CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 2, May – August 2024 130 AFRICA 3. Oi A, Tatsuishi W, Mohara J, Yamamoto T, Abe T. Coronary artery bypass grafting in a patient with situs inversus totalis: a case report. J Cardiothorac Surg 2022; 17(1): 56. 4. Hynes KM, Gau GT, Titus JL. Coronary heart disease in situs inversus totalis. Am J Cardiol 1973; 31(5): 666–669. 5. Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med 2008; 359: 2324–2336. 6. Ngam PI, Ong CC, Chai P, Wong SS, Liang CR, Teo LLS. Computed tomography coronary angiography – past, present and future. Singapore Med J 2020; 61(3): 109–115. 7. Karabay KO, Yildiz A, Geceer G, Uysal E, Bagirtan B. The incidence of coronary anomalies on routine coronary computed tomography scans. Cardiovasc J Afr 2013; 24(9): 351–354. … continued from page 126 By contrast, the incidence of myocardial infarction has decreased over recent decades, in association with national programmes of vascular checks to address key risk factors for ischaemic heart disease. This new study reinforces the principle that analogous primary-prevention programmes for AF are required to stem the apparent rise in incidence, associated disease burden, and cost. Unfortunately, the evidence base for primary prevention of AF predominantly relies on observational data and post hoc analyses of data from randomised clinical trials where AF was not pre-specified as a primary or secondary endpoint, and occurrence was not systematically collected. As a consequence, international guidelines do not provide specific recommendations for interventions to reduce the risk of new-onset AF. While difficulties in identifying a group at sufficiently high risk for AF historically impeded primary-prevention trials, opportunities are now available to comprehensively estimate risk by considering multiple risk factors. As such, Vinter and colleagues’ findings should act as a call to prioritise prospective trials in this area. The analysis is also noteworthy for quantifying longterm risks of sequelae after an AF diagnosis. AF care has improved considerably in recent decades, informed by randomised clinical trials showing that oral anticoagulation, and more recently, catheter ablation, reduce the risk of stroke and death. These interventions are being increasingly used worldwide. International guidelines emphasise stroke prophylaxis in patients with AF; yet, Vinter and colleagues’ analysis shows that the lifetime risk of heart failure outweighs the risk of stroke. The neglect of heart failure as a complication of AF in international guidelines is conspicuous because, similar to stroke, heart failure is associated with functional limitations, decreased quality of life, and poor prognosis, and the subpopulation who have both AF and heart failure have a significantly increased risk of cardiovascular and all-cause mortality. Prospective cohort studies have established factors identifying people at high risk of heart failure after an AF diagnosis. However, whether more intensive interventions directed towards modifiable cardiovascular risk factors could affect their long-term incidence of heart failure has not been prospectively tested and requires further investigation. Interventions to prevent stroke have dominated AF research and guidelines during the study period in Vinter and colleagues’ analysis, but no evidence suggests that these interventions can prevent incident heart failure. Alignment of both randomised clinical trials and guidelines to better reflect the needs of the real-world population with AF is necessary because further improvements to patient prognosis are likely to require a broader perspective on the condition’s management beyond prevention of stroke. This robust observational research by Vinter and colleagues provides novel information that challenges research priorities and guideline design, and raises critical questions for the research and clinical communities about how the growing burden of AF can be stopped. Source: MedicalBrief 2024
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