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Racial and Ethnic Differences in the Management of Atrial Fibrillation

Open AccessPublished:September 12, 2021DOI:https://doi.org/10.1016/j.cjco.2021.09.004

      Abstract

      Atrial fibrillation (AF) is the most common clinical arrhythmia, and it results in adverse outcomes and increased healthcare costs. Racial and ethnic differences in AF management, although recognized, are poorly understood. This review summarizes racial differences in AF epidemiology, genetics, clinical presentation, and management. In addition, it highlights the underrepresentation of racial and ethnic populations in AF clinical trials, especially trials focused on stroke prevention. Specific strategies are proposed for future research and initiatives that have potential to eliminate racial and ethnic differences in the care of patients with AF. Addressing racial and ethnic disparities in healthcare access, enrollment in clinical trials, resource allocation, prevention, and management will likely narrow the gaps in the care and outcomes of racial and ethnic minorities suffering from AF.

      Résumé

      La fibrillation auriculaire (FA) est la forme clinique d’arythmie la plus fréquente, et elle entraîne des résultats défavorables ainsi qu’une augmentation du coût des soins de santé. Les différences liées à la race et à l’origine ethnique qui existent dans la prise en charge de la FA, bien que reconnues, sont mal comprises. Le présent article de synthèse résume les différences liées à la race observées sur le plan de l’épidémiologie, de la génétique, du tableau clinique et de la prise en charge de la FA. En outre, il met en lumière la sous-représentation de groupes raciaux et ethniques dans les études cliniques sur la FA, en particulier celles axées sur la prévention des accidents vasculaires cérébraux. Des stratégies ad hoc sont proposées pour que la recherche et les initiatives futures favorisent l’éradication des différences liées à la race et à l’origine ethnique dans les soins prodigués aux patients atteints de FA. Le fait de s’attaquer aux disparités liées à la race et à l’origine ethnique qui touchent l’accès aux soins de santé, l’inscription aux essais cliniques, l’allocation des ressources, la prévention et la prise en charge des patients permettra probablement de réduire les lacunes en matière de soins et de résultats chez les personnes atteintes de FA issues de minorités raciales et ethniques.

      Graphical abstract

      Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia worldwide, estimated to affect 37.6 million people globally, and projected to increase by > 60% by the year 2050.
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      Global epidemiology of atrial fibrillation: an increasing epidemic and public health challenge.
      Currently, ∼1 million people in Canada and 5.2 million in the US have AF, with the number in the US predicted to increase to 12.1 million by the year 2030.
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      2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation.
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      Diagnostic accuracy of handheld electrocardiogram devices in detecting atrial fibrillation in adults in community versus hospital settings: a systematic review and meta-analysis.
      In Africa, the true prevalence of AF is underreported. Small cross-sectional studies reveal a prevalence of 0.7% to 5.5%, with some estimating that by the year 2050, the prevalence of AF in Africa will be the highest in the world.
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      Atrial fibrillation in Sub-Saharan Africa: epidemiology, unmet needs, and treatment options.
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      • Benjamin E.J.
      Global epidemiology of atrial fibrillation.
      From 1997 to 2017, the number of years of health lost from AF increased by 77%, correlating with increasing age and high socioeconomic–index countries.
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      • Cervellin G.
      Global epidemiology of atrial fibrillation: an increasing epidemic and public health challenge.
      Large variations were noted in AF prevalence across various regions of the world grouped by income level (7-fold increase in middle- income and 11-fold increase in high-income countries, compared with around 1 fold increase in low-income countries, where AF might be overlooked or underreported).
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      Population-based studies have consistently reported a lower AF burden among racial and ethnic minorities, despite their having a higher prevalence of traditional risk factors. Given this, race-specific risk factors that might contribute to AF should be better elucidated. In addition, AF management differences for various races and ethnicities have been reported; however, these data have not been systematically reviewed. The present paper reviews global differences based on race and ethnicity in AF epidemiology, genetics, clinical presentation and management, and factors that might contribute to these differences, including systemic biases and social determinants of health. We highlight possible strategies to address these differences in diverse racial and ethnic groups to ultimately help improve adverse outcomes in these patients.

      Epidemiologic Factors of AF in Relation to Race and Ethnicity: AF Risk

      Current epidemiologic studies have shown that AF is more prevalent in White patients than in other racial and ethnic groups. A recent study using the national inpatient sample (NIS) showed that of 30 million patients with AF at hospital discharge, significantly more White than Black patients had AF (11.3% vs 4.6%, P < 0.001).
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      • Padala S.K.
      • et al.
      Comparison of frequency of atrial fibrillation in Blacks versus Whites and the utilization of race in a novel risk score.
      This significant difference in AF held true across all age groups above 50 years, and it was most significant in those > 75 years old (31.4% White vs 18.2% Black patients, P < 0.01).
      • Kowlgi G.N.
      • Gunda S.
      • Padala S.K.
      • et al.
      Comparison of frequency of atrial fibrillation in Blacks versus Whites and the utilization of race in a novel risk score.
      Similarly, 2 separate large studies of patients with AF in California hospitals showed significantly lower odds of having AF for all non-White races/ethnicities, compared with White patients (0.53 for Black, 0.61 for Hispanic, and 0.68 for Asians patients, P < 0.01 for all; and 0.49 for Black, 0.58 for Hispanic, and 0.68 for Asian patients, P < 0.0001 for all).
      • Dewland T.A.
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      • Marcus G.M.
      Incident atrial fibrillation among Asians, Hispanics, Blacks, and Whites.
      In the Multi-Ethnic Study of Atherosclerosis (MESA), after adjusting for age and sex, the incidence of AF was 49%, 46%, and 65% lower for non-Hispanic Black (NHB), Hispanic, and Chinese patients, respectively, compared with non-Hispanic White (NHW) patients.
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      • et al.
      Atrial fibrillation incidence and risk factors in relation to race-ethnicity and the population-attributable fraction of atrial fibrillation risk factors: the Multi-Ethnic Study of Atherosclerosis.
      Another study of 417,525 patients from the United Kingdom showed that South Asians had 71% lower odds of having AF, with an age-adjusted prevalence of 0.4% vs 2.4%, compared with White patients.
      • Gillott R.G.
      • Willan K.
      • Kain K.
      • et al.
      South Asian ethnicity is associated with a lower prevalence of atrial fibrillation despite greater prevalence of established risk factors: a population-based study in Bradford Metropolitan District.
      The few studies that have been performed in South Asia show an AF prevalence of 0.1%-0.6%.
      • Wong C.X.
      • Brown A.
      • Tse H.-F.
      • et al.
      Epidemiology of atrial fibrillation: the Australian and Asia-Pacific perspective.
      Black individuals have a lower reported prevalence of AF compared with White individuals, despite having a higher prevalence of traditional AF risk factors; this disparity is termed the “AF paradox.”
      • Virani S.S.
      • Alonso A.
      • Aparicio H.J.
      • et al.
      Heart disease and stroke statistics—2021 update: a report from the American Heart Association.
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      • Lopez F.L.
      • Folsom A.R.
      • et al.
      Absolute and attributable risks of atrial fibrillation in relation to optimal and borderline risk factors: the Atherosclerosis Risk in Communities (ARIC) Study.
      • Lipworth L.
      • Okafor H.
      • Mumma M.T.
      • et al.
      Race-specific impact of atrial fibrillation risk factors in Blacks and Whites in the Southern Community Cohort Study.
      • Jensen P.N.
      • Thacker E.L.
      • Dublin S.
      • Psaty B.M.
      • Heckbert S.R.
      Racial differences in the incidence of and risk factors for atrial fibrillation in older adults: The Cardiovascular Health Study.
      In the Reasons for Geographic and Racial Differences in Stroke (REGARDS) prospective cohort study of nearly 14,000 patients followed for 9.4 years, Black individuals had a 0.46 relative risk of developing AF compared with their White counterparts, while having significantly more diabetes, hypertension, and obesity.
      • O’Neal W.T.
      • Judd S.E.
      • Limdi N.A.
      • et al.
      Differential impact of risk factors in Blacks and Whites in the development of atrial fibrillation: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.
      This paradox has also been noted in South Asians, who have higher age-adjusted rates of diabetes, hypertension, and coronary artery disease compared with Whites in the United Kingdom, but a very low rate of AF.
      • Gillott R.G.
      • Willan K.
      • Kain K.
      • et al.
      South Asian ethnicity is associated with a lower prevalence of atrial fibrillation despite greater prevalence of established risk factors: a population-based study in Bradford Metropolitan District.
      ,
      • O’Neill J.
      • Tayebjee M.H.
      Why are South Asians seemingly protected against the development of atrial fibrillation? A review of current evidence.
      Several theories have been proposed to explain this AF paradox, including differences in healthcare access, survival bias with longer life expectancy in NHWs leading to an increased risk of AF, and possible differences in symptom recognition and perception.
      • Dewland T.A.
      • Olgin J.E.
      • Vittinghoff E.
      • Marcus G.M.
      Incident atrial fibrillation among Asians, Hispanics, Blacks, and Whites.
      ,
      • Ugowe F.E.
      • Jackson L.R.
      • Thomas K.L.
      Racial and ethnic differences in the prevalence, management, and outcomes in patients with atrial fibrillation: a systematic review.
      Left atrial (LA) size and volume have been shown to differ across races, with larger LA size observed in White compared with East Asian, South Asian, and some Black populations.
      Echocardiographic Normal Ranges Meta-Analysis of the Left Heart Collaboration
      Ethnic-specific normative reference values for echocardiographic LA and LV size, LV mass, and systolic function: The EchoNoRMAL Study.
      Larger LA size/volume confers a higher AF risk, whereas smaller LA geometry confers a protective effect from AF.
      • Tsang T.S.
      • Barnes M.E.
      • Bailey K.R.
      • et al.
      Left atrial volume: important risk marker of incident atrial fibrillation in 1655 older men and women.
      • Marcus G.M.
      • Olgin J.E.
      • Whooley M.
      • et al.
      Racial differences in atrial fibrillation prevalence and left atrial size.
      • Badertscher P.
      • Gregg D.
      • Baicu C.F.
      • et al.
      Racial difference in atrial size and extracellular matrix homeostatic response to hypertension: Is this a potential mechanism of reduced atrial fibrillation in African Americans?.
      Most recently, Black patients have been found to have a unique extracellular matrix biomarker response that could be associated with attenuation of hypertensive atrial remodelling.
      • Badertscher P.
      • Gregg D.
      • Baicu C.F.
      • et al.
      Racial difference in atrial size and extracellular matrix homeostatic response to hypertension: Is this a potential mechanism of reduced atrial fibrillation in African Americans?.
      However, a recent study from a MESA cohort showed that although the prevalence of clinically detected AF was, again, lower in Black patients than White patients, the use of 14-day ambulatory electrocardiogram (ECG) patch monitoring showed no difference in AF prevalence among races/ethnicities.
      • Heckbert S.R.
      • Austin T.R.
      • Jensen P.N.
      • et al.
      Differences by race/ethnicity in the prevalence of clinically detected and monitor-detected atrial fibrillation: MESA.

