Discussion
The major findings of the JoFib study are: (i) One in 10 AF patients was
younger than 50 years of age, (ii) Young patients have more favorable
baseline clinical profiles and one year outcome compared with older
patients. All published clinical evidence clearly confirms major
differences in demographics, risk factor prevalence, and outcomes
between younger patients with AF and their older counterparts[3,18]. The definition of young differs between
the different studies and ranges from 40-60 years. The age cutoff of 50
years was chosen to ensure a sufficient number of patients in the young
group and to exclude the potential confounding effect of the 50–60 year
age group, a population that may exhibit an increased prevalence of risk
factors. This information is crucial in understanding the unique
characteristics and needs of AF patients in different age groups and
populations, which can inform the development of more effective
prevention and treatment strategies.
The majority (65.7%) of the young population in this study were males.
This is in contrast to the older age group, where females accounted for
56.3% of the whole group. This male preponderance in young patients
with AF has also been reported in a study by A. Wutzler et al. on 124
patients with AF and younger than 35, of whom 97.5% were males[5]. The reasons for the underrepresentation of
females in the young AF population are not clear. Possible explanations
include the tendency of females to delay reporting symptoms, their
complaints not being taken seriously [21], and a
higher prevalence of AF-related risk factors such as smoking in men
compared to women [22].
The higher prevalence of risk factors such as HTN, DM, dyslipidemia, HF,
and CKD in the older population suggests that these medical conditions
also play a significant role in the development of AF in older
individuals. Previous studies have also documented a higher prevalence
of DM, HTN and dyslipidemia in Middle Eastern populations compared with
populations in the West [19]. The prevalence of
HTN, DM, and dyslipidemia was 17.7%, 1.6%, and 4% respectively in
young German patients with AF, compared to a prevalence of 31.3%,
10.4%, and 23.9% in our young cohort [5].
Moreover, the prevalence of tobacco smoking (38%) was much higher in
our young group when compared to the older group (11%) or to young
patients with AF reported in studies from the West[5]. These findings emphasize the importance of
early detection and management of risk factors for AF in both young and
older populations. Effective strategies to reduce the risk of developing
AF, such as maintaining a healthy lifestyle, regular physical activity,
and effective management of underlying medical conditions, should be
encouraged in both populations.
Palpitations were the most common symptom in young patients with AF and
was present in over 65% of such patients. This finding highlights the
importance of taking symptoms such as palpitations seriously, especially
in young individuals who are otherwise healthy. In addition, paroxysmal
AF was the most common type of AF in both the young and old age groups.
It is important for healthcare providers to consider the possibility of
AF in such patients and to perform appropriate diagnostic tests to
confirm or rule out the diagnosis, especially in those with risk factors
and an increased CHA2DS2-VASc score. An
EKG, echocardiogram, extended Holter monitor, or even an implantable
loop recorder should be part of the routine workup for such patients
since a diagnosis of paroxysmal AF may necessitate the use of oral
anticoagulants to prevent thromboembolic complications[20].
In general, younger patients had lower mean
CHA2DS2-VASc
scores than the older population, as older patients get one or two
points for their age, and they tend to aggregate more risk factors.
Quite concerning, however, was the fact that younger patients with AF
and high CHA2DS2-VASc scores were less
likely to be on OAC therapy than older patients with the same scores.
These findings suggest that younger patients with AF may not be
receiving appropriate anticoagulant therapy based on their risk for
stroke and other thromboembolic complications. This disparity in
treatment between young and older populations with similar
CHA2DS2-VASc scores is concerning and
highlights the need for improved awareness and understanding of the
importance of anticoagulant therapy in preventing stroke and other
complications in young individuals with AF. On the other hand, when
younger populations are eligible to be anti-coagulated, they tend to be
on new direct-acting OACs (DOACs), rather than warfarin. The higher use
of DOACs in younger populations is in line with recent guidelines, which
recommend the use of DOACs as the preferred anticoagulant therapy for
AF.