Dr. Olivia Greenspan, ND RN

Abstract

Structured risk factor modification and longitudinal lifestyle care can improve atrial fibrillation outcomes beyond rate and rhythm control alone.

This article examines atrial fibrillation as a progressive, risk factor–driven cardiometabolic disease and reviews the evidence supporting lifestyle and risk factor modification as disease-modifying therapy. It outlines how naturopathic doctors can help close the care gap in atrial fibrillation management through early risk identification, patient education, and sustained, evidence-informed lifestyle interventions.

The Standard-of-Care Gap in Atrial Fibrillation Management

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a major contributor to stroke, heart failure, reduced quality of life, and cardiovascular mortality. Its prevalence continues to rise alongside aging populations and the increasing burden of cardiometabolic disease. While conventional management appropriately prioritizes anticoagulation, rate control, rhythm control, and procedural interventions, these strategies alone do not fully address the underlying drivers of AF progression.

A growing body of evidence now supports atrial fibrillation as a risk factor–driven, progressive condition, in which modifiable lifestyle and cardiometabolic factors play a central role in shaping the atrial substrate. As a result, conventional guidelines emphasize comprehensive risk factor modification as a foundational component of AF management. However, in routine clinical practice, due to constraints on time and system pressures, implementation remains inconsistent, and patients often receive limited education regarding how lifestyle factors influence disease trajectory and treatment outcomes.

Naturopathic doctors are uniquely positioned to help bridge this gap. Through early risk identification, patient education, longitudinal lifestyle intervention, and support for medication adherence and shared decision-making, NDs can play a meaningful role within the multidisciplinary AF care team. This article reviews the evidence supporting risk factor modification as disease-modifying therapy in atrial fibrillation and provides a practical framework for how naturopathic doctors can support patients at risk for, or diagnosed with, AF.

Modifiable Risk Factors Shape AF Progression

AF affects an estimated 60 million people worldwide and incidence is predicted to increase by over 60% by 2050, and prevalence of AF among individuals aged ≥65 years increases by 5% annually.1,2 AF is more common in men (1.5× higher risk) and in those with a first-degree family history.3 It significantly reduces quality of life, increases mortality up to fourfold, contributes to heart failure and stroke, causing up to 24% of all strokes and systemic embolisms.3

Common symptoms of AF patients experience include palpitations, dyspnea, fatigue, chest pain, syncope, and dizziness.4 However, a significant proportion of AF patients are asymptomatic creating a barrier to early detection. In a recent review and meta-analysis, it was found that 27% of patients were asymptomatic for AF, with 34% of new-onset AF experiencing no symptoms.4 In another study it was noted that asymptomatic AF accounts for 43-48% cases.5

While antiarrhythmic drugs, cardioversion, and ablation target the electrical expression of AF, risk factor modification directly targets the substrate itself. Lifestyle factors play a central role in shaping the atrial substrate by driving structural, electrical, and autonomic remodeling that facilitates the development and progression of AF. Modifiable risk factors—including obesity, physical inactivity, excessive alcohol intake, smoking, obstructive sleep apnea (OSA), hypertension, diabetes, and high-intensity endurance exercise—promote inflammatory, fibrotic, and structural changes within the atria.6 Addressing these risk factors early before AF develops or progresses to permanent AF, and even as part of prehabilitative care before ablation, is fundamental in reducing AF burden and improving quality of life.

There are several classifications of AF: Paroxysmal AF when recurrent episodes last longer than 30 seconds but less than 7 days; persistent AF when episodes last longer than 7 days, but less than 1 year; long-standing AF when AF lasts longer than 1 year but with a view to consider rhythm control; and permanent AF which is continuous AF where a decision has been to no longer try to achieve rhythm control and is made collaboratively between doctor and patient.3 The earlier healthcare providers can intervene along this trajectory the better outcomes patients will have.