      Is There Ascertainment Bias in AF Detection by Race?

      Some investigators have raised the possibility of an ascertainment bias in AF detection by race, owing to challenges in accessing health care.
      • Ugowe F.E.
      • Jackson L.R.
      • Thomas K.L.
      Racial and ethnic differences in the prevalence, management, and outcomes in patients with atrial fibrillation: a systematic review.
      For example, a study screening for AF using mobile ECG devices found a 3-fold higher AF prevalence in South Asian patients than that in previous reports, suggesting ascertainment bias.
      • Soni A.
      • Karna S.
      • Fahey N.
      • et al.
      Age- and-sex stratified prevalence of atrial fibrillation in rural Western India: results of SMART-India, a population-based screening study.
      Similarly, a substudy of 1556 participants of the MESA cohort looked at clinically detected AF vs AF detected by 14-day ambulatory ECG monitoring. Although the prevalence of clinically detected AF was higher in White than in Black, Hispanic, or Chinese patients after 14.4 years of follow-up, the proportion of individuals with monitor-detected AF over 14 days was similar among the 4 groups.
      • Heckbert S.R.
      • Austin T.R.
      • Jensen P.N.
      • et al.
      Differences by race/ethnicity in the prevalence of clinically detected and monitor-detected atrial fibrillation: MESA.
      However, other studies, either using 14-day ambulatory ECG monitoring or following patients with implantable cardiac devices to detect subclinical AF over longer periods of time, do not corroborate these observations.
      • Rooney M.R.
      • Soliman E.Z.
      • Lutsey P.L.
      • et al.
      Prevalence and characteristics of subclinical atrial fibrillation in a community-dwelling elderly population: The ARIC Study.
      • Lau C.P.
      • Gbadebo T.D.
      • Connolly S.J.
      • et al.
      Ethnic differences in atrial fibrillation identified using implanted cardiac devices.
      • Chen M.L.
      • Parikh N.S.
      • Merkler A.E.
      • et al.
      Risk of atrial fibrillation in Black versus White Medicare beneficiaries with implanted cardiac devices.
      • Kamel H.
      • Kleindorfer D.O.
      • Bhave P.D.
      • et al.
      Rates of atrial fibrillation in Black versus White patients with pacemakers.
      The characteristics and outcomes of these 5 different studies are summarized in Table 1. The differences in outcomes of these studies stress the need to adopt better monitoring in more-diverse samples of patients to gain further clarity on the role of ascertainment bias in the AF paradox.
      Table 1Summary of characteristics and outcomes of 5 studies
      StudyStudy designNMean duration of follow-upMain resultsComments
      Heckbert et al.,
      • Heckbert S.R.
      • Austin T.R.
      • Jensen P.N.
      • et al.
      Differences by race/ethnicity in the prevalence of clinically detected and monitor-detected atrial fibrillation: MESA.
      2020
      Cross-sectional analysis of a community-based cohort155614.4 yThe prevalence of clinically detected AF was 11.3% in White, 6.6% in Black, 7.8% in Hispanic, and 9.9% in Chinese patients. Monitor-detected AF using a 14-day ambulatory ECG monitor was similar in the 4 race/ethnicity groups: 7.1%, 6.4%, 6.9%, and 5.2%, respectivelyLower prevalence of cardiovascular disease
      Chen et al.,
      • Chen M.L.
      • Parikh N.S.
      • Merkler A.E.
      • et al.
      Risk of atrial fibrillation in Black versus White Medicare beneficiaries with implanted cardiac devices.
      2019
      Retrospective cohort of Medicare beneficiaries with implanted devices. (study used inpatient & outpatient claims from 2009 to 2015).47,4172.3 yAnnual incidence of AF /atrial flutter was 12.2 per 100 person-years in Black patients, and 17.6 per 100 person-years among non-Black patients. Adjusted results showed Black beneficiaries had a lower risk of AF /atrial flutter than non-Black patients (hazard ratio, 0.75; 95% CI , 0.70–0.80)Miscoding and misclassification errors are possible
      Rooney et al.,
      • Rooney M.R.
      • Soliman E.Z.
      • Lutsey P.L.
      • et al.
      Prevalence and characteristics of subclinical atrial fibrillation in a community-dwelling elderly population: The ARIC Study.
      2019
      Cross-sectional analysis of a community-based cohort. (participants used a leadless, ambulatory ECG monitor Zio XT [iRhythm Technologies, San Francisco, CA] Patch for up to 2 weeks)26164 wkThe prevalence of subclinical AF was 3.3% in White men, 2.5% in White women, 2.1% in Black men, and 1.6% in Black women.Small numbers of Black men (214) and Black women (469). Short follow-up.
      Kamel et al.,
      • Kamel H.
      • Kleindorfer D.O.
      • Bhave P.D.
      • et al.
      Rates of atrial fibrillation in Black versus White patients with pacemakers.
      2016
      Retrospective cohort study using administrative claims data in California, Florida, and New York (either 2005 or 2006 to 2010 or 2011)10,393 Black and 91,380 White patients with no known AF or atrial flutter before or during the initial encounter for pacemaker implantation3.7 yBlack patients had a significantly lower risk of AF (21.4%; 95% CI 19.8–23.2) than White patients (25.5%; 95% CI 24.9–26.0). Adjusted data showed that Black patients had a lower hazard of AF (hazard ratio 0.91; 95% CI 0.86–0.96) and a higher hazard of atrial flutter (hazard ratio 1.29; 95% CI 1.11–1.49)Miscoding and misclassification errors are possible
      Lau et al.,
      • Lau C.P.
      • Gbadebo T.D.
      • Connolly S.J.
      • et al.
      Ethnic differences in atrial fibrillation identified using implanted cardiac devices.
      2013
      Secondary analysis of a prospective multicentre cohort study2,5802.5 yAll 3 non-White race groups had a lower incidence of AF (8.3%, 10.1%, and 9.5% vs 18.0%, respectively, for AF > 6 min, P < 0.006). Adjusted data showed that Chinese patients had a lower incidence of AF > 6 minutes (P < 0.007), and Japanese and Black patients had a lower incidence of AF > 6 h (P < 0.04 and P = 0.057, respectively).Small number of non-White patients; 73 Black patients, 89 Chinese patients, and 105 Japanese patients
      AF, atrial fibrillation; CI, confidence interval; ECG, electrocardiogram.

