it remains inferior to that observed in Europe.79 Within the Americas, OAC prescription is relatively better in Latin America compared to North America (Latin America—79.6% of moderate risk and 86.6% of high-risk patients receiving OAC vs. 67.7% and 80.8% receiving OAC in North America, respectively),79 however, OAC prescription within Latin America favours younger and male patients, with older patients and women being less likely to receive adequate treatment.80,81 In addition, despite a clear recommendation favouring the use of DOACs some Latin American countries still rely heavily on the use of vitamin K antagonists (VKA), which is partially explained by the cost of these agents.81, 82, 83, 84, 85

Recently there has been interest in the use of non-pharmacological approaches to stroke prevention. Recognising that the dominant source of AF-associated strokes is the left atrial appendage, left atrial appendage closure (LAAC) has emerged as a nonpharmacologic stroke prevention strategy for patients in which long term oral anticoagulation is contraindicated.76, 77, 78,86 All three guidelines recommend LAAC for patients with atrial fibrillation and a contraindication to long term oral anticoagulation, though the strength of recommendation differs with the US attributing a Class IIa, the European guidelines a Class IIb, and the Canadian providing a weak recommendation.76, 77, 78 Unsurprisingly, the utilisation rates for LAAC follow, with the US implanting LAAC at a rate 33 times greater than Canada (462 per 1,000,000 beneficiaries in US in 2021 vs. 14 per 1,000,000 capita in Canada in 2024). In Latin America the LAAC implantation rates vary from 2 per 1,000,000 capita in Brasil to 7.7 1,000,000 capita in Chile and Costa Rica. For context, the LAAC implantation rate in Denmark was 55.6 per 1,000,000 capita in 2021.87

Regional variation in rhythm control therapies

Restoration and maintenance of sinus rhythm has been shown to alleviate symptoms, improve exercise capacity, and enhance quality of life in younger patients with highly symptomatic paroxysmal AF, and those with concomitant heart failure. In those with treatment-naïve AF, recent studies have demonstrated that an initial treatment strategy of catheter ablation significantly improved arrhythmia and patient-reported outcomes, significantly reduced healthcare resource utilization, and did not increase the risk of adverse events compared with initial antiarrhythmic drug therapy.88, 89, 90 Despite this evidence there are regional variations in the decision to pursue rhythm control across the Americas, with Mexico, Argentina, and Brazil being most likely to pursue rhythm control as the initial atrial fibrillation management strategy, and Chile and Canada being least likely.91

Similar to other invasive procedures, variability in access to catheter ablation is substantial, with the US performing atrial fibrillation ablation at a rate almost 3 times greater than Canada (434.8 per 1,000,000 in the US in 2019 vs. 176 per 1,000,000 in Canada), though the US rate is comparable to Denmark (451 per 1,000,000 capita) and less than Germany (610 per 1,000,000 capita).87,92,93 Within Latin America the rates of ablation generally reflect the overall healthcare expenditure, with rates of complex ablation being highest in Mexico (145 per 1,000,000), intermediate in Argentina, Colombia, and Peru (∼70–90 per million), low in Brazil, Chile, Ecuador, Uruguay, Costa Rica, Dominican Republic (∼<40 per million), and effectively non-existent in Cuba, Bolivia, Venezuela, El Salvador, Panama (<1 per million).94

