The Impact of Obesity on Atrial Fibrillation Review: Prevalence, Pathophysiology, and Challenges in Management

Atrial fibrillation is a growing global health concern due to increasing prevalence and increasing monetary cost on healthcare. Obesity independently contributes to the development of atrial fibrillation through structural, hemodynamic, and electrophysiological changes, necessitating accountability for these changes in atrial fibrillation treatment. With the prevalence of obesity rising as well, and around 18% of atrial fibrillation cases being attributable to obesity, there is a critical need to address obesity in atrial fibrillation. Despite these strong associations, obese patients remain to be underrepresented in atrial fibrillation clinical trials, limiting the applicability of current treatment guidelines to this population. Treatment of atrial fibrillation in obese patients is altered. Rate control strategies such as using beta-blockers and atrioventricular nodal blockers are less effective due to altered cardiac electrophysiology in obese patients. Rhythm control through cardioversion and catheter ablation also shows reduced efficacy, with higher energy thresholds and increased recurrence rates post-ablation. Increased bleeding risks in obese patients complicate drug pharmacokinetics of anticoagulation treatments. Furthermore, the association between obesity and sleep apnea may further increase risk of developing and worsening atrial fibrillations. Patients with atrial fibrillation and sleep apnea had higher incidences of stroke, pulmonary embolism, and more severe coronary artery disease, which were associated with elevated CHADS2 and CHA2DS2-VASc scores. Bariatric surgery has shown promise in reducing atrial fibrillation recurrence and improving procedural success. Lifestyle interventions and comprehensive metabolic may also reduce atrial fibrillation burden and improve outcomes in obese patients. This paper reviews challenges in atrial fibrillation treatment such as rate and rhythm control, anticoagulation, catheter ablation, cardioversion, highlighting the need for tailored therapeutic strategies and further research, particularly on the role of bariatric surgery and lifestyle modifications in atrial fibrillation prevention and treatment in obese populations.