      Genetics of AF

      Genome-wide association studies over the past 15 years, performed largely in those of European descent, have identified 9 loci associated with AF risk.
      • Tucker N.R.
      • Ellinor P.T.
      Emerging directions in the genetics of atrial fibrillation.
      In order to delineate the role of genetic factors in AF, Marcus et al.
      • Marcus G.M.
      • Alonso A.
      • Peralta C.A.
      • et al.
      European ancestry as a risk factor for atrial fibrillation in African Americans.
      studied White and Black patients of European Ancestry from the Cardiovascular Health Study (CHS) and Atherosclerosis Risk in Communities (ARIC) study. They found that for every 10% increase in European ancestry, there was a 13% increased risk of AF, even after adjusting for potential confounders.
      • Marcus G.M.
      • Alonso A.
      • Peralta C.A.
      • et al.
      European ancestry as a risk factor for atrial fibrillation in African Americans.
      Further work on 18,919 individuals of European ancestry found an up to 67% increased risk of new-onset AF for those in the highest quartile of genetic risk scores compared with those in the lowest quartile, exceeding the effects of traditional AF risk factors.
      • Lubitz S.A.
      • Yin X.
      • Lin H.J.
      • et al.
      Genetic risk prediction of atrial fibrillation.
      Multiethnic studies of AF genetics in underrepresented populations are beginning to be conducted.
      • Roselli C.
      • Chaffin M.D.
      • Weng L.-C.
      • et al.
      Multi-ethnic genome-wide association study for atrial fibrillation.
      Genome-wide admixture analysis and candidate single nucleotide polymorphism (SNP) study of the ARIC, the CHS, and the Health, Aging, and Body Composition (Health ABC) cohorts found that the minor protective allele of the AF SNP rs10824026 was more common among Black than White patients. However, as no novel genome-wide significant genetic variant was found in a meta-analysis, the authors felt that this difference was unlikely to fully account for the AF paradox.
      • Roberts J.D.
      • Hu D.
      • Heckbert S.R.
      • et al.
      Genetic investigation into the differential risk of atrial fibrillation among Black and White individuals.
      In a study of Han Chinese individuals that analyzed 6 SNPs associated with AF in those of European ancestry, SNP rs3807989 in the CAV1 gene on chromosome 7q31 was found to be significantly associated with a decreased risk of AF (adjusted odds ratio = 0.75; 95% CI: 0.63-0.89, P = 0.001).
      • Liu Y.
      • Ni B.
      • Lin Y.
      • et al.
      The rs3807989 G/A polymorphism in CAV1 is associated with the risk of atrial fibrillation in Chinese Han populations.
      In Hispanic patients, the presence of SNP rs10033464 at chromosome 4q25 conferred a 2.3-fold increase in the risk of AF after multiple risk-factor adjustment.
      • Chalazan B.
      • Mol D.
      • Sridhar A.
      • et al.
      Genetic modulation of atrial fibrillation risk in a Hispanic/Latino cohort.
      Recent work from the same group sequencing 60 candidate genes from Black and Hispanic/Latino people with early-onset AF was able to identify likely pathogenic variants in a small number of probands.
      • Chalazan B.
      • Mol D.
      • Darbar F.A.
      • et al.
      Association of rare genetic variants and early-onset atrial fibrillation in ethnic minority individuals.
      Black and Hispanic patients with early-onset AF have been found to have higher odds than White patients of having a first-degree family member with AF, supporting genetic predispositions that should be further explored.
      • Alzahrani Z.
      • Ornelas-Loredo A.
      • Darbar S.D.
      • et al.
      Association between family history and early-onset atrial fibrillation across racial and ethnic groups.
      Whether environmental or genetic, there appear to be ethnicity-specific factors that either protect Black patients from AF or make White patients more prone to AF.
      • Gbadebo T.D.
      • Okafor H.
      • Darbar D.
      Differential impact of race and risk factors on incidence of atrial fibrillation.
      Although genetics cannot fully account for the differential AF risk across races, its role with or without the contribution of ascertainment bias in AF detection by race warrants further investigation, as it could provide important insight into the AF paradox in the Black population. However, available data suggest that environmental and genetic factors contribute to the paradoxical race-related risk of AF among White and Black individuals.
      • Roberts J.D.
      • Hu D.
      • Heckbert S.R.
      • et al.
      Genetic investigation into the differential risk of atrial fibrillation among Black and White individuals.

      Differences Relating to Race and Ethnicity in Symptoms and Quality of Life

      There appear to be differences in symptoms attributable to AF that are based on race and sex.
      • Ugowe F.E.
      • Jackson L.R.
      • Thomas K.L.
      Racial and ethnic differences in the prevalence, management, and outcomes in patients with atrial fibrillation: a systematic review.
      ,
      • Golwala H.
      • Jackson L.R.
      • Simon D.N.
      • et al.
      Racial/ethnic differences in atrial fibrillation symptoms, treatment patterns, and outcomes: insights from Outcomes Registry for Better Informed Treatment for Atrial Fibrillation Registry.
      The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF), a multicentre, prospective registry of outpatients with incident or prevalent AF, examined racial and ethnic differences in quality of life, treatment, and outcomes associated with AF.
      • Golwala H.
      • Jackson L.R.
      • Simon D.N.
      • et al.
      Racial/ethnic differences in atrial fibrillation symptoms, treatment patterns, and outcomes: insights from Outcomes Registry for Better Informed Treatment for Atrial Fibrillation Registry.
      Compared with White individuals or those of Hispanic ethnicity, Black patients reported more severe symptoms associated with AF. Black patients were more likely to report palpitations, dyspnea on exertion, decreased exercise tolerance, dizziness, dyspnea at rest, fatigue, and chest discomfort compared with White and Hispanic patients (Fig. 1). Based on the European Heart Rhythm Association AF symptom scores reported at baseline, Black patients reported more severe or disabling symptoms (20.4%), compared with White (16.4%) and Hispanic patients (8.5%). Furthermore, Black patients reported lower overall quality-of-life scores within 2 years of follow-up.
      • Golwala H.
      • Jackson L.R.
      • Simon D.N.
      • et al.
      Racial/ethnic differences in atrial fibrillation symptoms, treatment patterns, and outcomes: insights from Outcomes Registry for Better Informed Treatment for Atrial Fibrillation Registry.
      Figure thumbnail gr1
      Figure 1Symptoms of AF. AF, atrial fibrillation.

      Are There Delays in Presentation and Diagnosis of AF?