Future perspectives

Atrial fibrillation management in the Americas is highly variable, mainly driven by country-specific economic differences which ultimately lead to marked variations in health-care expenditure as well as regional differences in access to medical services, diagnostics, treatments and technologies (Fig. 2). It is important that healthcare policies address these within and between country barriers, which will lead to improved care and a reduction in the overall economic burden of AF. For example, although healthcare expenditure is high in the United States, there is significant inequality in healthcare access leading to marked differences in medical and interventional treatment according to race, ethnicity, and most importantly, household income. Thus, it is likely that policies oriented towards improving universal access would have the greatest impact on atrial fibrillation outcomes. In Canada, although public healthcare is portable, universal, accessible, and comprehensive, the fragmented provincial administration leads to regional disparities in access and treatment. Moreover, access is limited in distant rural areas. As such, policies oriented at unifying treatment standards, as well as diminishing the rural-urban divide should have a significant impact on health outcomes. In the case of Latin America, although the region is composed of several countries with different governments and health policies, the major common obstacle is the lack of funding (predominantly due to weaker economies). Thus, policies oriented at improving funding of healthcare systems would improve outcomes. Moreover, rural and indigenous populations comprise a significant proportion of inhabitants in several Latin American countries, and lack of access is frequent in these populations. Thus, policies should focus on improving disease awareness, creating adequate treatment pathways oriented towards early diagnosis and adequate treatment of patients with AF, providing orientation on the importance of proper medical treatment, and improving access to specialist services for these populations. Specifically, it is our opinion that all the Americas would benefit from the development of patient-centered protocols tailored to their region, with the goal of empowering community health agents and facilitating collaboration in remote and underserviced regions of each member country. One such example, the Global Health Research Group on Atrial Fibrillation Management (GHRG-AF), has launched an initiative to provide patient-centered care in rural (i.e., Amazonia) areas, and could be used as an example for which similar programs could be developed in other countries.95

Fig. 2.

Fig. 2

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Regional Variability and barrier in the optimal management of AF.

Several pragmatic considerations toward advancing atrial fibrillation management across the Americas include: 1. Improve collaboration among the three major professional societies within the Americas that focus on the treatment of arrhythmias (Heart Rhythm Society [HRS], Canadian Heart Rhythm Society [CHRS], and Latin American Heart Rhythm Society [LAHRS]). 2. Enhancement of specialist manpower resources though expansion of fellowship training programs focused on the treatment of arrhythmias, particularly in Latin American countries, rural communities, and other marginalized communities throughout the Americas. This process should include standardization of training programs as well as provide ongoing educational support/continued medical education for clinicians and ancillary staff who treat arrhythmias in the Americas. 3. Engagement with governmental stakeholders to advocate for enhancement in global healthcare funding, with a specific focus on resource allocation towards arrhythmia care in low-middle income countries, 4. Engagement with industry partners to ensure that developing countries and resource limited areas in the Americas can access the required technology to provide advanced arrhythmia care. 5. Facilitate partnerships between centres in the Americas in order to provide knowledge exchange, as well as mentorship in the development of centers of excellence for arrhythmia care. 6. Alignment of guideline documents to avoid discordant recommendations that enable treatment gaps.

Conclusion

Regional variations and challenges in the management of atrial fibrillation are present throughout the Americas. Failure to remediate health inequities in the management of atrial fibrillation will exacerbate the burden of healthcare resources attributed toward the management of this disease.

Contributors

Conceptualization, project administration (JA, GL), Literature search, writing—original draft (JA, LRJ, JCD), writing—review & editing (MC, JH, CM, GL, NLC), Decision to submit the manuscript (JA).

Editorial disclaimer

The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

Declaration of interests

Jason G. Andrade reports honoraria from Medtronic, Boston Scientific, Biosense Webster. Larry R. Jackson II reports honoraria from Sanofi, Biosense Webster, J&J Med Tech, East Carolina University, Bristol Myers Squibb, Association Block Cardiologists. Juan Carlos Diaz reports honoraria from Biotronik, Abbott, Medtronic, Biosense Webster. Mina Chung reports grants from the NIH and AHA. Jody Hurwitz reports consulting fees from Medtronic and had a leadership or fiduciary role as Past president of the Heart Rhythm Society. Carlos A. Morillo reports honoraria from Kardium, Novartis, Medtronic, grants from CIHR and NIH, NIH Sponsored DSMB Chair for the VELVET and BETTY Trials. Gregory Y. H. Lip has nothing to disclose. Nestor Lopez-Cabanillas has nothing to disclose.

Acknowledgements

Funding Sources: None.

Footnotes

Appendix A

Supplementary data related to this article can be found at https://doi.org/10.1016/j.lana.2025.101110.

Appendix A. Supplementary data

Supplementary Tables
mmc1.docx (70.4KB, docx)

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