Table 16.

Consensus statements on AF prevention I: risk factors and lifestyle modification

Risk factor/trigger	Recommendations for clinical practice	Recommendations for research
Obesity	Inform overweight and obese patients of greater risk of developing AF and a subsequent risk of stroke and death. Assess BMI and start lifestyle programmes if BMI is overweight or obese	More studies are needed on how to effectively prevent weight gain and promote weight loss in individuals who are overweight or obese More randomized controlled studies with long-term follow-up (>5 years) are needed to clarify the obesity paradox
General dietary considerations	Recommend healthy nutrition and lifestyle to reduce risk of AF Mediterranean diet enriched with olive oil may reduce risk of AF and its complications	More studies are needed on: the effect of unhealthy nutrition on risk of AF Whether modification of diet reduces risk of arrhythmia
Blood lipids, fish consumption	Inform patients with low HDL (<40 mg/dL) and high triglyceride (TGs >200 mg/dL) levels of risk of AF and its complications Recommend to patients with abnormal blood lipids to consume of a diet ‘that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils, and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats’66 Recommend combination of diet with moderate physical activity and maintenance of a healthy lifestyle and weight	Lacking direct evidence, more studies are needed to define whether modification of blood lipids reduces the risk of AF.
Obstructive sleep apnoea	Inform patients with obstructive sleep apnoea that there is a greater risk of developing AF and their subsequent risk of stroke and death. Assess by anamnesis (snoring, daytime fatigue) the possibility of OSA Refer to specialised clinic, as needed.	More studies are needed: To investigate how comorbidity in patients with obstructive sleep apnoea affects the risk of AF To show the benefit of diagnostic efforts and the effect of treatment with CPAP. On adequate assessment of presence of OSA in AF population. To show reduced risk of AF in well powered RCTs using systematic therapeutic approach together with other lifestyle changes
Hypertension	Uncontrolled blood pressure is associated with AF risk Adequately assess patients at risk Control BP to reduce AF risk	Additional well-conducted secondary AF prevention trials will be important to define target SBP optimal to prevent AF Implement in RCTs together with other lifestyle management
Diabetes mellitus	Longer duration of diabetes and worse glycemic control are associated with increased AF risk Control diabetes to reduce AF risk	More research is needed on the effect of glycemic control on AF risk in patients with diabetes
Tobacco smoking	Intensively encourage children, young and older adults not to begin smoking. In individuals who smoke support smoking cessation to prevent AF incidence, recurrence, symptoms, and complications. Primordial prevention. Support efforts to prevent the uptake of tobacco smoking. Primary prevention. Encourage individuals to quit smoking. Secondary prevention. In individuals with AF promote efforts to quit smoking to improve AF frequency, duration, and symptoms	Investigate whether electronic cigarettes and second hand smoke are associated with an increased risk of new-onset AF, and in individuals with prevalent AF, whether electronic cigarettes and second hand smoke are associated with AF recurrence and AF symptoms. In individuals with AF, examine the efficacy and effectiveness of smoking cessation interventions to decrease the risk of stroke, myocardial infarction, chronic kidney disease, dementia, and all-cause mortality.
Air pollution	No association with chronic exposure; patients prone to AF should refrain from severe pollution exposure.	Overall data are scarce and should be increased specifically aimed at incidence of AF in patients with known cardiac disease.
Caffeine	No increase in risk, rather a reduced association, even for heavy consumption.	Data should be extended to randomized intervention studies addressing caffeine consumption in patients with paroxysmal AF
Alcohol	Moderate-heavy and binge drinking increases AF risk To reduce AF risk: Recommend to avoid binge drinking (>4 drinks in women and >5 drinks in men on a single occasion) Recommend to refrain consumption to no more than 2 drinks per day for men and 1 drink per day for women Obtain a detailed history on alcohol consumption Provide appropriate counselling to reduce alcohol consumption in patients with AF	More intervention studies are needed on the effect of alcohol consumption reduction on AF risk
Medications	Many drugs increase AF risk; common (>20%) - dobutamine, cisplatin; infrequent (5–20 %) - anthracyclines, melphalan, interleukin, NSAIDS, bisphosphonates; rare (<5 %) - adenosine, corticosteroids, aminophylline, antipsychotics, ivabradin, ondansetron. In patients with new-onset AF, review the pharmacological history to identify whether any of the prescribed drugs may cause the arrhythmia.	More research on the effects on AF incidence for drug induced new-onset AF is needed, as many studies show conflicting results. Also more research is needed on which medications cause increased risk of AF.
Recreational drugs	Recreational drugs (cannabis, ecstasy and anabolic-androgenic steroids) may increase risk of AF. Examine for recreational drug abuse in new-onset AF Encourage avoidance of recreational drugs.	More research is needed on the effect of illicit drugs, particularly cannabis, on new-onset AF, as most of the evidence is from case reports
Psychological distress	Identify significant psychological distress, particularly depression and anxiety, and treat appropriately to reduce the likelihood of adverse lifestyle choices (smoking, excessive alcohol intake, poor diet, physical inactivity) and poorer adherence to medication and lifestyle modification, all of which may increase the likelihood of development of other risk factors for AF, and hence predispose people to incident AF and other chronic diseases.	Further investigation of the impact of psychological distress on the development of AF in more diverse populations is warranted since the current limited evidence is based predominantly on white, middle-class, and middle-aged cohorts, and is only evident in men.
Physical activity	Recommend daily moderate exercise to reduce risk of AF	Role of physical activity clearly warrants further research, plus genetics involved in AF in excessive sports

AF, atrial fibrillation; BMI, body mass index; BP, blood pressure; CPAP, continuous positive airway pressure; HDL, high-densiy lipoprotein cholesterol; OSA, obstructive sleep apnoea; RCT, randomised controlled trial; SBP, systolic blood pressure.