      Specific data on racial disparities related to delays in seeking medical attention for symptoms related to AF, and investigations to diagnose AF, are lacking. However, sex- and race-based differences in access to more advanced interventions for cardiovascular diseases, including coronary artery disease and heart failure, are well documented.
      • Bhave P.D.
      • Lu X.
      • Girotra S.
      • Kamel H.
      • Vaughan Sarrazin M.S.
      Race- and sex-related differences in care for patients newly diagnosed with atrial fibrillation.
      Not all of these differences can be explained by a lack of either health insurance coverage or access to health care. Factors such as socioeconomic status and lack of supplemental insurance coverage, as well as documented sex- and race-based differences in preferences related to medical care, might contribute to delays in diagnosing AF.
      • Eberly L.A.
      • Garg L.
      • Yang L.
      • et al.
      Racial/ethnic and socioeconomic disparities in management of incident paroxysmal atrial fibrillation.
      Lack of health literacy may limit patient engagement and impact decisions for treatment of AF. Non-White patients and those with a lower education level have been shown to be less likely to receive care from a cardiologist for AF.
      • O'Neal W.T.
      • Sandesara P.B.
      • Claxton J.S.
      • et al.
      Influence of sociodemographic factors and provider specialty on anticoagulation prescription fill patterns and outcomes in atrial fibrillation.
      Some data report that women and Hispanic patients are less likely to be referred to an electrophysiologist or a tertiary-care centre specializing in AF management.
      • Mason P.K.
      • Moorman L.
      • Lake D.E.
      • et al.
      Gender and racial characteristics of patients referred to a tertiary atrial fibrillation center.
      In a US biracial study investigating racial disparities in stroke risk among individuals confirmed to have AF by ECG, Black patients were approximately one third as likely to be aware that they had AF as White patients.
      • Meschia J.F.
      • Merrill P.
      • Soliman E.Z.
      • et al.
      Racial disparities in awareness and treatment of atrial fibrillation: the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

      Racial and Ethnic Differences in AF Outcomes

      Studies have found racial and ethnic differences in the outcomes of AF. Data from the prospective ARIC study showed that although both Black and White patients with AF had higher risk of stroke, heart failure, coronary artery disease, and death than those without AF, Black patients with AF had a 1.5 to 2 times higher risk for each outcome than White patients with AF.
      • Magnani J.W.
      • Norby F.L.
      • Agarwal S.K.
      • et al.
      Racial differences in atrial fibrillation-related cardiovascular disease and mortality: The Atherosclerosis Risk in Communities (ARIC) Study.
      A Medicare claims database study examining > 500,000 patients over 65 years of age with AF showed that Black and Hispanic patients had a higher unadjusted risk of death (46% and 11%, P < 0.001 for both) and stroke (66% and 21%, P < 0.001 for both) than White patients. Adjusting for demographics and comorbidities eliminated the higher risk of death, but stroke risk remained significantly higher in Black and Hispanic patients (46% and 11%).
      • Kabra R.
      • Cram P.
      • Girotra S.
      • et al.
      Effect of race on outcomes (stroke and death) in patients > 65 years with atrial fibrillation.
      In a smaller study of 236 patients, Mexican American patients with AF had a 2-fold higher risk of recurrent stroke and greater stroke severity than a comparator group of NHW patients with AF; however, there was no difference in all-cause mortality.
      • Simpson J.R.
      • Zahuranec D.B.
      • Lisabeth L.D.
      • et al.
      Mexican Americans with atrial fibrillation have more recurrent strokes than do non-Hispanic whites.
      Lastly, in a large cohort (National Cardiovascular Data Registry [NCDR] Practice Innovation and Clinical Excellence [PINNACLE] Registry) study of North-American Asian patients and White patients with AF, there were no significant race-based differences in stroke, life-threatening bleeding, or all-cause mortality.
      • Gu K.
      • Mahtta D.
      • Kaneria A.
      • et al.
      Racial disparities among Asian Americans with atrial fibrillation: an analysis from the NCDR® PINNACLE Registry.
      However, this lower risk does not necessarily translate to non–North American Asians.
      • Chiang C.-E.
      • Okumura K.
      • Zhang S.
      • et al.
      2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation.
      AF-associated stroke prevalence across Asia is reported to be as low as 1.3% to as high as 15.4%, depending upon the geographic area studied and the availability of oral anticoagulation.
      • Chiang C.-E.
      • Okumura K.
      • Zhang S.
      • et al.
      2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation.
      Both ischemic and hemorrhagic stroke incidences were higher for NHB and Asian patients in a subanalysis of the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF).
      • Shen A.Y.-J.
      • Contreras R.
      • Sobnosky S.
      • et al.
      Racial/ethnic differences in the prevalence of atrial fibrillation among older adults—a cross-sectional study.
      ,
      • Patel M.R.
      • Mahaffey K.W.
      • Garg J.
      • et al.
      Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.
      In addition, both ischemic and nonischemic stroke incidences were higher for East Asian vs non–East Asian individuals in the Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY) and the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trials, indicating a higher risk of both types of stroke with anticoagulation in some Asian patients.
      • Chiang C.-E.
      • Okumura K.
      • Zhang S.
      • et al.
      2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation.
      Lastly, intracranial hemorrhage has also been shown to be significantly higher in non-White vs White patients with AF on anticoagulation. In a large retrospective multiethnic cohort of > 18,000 AF patients on warfarin without previous stroke, hazard ratios for intracranial hemorrhage were 4.06 for Asians, 2.06 for Hispanics, and 2.04 for Blacks.
      • Shen A.Y.
      • Yao J.F.
      • Brar S.S.
      • Jorgensen M.B.
      • Chen W.
      Racial/ethnic differences in the risk of intracranial hemorrhage among patients with atrial fibrillation.

      Disparities in Treatment of AF

      Anticoagulation

      Stroke prevention is one of the most important therapeutic goals in AF management. Several groups have highlighted major racial differences in care in relation to stroke prevention in AF. Historical studies and Medicare data have shown that NHB and Hispanic patients with AF were significantly less likely to be prescribed vitamin K antagonists than were other ethnic groups, despite having higher stroke-risk scores, and they were also frequently lost to international normalized ratio (INR) monitoring.
      • Golwala H.
      • Jackson L.R.
      • Simon D.N.
      • et al.
      Racial/ethnic differences in atrial fibrillation symptoms, treatment patterns, and outcomes: insights from Outcomes Registry for Better Informed Treatment for Atrial Fibrillation Registry.
      ,
      • Meschia J.F.
      • Merrill P.
      • Soliman E.Z.
      • et al.
      Racial disparities in awareness and treatment of atrial fibrillation: the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study.
      ,
      • Shen A.Y.-J.
      • Contreras R.
      • Sobnosky S.
      • et al.
      Racial/ethnic differences in the prevalence of atrial fibrillation among older adults—a cross-sectional study.
      ,
      • Thomas K.L.
      • Piccini J.P.
      • Liang L.
      • et al.
      Racial differences in the prevalence and outcomes of atrial fibrillation among patients hospitalized with heart failure.
      • Lewis W.R.
      • Fonarow G.C.
      • Grau-Sepulveda M.V.
      • et al.
      Improvement in use of anticoagulation therapy in patients with ischemic stroke: results from Get with the Guidelines—Stroke.
      • Birman-Deych E.
      • Radford M.J.
      • Nilasena D.S.
      • et al.
      Use and effectiveness of warfarin in Medicare beneficiaries with atrial fibrillation.
      Similarly, Black race was associated with a significantly decreased time in therapeutic range, compared with NHW race, even after adjusting for medication compliance and monitoring frequency.
      • Yong C.
      • Azarbal F.
      • Abnousi F.
      • et al.
      Racial differences in quality of anticoagulation therapy for atrial fibrillation (from the TREAT-AF Study).
      In a mixed cohort in the United Kingdom, the quality of INR control was shown to be inferior in African Caribbean and South Asian patients compared with White patients, despite similar INR testing frequency.
      • Zulkifly H.
      • Cheli P.
      • Lutchman I.
      • et al.
      Anticoagulation control in different ethnic groups receiving vitamin K antagonist therapy for stroke prevention in atrial fibrillation.
      Non-White ethnicity remained the strongest independent predictor of poor therapeutic range.
      • Zulkifly H.
      • Cheli P.
      • Lutchman I.
      • et al.
      Anticoagulation control in different ethnic groups receiving vitamin K antagonist therapy for stroke prevention in atrial fibrillation.
      Among 11,575 newly diagnosed AF patients with a CHA2DS2VASc (Congestive Heart Failure, Hypertension, Age ≥ 75 years, Diabetes Mellitus, Stroke, Vascular Disease, Age 65 to 74 Years, Sex Category) score of 2 or more, after adjusting for multiple factors, including income and insurance status, the odds of receiving any oral anticoagulant was 0.69 (95% confidence interval [CI]: 0.58-0.83) in Black patients, 0.74 (0.53-1.90) in Hispanic patients, and 0.75 (0.58-0.95) in Asian patients, compared with White patients.
      • Tedla Y.G.
      • Schwartz S.M.
      • Silberman P.
      • Greenland P.
      • Passman R.S.
      Racial disparity in the prescription of anticoagulants and risk of stroke and bleeding in atrial fibrillation patients.
      The odds of receiving direct oral anticoagulants (DOACs) among those who were prescribed oral anticoagulants were lower for Black and Hispanic patients.
      • Tedla Y.G.
      • Schwartz S.M.
      • Silberman P.
      • Greenland P.
      • Passman R.S.
      Racial disparity in the prescription of anticoagulants and risk of stroke and bleeding in atrial fibrillation patients.
      Among those with prior gastrointestinal bleeding, White patients were nearly 5-fold more likely to be discharged on an oral anticoagulant than were non-White patients, independent of income.
      • Haddad A.
      • Bocchese M.
      • Garber R.
      • et al.
      Racial and ethnic differences in left atrial appendage occlusion wait time, complications, and periprocedural management.
      Lower use of DOACs in Black and Hispanic patients has been reported in other studies. In the ORBIT-AF study, Black race, and Hispanic ethnicity, relative to White race, were associated with lower odds of being switched from warfarin to a DOAC.
      • Steinberg B.A.
      • Holmes D.N.
      • Piccini J.P.
      • et al.
      Early adoption of dabigatran and its dosing in US patients with atrial fibrillation: results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation.
      A Veteran Affairs study showed that NHW patients were more likely than NHB patients and those of other races or Hispanic ethnicity to be switched from warfarin to dabigatran in the setting of labile INR.
      • Vaughan Sarrazin M.S.
      • Jones M.
      • Mazur A.
      • et al.
      Bleeding rates in Veterans Affairs patients with atrial fibrillation who switch from warfarin to dabigatran.
      The FLorida Puerto Rico Atrial Fibrillation Stroke Study Stroke study found that Black patients had the lowest rate of DOAC initiation at discharge.
      • Sur N.B.
      • Wang K.
      • Di Tullio M.R.
      • et al.
      Disparities and temporal trends in the use of anticoagulation in patients with ischemic stroke and atrial fibrillation.
      Data from the Get with The Guidelines–Stroke program, showed that Black, Asian, and Hispanic patients had lower odds of DOAC prescription, relative to NHW patients.
      • Hankey G.J.
      • Stevens S.R.
      • Piccini J.P.
      • et al.
      Intracranial hemorrhage among patients with atrial fibrillation anticoagulated with warfarin or rivaroxaban: the rivaroxaban once daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation.
      Similar results were seen among Medicare beneficiaries.
      • Baik S.H.
      • Hernandez I.
      • Zhang Y.
      Evaluating the initiation of novel oral anticoagulants in Medicare beneficiaries.

