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.