The World Heart Federation Roadmap for Nonvalvular Atrial Fibrillation.
The World Heart Federation has undertaken an initiative to develop a series of Roadmaps to promote development of national policies and health systems approaches, and to identify potential roadblocks on the road to effective prevention, detection, and management of cardiovascular disease in low-and middle-income countries (LMICs) and develop strategies for overcoming these. This Roadmap focuses on atrial fibrillation (AF). AF is the most common, clinically significant arrhythmia and, among other clinical outcomes, is associated with increased risk of stroke.



Development of this Roadmap included a review of published guidelines and research papers, and consultation with an expert committee comprising experts in clinical management of AF and health systems research in LMICs. The Roadmap identifies 1) key interventions for detection, diagnosis, and management of AF; 2) gaps in implementation of these interventions (knowledge-practice gaps); 3) health system roadblocks to implementation of AF interventions in LMICs; and 4) potential strategies for overcoming these.



More research is needed on determinants and primary prevention of AF. Knowledge-practice gaps for detection, diagnosis, and management of AF are present worldwide, but may be more prominent in LMICs. Potential barriers to implementation of AF interventions include long distances to health facilities, shortage of health care professionals with training in AF, including interpretation of ECG, unaffordability of oral anticoagulants for patient households, reluctance on the part of physicians to initiate oral anticoagulant (OAC) therapy, and lack of awareness of the importance of persistent adherence to OAC therapy. Potential solutions include training of nonphysician health workers and pharmacists in pulse-taking, use of telemedicine technologies to transmit electrocardiogram results, engagement of nonphysician health workers in OAC therapy adherence support, and country-specific support and education programs for noncardiologist health care professionals.



AF affects millions of people worldwide and, left untreated, increases the risk and severity of stroke and heart failure. Although guidelines for the detection, diagnosis, and management of AF exist, there are gaps in implementation of these guidelines globally, and in particular in LMICs. This Roadmap identifies some potential solutions that may improve AF outcomes in LMICs but require further evaluation in these settings.
Centre for Health and Social Change, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom. Electronic address: Adrianna.Murphy@lshtm.ac.uk.
Adrianna
A
Murphy
Farr Institute of Health Informatics Research, University College London, London, United Kingdom.
Amitava
A
Banerjee
Department of Cardiovascular Medicine, Division of Clinical and Experimental Electrophysiology, University Hospital Münster, Münster, Germany, and Atrial Fibrillation Network e.V. (AFNET).
Günter
G
Breithardt
Cardiology Clinical Academic Group, St. George's University of London, and Imperial College, London, United Kingdom.
A John
AJ
Camm
Cardiac Clinic, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
Patrick
P
Commerford
Heart Research Institute/Charles Perkins Centre and Sydney Medical School, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia.
Ben
B
Freedman
Instituto Nacional de Cardiología Ignacio Chavez, Mexico City, Mexico.
J Antonio
JA
Gonzalez-Hermosillo
Icahn School of Medicine at Mount Sinai, The Zena and Michael A. Wiener Cardiovascular Institute, The Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, NY, USA.
Jonathan L
JL
Halperin
Department of Medicine, The University of Hong Kong, Hong Kong.
Chu-Pak
CP
Lau
World Heart Federation, Geneva, Switzerland; London School of Hygiene & Tropical Medicine, London, United Kingdom.
Pablo
P
Perel
Pharmacology and Clinical Research, St. John's Medical College and Research Institute, Bangalore, India.
Denis
D
Xavier
World Heart Federation, Geneva, Switzerland; National Heart and Lung Institute, Imperial College London, London, United Kingdom.
David
D
Wood
Cardiology Department, Hôpital Européen Georges Pompidou, Paris, France.
Xavier
X
Jouven
Department of Cardiac Sciences, Cumming School of Medicine, Division of Cardiology, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Foothills Medical Centre, Calgary, Alberta, Canada.
Carlos A
CA
Morillo
D001281:Atrial Fibrillation / Q000628:therapy*; D002309:Cardiology / Q000592:standards*; D006801:Humans; D011050:Policy Making; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards*; D012955:Societies, Medical