      Left atrial appendage occlusion

      Left atrial appendage occlusion (LAAO) has emerged as a promising alternative stroke-risk–reduction strategy in patients who are deemed unsuitable for long-term oral anticoagulant therapy.
      There has been a lack of inclusion of diverse populations in large trials involving percutaneous LAAO; 91%-94% of participants in the Percutaneous LAAO for WATCHMAN LAA System for Embolic Protection in Patients With Atrial Fibrillation (PROTECT-AF) and the Prospective Randomized Evaluation of the WATCHMAN LAA Closure Device in Patients With Atrial Fibrillation vs Long-Term Warfarin Therapy (PREVAIL) study were White.
      • Reddy V.Y.
      • Sievert H.
      • Halperin J.
      • et al.
      Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation: a randomized clinical trial.
      ,
      • Holmes Jr., D.R.
      • Kar S.
      • Price M.J.
      • et al.
      Prospective randomized evaluation of the Watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL Trial.
      In the NCDR LAAO registry, with over 38,000 Watchman procedures conducted between 2016 and 2018, only 7.4% patients were non-White.
      • Freeman J.V.
      • Varosy P.
      • Price M.J.
      • et al.
      The NCDR Left Atrial Appendage Occlusion Registry.
      Most data on racial, ethnic, and socioeconomic disparity in LAAO have emerged from the NIS. Three studies using NIS data on hospitalization for the LAAO procedure reported underrepresentation, greater complication rate, longer hospital stay, and higher discharge complexity in the non-White population receiving LAAO, compared with White patients.
      • Vincent L.
      • Grant J.
      • Ebner B.
      • et al.
      Racial disparities in the utilization and in-hospital outcomes of percutaneous left atrial appendage closure among patients with atrial fibrillation.
      • Sparrow R.
      • Sanjoy S.
      • Choi Y.H.
      • et al.
      Racial, ethnic and socioeconomic disparities in patients undergoing left atrial appendage closure.
      • Khan M.Z.
      • Munir M.B.
      • Darden D.
      • et al.
      Racial disparities in in-hospital adverse events among patients with atrial fibrillation implanted with a Watchman left atrial appendage occlusion device: a US national perspective.
      Lower socioeconomic status was not associated with a higher complication rate.
      • Vincent L.
      • Grant J.
      • Ebner B.
      • et al.
      Racial disparities in the utilization and in-hospital outcomes of percutaneous left atrial appendage closure among patients with atrial fibrillation.
      • Sparrow R.
      • Sanjoy S.
      • Choi Y.H.
      • et al.
      Racial, ethnic and socioeconomic disparities in patients undergoing left atrial appendage closure.
      • Khan M.Z.
      • Munir M.B.
      • Darden D.
      • et al.
      Racial disparities in in-hospital adverse events among patients with atrial fibrillation implanted with a Watchman left atrial appendage occlusion device: a US national perspective.
      In another analysis using the same NIS data, only 12.4% of non-White patients were reported to have undergone the LAAO procedure in the US.
      • Badheka A.O.
      • Chothani A.
      • Mehta K.
      • et al.
      Utilization and adverse outcomes of percutaneous left atrial appendage closure for stroke prevention in atrial fibrillation in the United States: influence of hospital volume.
      Higher odds of mortality and other adverse outcomes were reported in one study among non-White patients undergoing the LAAO procedure, compared with odds for White patients.
      • Ranka S.
      • Acharya P.
      • Sami F.A.
      • et al.
      Effect of sex and race on outcomes after left atrial appendage occlusion: a report from national inpatient sample.
      One hypothesis for why the complication rate is higher in non-White patients is that these procedures are performed in low-volume centres that may have worse outcomes. Caution must be exercised in drawing the inference that individuals from diverse racial and ethnic backgrounds are more prone to complications or in using this as a reason not to consider LAAO. Rather, these results call for continued investigation of reasons for racial and ethnic differences in adverse outcomes in AF.
      A similar lack of diversity has been documented in the surgical LAAO. Patient data extracted from a large US administrative database showed underrepresentation (∼20%) of non-White patients.
      • Yao X.
      • Gersh B.J.
      • Holmes Jr., D.R.
      • et al.
      Association of surgical left atrial appendage occlusion with subsequent stroke and mortality among patients undergoing cardiac surgery.
      In another retrospective analysis of Medicare recipients with AF undergoing cardiac surgery, the majority (93%) of patients receiving surgical LAAO were White.
      • Friedman D.J.
      • Piccini J.P.
      • Wang T.
      • et al.
      Association between left atrial appendage occlusion and readmission for thromboembolism among patients with atrial fibrillation undergoing concomitant cardiac surgery.