Historically, AF management focused on rate and rhythm control, and anticoagulation. However, substantial evidence supports risk factor modification as a form of disease-modifying therapy in AF, rather than an adjunct or optional component of care.7 AF is increasingly understood as a progressive condition driven by structural, electrical, and autonomic remodeling of the atria. Modifiable risk factors such as hypertension, obesity, insulin resistance, sleep apnea, alcohol use, and physical inactivity are upstream drivers of this remodeling process. When these drivers remain unaddressed, AF progression continues despite appropriate use of antiarrhythmic medications, anticoagulation, or procedural interventions. Conversely, targeted risk factor management has been shown to reduce AF burden, slow disease progression, improve symptom control, and enhance the durability of rhythm control strategies, including catheter ablation.8

Although the management of AF comorbidities and risk factors is a Class I recommendation in the latest European Society of Cardiology guidelines, and has been highlighted in guidelines for more than a decade, it continues to be inconsistently implemented in mainstream AF care.6,9-11 The ESC guidelines AF-CARE framework, places comorbidities (“C”) and risk factors for AF as the initial and central component of patient management.7

What improves when upstream drivers are addressed

Risk factor modification reduces AF symptom burden and episode frequency. There is no clear consensus on the amount of alcohol that is safe for patients with AF or for prevention, however, it is well established that alcohol intake increases both the risk of AF and recurrences.7, 10-12 Alcohol influences AF by its direct effect on atrial substrate and indirectly by influencing other AF risk factors such as obesity, obstructive sleep apnea and hypertension.12 Those with AF who undergo rhythm control strategies such as catheter ablation, had a longer time to AF recurrence and reduced AF burden when they abstained from alcohol.12,13 The most current recommendation for alcohol intake is no more than 3 standard drinks weekly.7

Obstructive sleep apnea (OSA) is highly prevalent in individuals with atrial fibrillation (AF) and remains frequently underdiagnosed and undertreated.7 Although evidence evaluating continuous positive airway pressure (CPAP) therapy and AF outcomes is mixed, data suggest that OSA is associated with an increased incidence of AF and poorer response to rhythm-control strategies and higher recurrence rates following catheter ablation.14,15

A small randomized trial demonstrated reversal of atrial remodeling with CPAP in patients with moderate OSA, supporting a potential disease-modifying role.16 However, other randomized studies have not consistently shown reductions in AF burden or procedural success.17

Interpretation of these findings is limited by methodological challenges, including short trial durations, small sample sizes, variable CPAP adherence, heterogeneity in OSA severity, and shared cardiometabolic risk factors. Importantly, standard definitions of CPAP “compliance” (≥4 hours per night) may underestimate therapeutic exposure, as apneic events occur most frequently during rapid eye movement sleep in the latter half of the night. Given the high prevalence of OSA in AF, naturopathic doctors should routinely screen for sleep-disordered breathing and facilitate appropriate referral for diagnostic testing and collaborative management.

Obesity influences AF outcomes in several ways through left atrial enlargement, increasing the risk of several overlapping comorbidities including hypertension, insulin resistance, coronary artery disease, OSA and heart failure, all of which contribute to the development of AF, while also influencing pharmacokinetics and procedural outcomes.18

Excess body weight is a major modifiable contributor to atrial fibrillation (AF), promoting adverse atrial remodeling and clustering of cardiometabolic comorbidities that influence AF burden and progression. Non-surgical weight loss has been shown to reverse obesity-mediated atrial remodeling, improve AF outcomes, and favorably modify associated risk factors such as hypertension, diabetes, and obstructive sleep apnea.19 In the LEGACY study, even modest weight loss (>3%) was associated with incremental improvements in AF outcomes, while sustained weight loss of ≥10% resulted in significantly greater reductions in AF burden, improved symptom control, and enhanced quality of life.19 Findings from the REVERSE-AF study further demonstrate that the degree of weight loss is closely linked to AF trajectory, with greater and sustained weight loss associated with reduced progression and, in some cases, reversal from persistent to paroxysmal AF.20 Importantly, clinically meaningful and durable weight loss was most consistently achieved through structured, healthcare provider–led programs, supporting the role of longitudinal, integrated care in modifying AF disease course.19,20

Approximately 25% of patients with atrial fibrillation (AF) have coexisting diabetes mellitus, which is associated with increased morbidity and mortality, higher healthcare utilization, greater cardiovascular event rates, and elevated thromboembolic risk.7 Diabetes is also linked to longer hospital stays and higher rates of AF recurrence following catheter ablation.7 Importantly, several cohort studies evaluating comprehensive risk factor management programs—including glycemic control as a core component—have demonstrated improvements in AF symptom severity, reductions in AF burden, reversal from persistent to paroxysmal AF or maintenance of sinus rhythm, and improved long-term rhythm outcomes.19,20 Current evidence supports targeting moderate glycemic control, with a hemoglobin A1c goal of ≤7%, as intensive glucose-lowering strategies aiming for HbA1c <6.0% have not demonstrated a protective effect on incident AF and may increase adverse outcomes.3,7