      Rate control vs rhythm control

      Historically, there has been a paucity of studies assessing rate- vs rhythm-control approaches among different racial and ethnic populations with AF. Examination of the ORBIT-AF registry demonstrated a low enrollment of Black (5%) and Hispanic (4%) patients.
      • Golwala H.
      • Jackson L.R.
      • Simon D.N.
      • et al.
      Racial/ethnic differences in atrial fibrillation symptoms, treatment patterns, and outcomes: insights from Outcomes Registry for Better Informed Treatment for Atrial Fibrillation Registry.
      Over the past several years, the emergence of AF registries and the use of administrative datasets have provided the infrastructure to assess this issue. Studies utilizing these registries have demonstrated that Black and Hispanic patients are less likely than White patients to receive rhythm-control or catheter-ablation treatment, despite the presence of symptoms.
      • Golwala H.
      • Jackson L.R.
      • Simon D.N.
      • et al.
      Racial/ethnic differences in atrial fibrillation symptoms, treatment patterns, and outcomes: insights from Outcomes Registry for Better Informed Treatment for Atrial Fibrillation Registry.
      ,
      • Eberly L.A.
      • Garg L.
      • Yang L.
      • et al.
      Racial/ethnic and socioeconomic disparities in management of incident paroxysmal atrial fibrillation.
      A recent meta-analysis reported similar rates of atrioventricular node ablation but lower rates of AF ablation among Black patients, compared with White patients.
      • Ugowe F.E.
      • Jackson L.R.
      • Thomas K.L.
      Racial and ethnic differences in the prevalence, management, and outcomes in patients with atrial fibrillation: a systematic review.
      In the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) randomized clinical trial, 90.1% of patients were White, and only 6.6% and 3.3% of patients were Black and Hispanic, respectively. Black and Hispanic patients tended to have a higher prevalence of heart failure and a lower ejection fraction.
      • Bush D.
      • Martin L.W.
      • Leman R.
      • et al.
      Atrial fibrillation among African Americans, Hispanics and Caucasians: clinical features and outcomes from the AFFIRM Trial.
      Hispanic patients were more likely than White patients to be taking digoxin, but there was no difference in the use of beta-blockers or calcium-channel blockers between the 2 groups. The AFFIRM analysis did not compare achievement of adequate rate control among different races/ethnicities.
      • Bush D.
      • Martin L.W.
      • Leman R.
      • et al.
      Atrial fibrillation among African Americans, Hispanics and Caucasians: clinical features and outcomes from the AFFIRM Trial.

      Rhythm control: pharmaco-therapy and catheter ablation

      In an analysis of the ORBIT-AF registry, White patients, relative to Black and Hispanic patients, had undergone more cardioversions and catheter ablations for AF and were treated with more anti-arrhythmic therapies.
      • Golwala H.
      • Jackson L.R.
      • Simon D.N.
      • et al.
      Racial/ethnic differences in atrial fibrillation symptoms, treatment patterns, and outcomes: insights from Outcomes Registry for Better Informed Treatment for Atrial Fibrillation Registry.
      Similarly, in a Medicare dataset, individuals identified as having Hispanic ethnicity were less likely to undergo catheter ablation, relative to individuals identified as being of White race.
      • Bhave P.D.
      • Lu X.
      • Girotra S.
      • Kamel H.
      • Vaughan Sarrazin M.S.
      Race- and sex-related differences in care for patients newly diagnosed with atrial fibrillation.
      A sample study using hospital inpatient discharge and the ambulatory outpatient datasets from the Florida Agency for Healthcare Administration between the years 2006 and 2009 has shown that Black and Hispanic patients were less likely to undergo catheter ablation for AF than were White patients, with adjusted odds ratios of 0.67 (95% CI 0.60-0.75, P = 0.01) and 0.83 (95% CI 0.75-0.91, P = 0.01), respectively.
      • Tamariz L.
      • Rodriguez A.
      • Palacio A.
      • Li H.
      • Myerburg R.
      Racial disparities in the use of catheter ablation for atrial fibrillation and flutter.
      A recent 2021 publication analyzed data from the Optum Clinformatics Data Mart, a deidentified database of administrative claims by members of a commercial insurance plan and Medicare Advantage plan that included patients with paroxysmal AF. The findings were consistent with those of prior studies; compared with White patients, Black patients were significantly less likely to be treated with rhythm control (adjusted odds ratio 0.89 [95% CI 0.83-0.94], P < 0.001), and those of Latino ethnicity were significantly less likely to undergo catheter ablation.
      • Eberly L.A.
      • Garg L.
      • Yang L.
      • et al.
      Racial/ethnic and socioeconomic disparities in management of incident paroxysmal atrial fibrillation.
      Data from the PINNACLE/NCDR registry were utilized to assess AF management among American Indian and Alaskan Native patients. These patients were significantly less likely to be treated with rhythm-control strategies, compared with non-American Indian/Alaskan Native patients.
      • Khalid U.
      • Marzec L.N.
      • Mantini N.
      • et al.
      Treatment of AF in American Indians and Alaska Natives: insights from the NCDR PINNACLE-AF Registry.
      Another single-centre study that included 792 patients showed that most patients who received catheter ablation for AF were White (93.3%), rather than Black (2.1%), Hispanic (0.1%), or Asian (0.9%).
      • Hoyt H.
      • Nazarian S.
      • Alhumaid F.
      • et al.
      Demographic profile of patients undergoing catheter ablation of atrial fibrillation.
      In a hospitalized cohort of AF patients, Naderi et al.
      • Naderi S.
      • Rodriguez F.
      Wang Y, Foody JM. Racial disparities in hospitalizations, procedural treatments and mortality of patients hospitalized with atrial fibrillation.
      reported the lowest rates of catheter ablation among Black women, a difference for that specific subgroup that has been noted in other invasive electrophysiology procedures.
      • Hernandez A.F.
      • Fonarow G.C.
      • Liang L.
      • et al.
      Sex and racial differences in the use of implantable cardioverter-defibrillators among patients hospitalized with heart failure.
      ,
      • Thomas K.L.
      • Al-Khatib S.M.
      • Kelsey R.C.
      • et al.
      Racial disparity in the utilization of implantable-cardioverter defibrillators among patients with prior myocardial infarction and an ejection fraction of ≤35%.
      A noteworthy point is that randomized clinical trials and a meta-analysis of recent trials have shown that catheter ablation compared with antiarrhythmic drugs is associated with reductions in recurrence of atrial arrhythmias and hospitalizations, with no difference in major adverse events.
      • Marrouche N.F.
      • Brachmann J.
      • Andresen D.
      • et al.
      Catheter ablation for atrial fibrillation with heart failure.
      Recent studies, namely the East AF Network (EAST AFNET) trial and the Early Aggressive Invasive Intervention for Atrial Fibrillation (EARLY-AF) trial, have suggested that early rhythm control of AF may be beneficial in many patients with AF.
      • Kirchhof P.
      • Camm A.J.
      • Goette A.
      • et al.
      Early rhythm-control therapy in patients with atrial fibrillation.
      ,
      • Andrade J.G.
      • Champagne J.
      • Deyell M.W.
      • et al.
      A randomized clinical trial of early invasive intervention for atrial fibrillation (EARLY-AF)—methods and rationale.
      Current guidelines recommend catheter ablation as a treatment option for patients with heart failure with reduced ejection fraction and AF, as catheter ablation has been shown to decrease mortality and heart failure hospitalizations, as well as increase left ventricular ejection fraction in these patients.
      • Marrouche N.F.
      • Brachmann J.
      • Andresen D.
      • et al.
      Catheter ablation for atrial fibrillation with heart failure.
      ,
      • Shah K.S.
      • Xu H.
      • Matsouaka R.A.
      • et al.
      Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes.
      Given the higher heart failure burden in racial and ethnic minorities compared with that in White individuals, racial and ethnic minorities particularly may benefit from rhythm-control strategies.

      Social Determinants of Health

      Many factors might contribute to the racial and ethnic disparities in AF management, including systemic biases, social determinants of health, trust in healthcare providers, health literacy, and perceived differences in response to therapy that may or may not be real.
      • Merchant F.
      What can administrative data teach us about racial/ethnic disparities in atrial fibrillation management?.
      As previously mentioned, Black race and lower income were independently associated with lower use of rhythm control and, among patients receiving rhythm control, Hispanic ethnicity and lower income were independently associated with lower use of catheter ablation.
      • Eberly L.A.
      • Garg L.
      • Yang L.
      • et al.
      Racial/ethnic and socioeconomic disparities in management of incident paroxysmal atrial fibrillation.
      The lower utilization of rhythm-control interventions in Black and Hispanic patients may equate to the delivery of lower-quality care, or conversely, this difference arguably may represent overutilization of rhythm-control interventions in White patients.
      Private insurance and higher household income were also associated with greater likelihood of undergoing ablation in another study.
      • Kummer B.R.
      • Bhave P.D.
      • Merkler A.E.
      • et al.
      Demographic differences in catheter ablation after hospital presentation with symptomatic atrial fibrillation.
      In addition, patients with Medicare or Medicaid coverage, and uninsured patients, had lower rates of AF-ablation treatment compared with those with private insurance.
      • Patel N.
      • Deshmukh A.
      • Thakkar B.
      • et al.
      Gender, race, and health insurance status in patients undergoing catheter ablation for atrial fibrillation.
      Racial differences in outcomes for hospitalized patients with AF have been identified.
      • Kwan G.F.
      • Enserro D.M.
      • Benjamin E.J.
      • et al.
      Racial differences in hospital death for atrial fibrillation: the National Inpatient Sample 2001-2012.
      In a study using the NIS of hospitalized patients with the principal diagnosis of AF, Black race was associated with an increased risk of death. This occurred particularly in hospitals with larger proportions of Black patients, compared to hospitals that had fewer Black patients, suggesting that Black patients may be more likely to be admitted to poorer-performing hospitals.
      • Kwan G.F.
      • Enserro D.M.
      • Benjamin E.J.
      • et al.
      Racial differences in hospital death for atrial fibrillation: the National Inpatient Sample 2001-2012.
      Regional differences in stroke incidence in patients with AF have also been reported in the US, with the highest age- and sex-standardized stroke incidence occurring in the Middle Atlantic and East South-Central regions, and the lowest occurring in the West North-Central region.
      • Claxton J.S.
      • Lutsey P.L.
      • MacLehose R.F.
      • et al.
      Geographic disparities in the incidence of stroke among patients with atrial fibrillation in the United States.
      Improving awareness of the differences in the clinical community would potentially tackle systemic bias in clinical research and data interpretation.
      • Breathett K.
      • Spatz E.S.
      • Kramer D.B.
      • et al.
      The groundwater of racial and ethnic disparities research: a statement from Circulation: Cardiovascular Quality and Outcomes.
      In this context, a noteworthy point is that health behaviour can be influenced by many factors. Education, cultural and religious preferences, acceptance of new drugs, devices, and procedures, as well as access to health care based on economic status play critical roles in health-related outcomes.
      • Egede L.E.
      Race, ethnicity, culture, and disparities in health care.
      Additionally, with an increasing number of people belonging to multiple racial and ethnic categories, interpretation of data based on race and ethnicity is challenging.
      • Egede L.E.
      Race, ethnicity, culture, and disparities in health care.
      Understanding these potential contributors to racial and ethnic disparities in AF management is clearly beyond the scope of administrative studies of commercially insured patients. Such understanding requires a deeper look into individual patients, the role of social factors, and interaction of patients with physicians.
      • Merchant F.
      What can administrative data teach us about racial/ethnic disparities in atrial fibrillation management?.
      Heterogeneity within populations must be recognized so that care can be better customized. Use of the word “ethnicity” interchangeably with “race” by biomedical researchers hinders heterogeneity-based data analysis. Hispanic and Latino populations are diverse and come from different parts of the globe with differing ethnic backgrounds, including Puerto Rico, the Dominican Republic, Mexico, and other parts of South America, as well as Spain. Asians are not only East Asians but also South Asians. Given this range, data collection and classification should be more granular, using terms that allow for better scientific precision and communication.
      • Breathett K.
      • Spatz E.S.
      • Kramer D.B.
      • et al.
      The groundwater of racial and ethnic disparities research: a statement from Circulation: Cardiovascular Quality and Outcomes.
      Understanding the dynamics of how social determinants of health affect adherence to treatment is vital before labeling patients as “noncompliant.” A set of skills and approaches, using the mnemonic “RESPECT” (Respect, Explanatory Model, Show Context, Power, Empathy, Concerns/Fears, Trust) to better understand a patient’s values and autonomy, has been suggested to help clinicians at all levels mitigate the social determinants of health barriers.
      • Kressin N.R.
      • Chapman S.E.
      • Magnani J.W.
      A tale of two patients: patient-centered approaches to adherence as a gateway to reducing disparities.

      Possible Solutions to Help Narrow the Gaps

      The National Healthcare and Quality Disparities report highlights pervasive racial and ethnic disparities in healthcare access, quality of healthcare delivery, and outcomes.

      United States Agency for Healthcare Quality. National healthcare disparities report 2010. Availabe at: https://www.ahrq.gov/research/findings/nhqrdr/index.html. Accessed November 15, 2021.