Hypertension, a primary modifiable cardiovascular risk factor, is a well-established risk factor for AF that facilitates structural and electrical changes in the atria, including dilation, fibrosis, and pressure overload.21 Unfortunately, according to the World Health Organization (WHO) global report on hypertension, only about half of people with hypertension are diagnosed (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg), and a significant proportion remain either untreated or undertreated, not reaching guideline recommended thresholds.22

Blood pressure control plays an important role in atrial fibrillation (AF) prevention and management, although optimal targets appear to vary by age and clinical context. In adults under 80 years, maintaining systolic blood pressure in the range of 120–129 mmHg/<80 mmHg is associated with a lower incidence of AF, whereas in adults aged 80 years and older, a more conservative target of 130–139/80–89 mmHg appears more appropriate.23 Current evidence does not support aggressive blood pressure lowering in isolation as a strategy to improve post-ablation outcomes; however, blood pressure management as part of comprehensive risk factor modification may favorably influence the atrial substrate and improve overall AF outcomes, and also reduces stroke risk in patients with AF receiving oral anticoagulation.23 It is important to remember that excessive blood pressure lowering (<120/80 mmHg) increases the risk of hypotension, particularly in older adults.24

While a sedentary lifestyle increases the risk of developing AF, there appears to be a U-shaped curve showing increased AF risk in extreme endurance athletes.25 Physical activity not only promotes AF risk factor control but also appears to independently reduce the development of AF. Those who achieve guideline directed 500-1500 met min weekly of physical activity had a reduced incidence of AF, with the benefit being more pronounced for women (5-10% reduction for men, 6-15% reduction for women).26 In the ACTIVE-AF study, patients with paroxysmal or persistent AF who received a tailored exercise program had a reduced recurrence of AF and symptom severity.27 Many patients are apprehensive about engaging in physical activity for fear of triggering their AF but research encourages regular moderate physical activity to reduce AF recurrence rates and symptom burden, and improve quality of life.

AF is a progressive, risk factor–driven cardiometabolic disease, rather than an isolated electrical abnormality. While conventional management prioritizes anticoagulation, rate and rhythm control, and procedural interventions, these strategies alone do not adequately address the upstream drivers of atrial remodeling that determine long-term disease trajectory. The persistent gap between guideline recommendations and real-world implementation of risk factor modification creates a critical and clinically meaningful role for naturopathic doctors.

Naturopathic doctors are well positioned to identify patients at elevated risk for AF long before the arrhythmia becomes persistent or permanent. This includes recognizing clustering cardiometabolic risk factors, screening for commonly underdiagnosed conditions such as hypertension and obstructive sleep apnea, and identifying lifestyle patterns that promote adverse atrial remodeling. Early intervention at this stage offers the greatest opportunity to modify disease progression and reduce future AF burden.

Importantly, evidence consistently demonstrates that sustained, provider-led lifestyle interventions—rather than brief or generic advice—produce the most meaningful improvements in AF outcomes. Naturopathic doctors are uniquely equipped to deliver longitudinal care focused on achievable, evidence-based targets for weight management, physical activity, blood pressure control, glycemic regulation, alcohol reduction, and sleep optimization. This ongoing therapeutic relationship enables accountability, individualized adjustment, and reinforcement over time, positioning risk factor modification as a true disease-modifying strategy in atrial fibrillation care.

Dr. Olivia Greenspan, ND, RN is a licensed naturopathic doctor and registered nurse with a clinical focus on cardiovascular health, cardiometabolic disease prevention, and integrative care for complex chronic conditions. She bridges conventional and naturopathic medicine through a strong foundation in acute care nursing and evidence-based natural therapeutics, with particular expertise in atrial fibrillation risk reduction, lifestyle medicine, and long-term disease management. Dr. Greenspan is committed to closing care gaps through patient education, risk factor modification, and collaborative, multidisciplinary care that emphasizes prevention, resilience, and improved quality of life. She brings a systems-based, evidence-informed approach to helping patients actively participate in their cardiovascular health journey. She can be reached at her website https://oliviagreenspan.ca/ 

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