      As detailed in this article, these disparities have plagued all aspects of AF management. Important to note is that studies on disparities in AF care have been conducted mostly in the US, which begs for a global call to conduct studies in all regions of the world. Data specific to each region are instrumental to inform the development and customization of strategies most likely to be effective in that region. A multi-pronged approach is needed to address these disparities in AF care.
      As mentioned earlier, existing clinical trials generating the evidence on efficacious and effective therapies for AF have not included racially and ethnically diverse populations. In a recent study, only 44% of randomized clinical trials on AF reported participant-level information on race/ethnicity.
      • Sarraju A.
      • Maron D.J.
      • Rodriguez F.
      Under-reporting and under-representation of racial/ethnic minorities in major atrial fibrillation clinical trials.
      Black and Hispanic patients accounted for just 2% and 5.6% of trial participants, despite making up 13.4% and 18.3% of the US population in 2018.
      • Sarraju A.
      • Maron D.J.
      • Rodriguez F.
      Under-reporting and under-representation of racial/ethnic minorities in major atrial fibrillation clinical trials.
      These findings document the striking lack of racial and ethnic diversity in AF trials that limits the generalizability of the results to the global population. Poor access to health care also contributes to under-recruitment in clinical trials, which in turn results in poor understanding of race-specific risk factors.
      • Zhang T.
      • Tsang W.
      • Wijeysundera H.C.
      • et al.
      Reporting and representation of ethnic minorities in cardiovascular trials: a systematic review.
      As a recent example, a study examined one of the latest advancements in AF ablation technologies—pulsed field ablation,a non-thermal energy modality with several potential advantages over existing ablation modalities.
      • Reddy V.Y.
      • Koruth J.
      • Jais P.
      • et al.
      Ablation of atrial fibrillation with pulsed electric fields: an ultra-rapid, tissue-selective modality for cardiac ablation.
      ,
      • Bradley C.J.
      • Haines D.E.
      Pulsed field ablation for pulmonary vein isolation in the treatment of atrial fibrillation.
      The racial and ethnic distribution of the study population was not provided in the human safety and efficacy pulsed field ablation trials.
      • Reddy V.Y.
      • Koruth J.
      • Jais P.
      • et al.
      Ablation of atrial fibrillation with pulsed electric fields: an ultra-rapid, tissue-selective modality for cardiac ablation.
      ,
      • Reddy V.Y.
      • Neuzil P.
      • Koruth J.S.
      • et al.
      Pulsed field ablation for pulmonary vein isolation in atrial fibrillation.
      • Reddy V.Y.
      • Anter E.
      • Rackauskas G.
      • et al.
      Lattice-tip focal ablation catheter that toggles between radiofrequency and pulsed field energy to treat atrial fibrillation: a first-in-human trial.
      • Reddy V.Y.
      • Anic A.
      • Koruth J.
      • et al.
      Pulsed field ablation in patients with persistent atrial fibrillation.
      Moreover, catheter ablation using the standard radio-frequency energy in the Prospective Review of the Safety and Effectiveness of the THERMOCOOL SMARTTOUCH SF Catheter Evaluated for Treating Symptomatic Persistent AF (PRECEPT) trial was used less commonly for Black patients, but the technology was deemed to be equally effective across all racial cohorts.
      • Mansour M.
      • Calkins H.
      • Osorio J.
      • et al.
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      ,
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      Impact of race and gender on clinical outcomes of catheter ablation in patients with atrial fibrillation.
      Underenrollment of diverse races and ethnicities into AF clinical trials and studies can be addressed in the following ways:
      • The sample size of racial and ethnic groups in traditional and pragmatic clinical trials with granular data capture should be prespecified. Post-marketing studies will provide much needed data in unlocking the causal mechanisms associated with worse outcomes in these populations.
      • Multicentre international or global trials should be designed with diversified hospital-catchment areas, including communities with diverse races, ethnicities, and socioeconomic strata. Such design is key to a better understanding of the barriers to underrepresentation in clinical trials.
      • Practical considerations, including transportation and language barriers, should be taken into account. Hiring of diverse advocacy workers by the study administrators can help improve communication between recruiters and the minority population.
        • Frey W.H.
        America reaches its demographic tipping point. Available at.
        If and when possible, remote follow-up and mobile-health technology should be utilized for patient monitoring, with provision of digital health technology to prevent worsening of the digital divide.
      Data on AF collected by both administrative claims and registries are in need of improvement, as studies utilizing these methods to examine racial and ethnic differences in AF care can be fraught with limitations.
      • Breathett K.
      • Spatz E.S.
      • Kramer D.B.
      • et al.
      The groundwater of racial and ethnic disparities research: a statement from Circulation: Cardiovascular Quality and Outcomes.
      The decision to pursue rhythm control can be complicated and should incorporate several important factors, such as symptoms, burden of AF, and –left ventricular ejection fraction, none of which are well captured in administrative claims data and many registries. Studies of differences in AF care should collect and report these data and should consider that many times a clear preference for one form of treatment over another is not obvious. In addition, administrative data lack reasons that differences in treatment exist. Appropriately designed registries can provide these data.
      • Breathett K.
      • Spatz E.S.
      • Kramer D.B.
      • et al.
      The groundwater of racial and ethnic disparities research: a statement from Circulation: Cardiovascular Quality and Outcomes.
      The current use of “ethnicity” in biomedical research as a binary term (which is the current standard in the US) is flawed and needs to be revamped and standardized to separate race from ethnicity.
      Insurance and socioeconomic barriers are important contributors to differences in AF care. Racial and ethnic minorities are less likely to be insured and to have primary care providers who play a key role in early recognition and prevention of AF.
      • Simpson J.R.
      • Zahuranec D.B.
      • Lisabeth L.D.
      • et al.
      Mexican Americans with atrial fibrillation have more recurrent strokes than do non-Hispanic whites.
      Moreover, there is a dearth of studies reporting on AF management in different races matched on ability to pay. When more data from single-payer health systems emerge in the near future, it will be important to examine racial and ethnic differences in AF management.
      Moreover, the US population is projected to become even more racially and ethnically diverse in the next few decades.
      • Simpson J.R.
      • Zahuranec D.B.
      • Lisabeth L.D.
      • et al.
      Mexican Americans with atrial fibrillation have more recurrent strokes than do non-Hispanic whites.
      By 2060, Hispanic patients will make up 29% of the US population, up from 17% in 2014; individuals with Black race alone or in combination with one or more other races will make up nearly 18% of the total population, up from 14% in 2014.
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      Racial disparities in healthcare outcomes persist, even after adjusting for socioeconomic factors.
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      Although these issues are not easy to address, new health coverage plans, and customized clinical workflows, are important to enhance access to and quality of care received by underrepresented racial and ethnic minorities.
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      As previously mentioned, cultural factors can affect the AF patient’s perception of illness and symptom reporting. This in turn may result in underdiagnosis and suboptimal care in a racially and ethnically diverse population of patients. Patient education has been shown to improve recognition of symptoms of heart disease in general.
      • Bell M.
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      Improved recognition of heart attack and stroke symptoms after a community-based intervention for older adults, Georgia, 2006-2007.
      AF is a complex disease for patients, owing to its specialized terminology, symptom recognition, and complicated therapeutic options requiring shared decision-making.
      • Aronis K.N.
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      • Lin W.
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      Health literacy and atrial fibrillation: relevance and future directions for patient-centred care.
      There is a critical need to understand whether integration of health literacy into the care of patients with AF improves management, including decision-making, treatment adherence, persistence, and outcomes.
      • Aronis K.N.
      • Edgar B.
      • Lin W.
      • et al.
      Health literacy and atrial fibrillation: relevance and future directions for patient-centred care.
      Clinicians’ implicit biases add another confounding layer to the underlying apprehension and mistrust experienced by patients from underrepresented backgrounds and can contribute to differences in AF care. Implicit biases are pervasive among all, including physicians, administrators, allied professionals, and nurses.
      • Hall W.J.
      • Chapman M.V.
      • Lee K.M.
      • et al.
      Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review.
      Repetitive and purposeful interventions on both individual and systemic levels are essential to move the medical community forward in this regard.
      • Devine P.G.
      • Forscher P.S.
      • Austin A.J.
      • et al.
      Long-term reduction in implicit race bias: a prejudice habit-breaking intervention.
      Taking self-assessment tests and soliciting feedback are initial key steps toward addressing and mitigating individual-level bias.
      • Tony G.
      • Mahzarin B.
      • Brian N.
      Including diversity and inclusion training as an integral part of the curriculum is essential for systematic, grassroots change.
      • Saunders S.
      • Kardia D.
      Center for Research on Learning and Teaching. Creating inclusive college classrooms. Available at.
      Racially diversifying the workforce improves healthcare quality and minority patients' utilization of health services, leads to more culturally responsive and patient-centred interaction, and enhances research with a broader range of racial/ethnic perspectives.
      • LaVeist T.A.
      • Pierre G.
      Integrating the 3Ds—social determinants, health disparities, and health-care workforce diversity.
      ,
      • Alsan M.
      • Garrick O.
      • Graziani G.
      Does diversity matter for health? Experimental evidence from Oakland.
      Diversity among research investigators enhances involvement of underrepresented populations in research planning.
      • Brown S.D.
      • Lee K.
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      • et al.
      Minority recruitment into clinical trials: experimental findings and practical implications.
      Concerted and intentional efforts should be made to form diverse and inclusive study teams, develop methodological strategies backed by conceptual frameworks, and train investigators to avoid generalized hypotheses to answer race- and ethnicity-specific questions.
      • Breathett K.
      • Spatz E.S.
      • Kramer D.B.
      • et al.
      The groundwater of racial and ethnic disparities research: a statement from Circulation: Cardiovascular Quality and Outcomes.
      Training future physicians on cultural humility and structural racism, equity-oriented healthcare initiatives, and advocacy for reformation is vital to maintain the momentum of change toward health equity for future generations. Without tackling structural racism from all angles, health inequities will persist. A concerted effort will help narrow the gaps in health care and beyond.
      • Bailey Z.D.
      • Krieger N.
      • Agénor M.
      • et al.
      Structural racism and health inequities in the USA: evidence and interventions.
      Finally, professional societies and organizations play a pivotal role in addressing differences, as they are the public face and voice of cardiovascular professionals. The Heart Rhythm Society has paved the way with the formation of the Diversity, Equity and Inclusion Task Force, consisting of stakeholders and leaders who are committed to providing an all-inclusive environment, by striving for leaders who represent all aspects of diversity with the goal of narrowing gaps in healthcare outcomes for patients with not only AF, but also other electrophysiological disorders.
      Heart Rhythm Society
      Diversity, equity, inclusion statement. Available at.

      Conclusion

      The world is at a critical crossroad regarding the relationship of race and ethnicity with healthcare outcomes. By providing comprehensive data on disparities in AF management and proposing potential strategies to address these disparities, it is hoped that this paper will create more momentum for future work in this area. It is high time for the medical community to seize the opportunity to test and implement strategies that reduce differences and improve the care and outcomes of all patients from underrepresented racial and ethnic backgrounds with AF worldwide.

      Funding Sources

      The authors have no funding sources to declare.

      Disclosures

      S.M.A. receives research funding from Medtronic, Boston Scientific, and Abbott. J.K.H. receives speaking honoraria from Abbott, Boston Scientific, and Medtronic. A.N. is a consultant for Abbott, Baylis, Biosense Webster, Boston Scientific, Biotronik, and Medtronic. D.G. is a recipient of institutional research grants from Biosense Webster, Boston Scientific, and Medtronic; is on the advisory board for Boston Scientific and Boehringer Ingelheim; and receives speaking honoraria from Biosense Webster, and Boston Scientific. A.M.R. receives instirutional research funding from BMS-Pfizer, Boston Scientific, Kestra, and Medilynx; is on the research steering committee for Boston Scientific and Medtronic; and is a consultant for Biosense Webster, Medtronic, and PaceMate. A.A-A. is a consultant for and receives speaking honoraria from Biosense Webster, Abbott, Medtronic, and Boston Scientific. K.L.T. is a consultant for Biosense Webster. All the other authors have no conflicts of interest to disclose.

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