Food and Atrial Fibrillation: Good Eats and Bad

Patients with atrial fibrillation (AF) regularly ask their physicians what foods, beverages and other exposures might trigger the arrhythmia and those who may be at risk want to know how to avoid developing A. A significant component of treating AF is counseling patients on lifestyle and diet choices, an intervention that should be as much a part of every visit as a discussion on oral anticoagulation options and on rate vs rhythm control.

Find out what you know about the evidence associating AF with the 6 foods and substances that follow-many of your patients in primary care may use 1 or several of these on a regular basis. For each option, choose whether it is associated with (A) reduced risk of atrial fibrillation, (B) increased risk of atrial fibrillation or (C) no known association with atrial fibrillation.

START THE QUIZ - QUESTION 1>>

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1. Alcohol

A. Reduced risk of AF

B. Increased risk of AF

C. No known association with AF

ANSWER>>

The correct answer is: B. Increased risk

Alcohol consumption has a well-known association with increased risk of developing AF. In a review in the Journal of the American College of Cardiology (JACC) of many prior studies,1 it was reported that:  
^♦ > 21 drinks/wk increased AF by 39%
^♦  > 35 drinks/wk increased AF by 45% -90%
^♦  In women, ≥ 2 drinks/day increased AF by 60%; 1.5 drinks/day increase AF by 25-46%
^♦  Each drink/day increased AF by ~8%

Alcohol can be an important risk factor in the development of new-onset AF in young patients with otherwise structurally normal hearts, the so-called “holiday heart.” Alcohol is also linked to increased frequency of AF episodes in patients with paroxysmal AF as described by researchers at UCSF.² The mechanism is thought to be mediated by a shorter atrial refractory period. The type of alcohol found to be the most common trigger? Beer.

 QUESTION 2 >>

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2. Coffee

A. Reduced risk of AF

B. Increased risk of AF

C. No known association with AF

ANSWER>>

The correct answer is A. Reduced risk

Caffeine consumption (including daily consumption of coffee, tea, cola, cocoa and chocolate) in individuals with a mean age of 56 years was not associated with increased risk of AF or atrial flutter. Results are from an observational study from the Danish Diet, Cancer and Health Study of 47,949 individuals followed for 5.7 years.³ However, caffeine significantly increased blood pressure, which has been associated with increased risk of AF. Another study⁴ from a meta-analysis of 228,465 participants from Sweden and Denmark followed for 25 years indicated that habitual caffeine consumption suggested an association with reduced AF risk. This could be due, in part, to theoretical antifibrotic effects of caffeine and attenuation of the adrenergic effects of caffeine related to habitual use.

QUESTION 3 >>

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3. Chocolate 

A. Reduced risk of AF

B. Increased risk of AF

C. No known association with AF

ANSWER>>

The correct answers are A. Reduced risk and C. No known association

In previous studies, chocolate consumption has been associated with lower as well as neutral risk of incident AF. Most recently published and getting a lot of publicity is a large analysis of the Danish Diet, Cancer and Health Study,⁵ which reported that consuming 1-3 servings of dark chocolate per month decreased risk for AF by 10% compared with eating < 1 serving. However, the study is prone to the challenges of an observational study, and there was some suggestion that chocolate consumers are healthier with better lifestyle habits. In another study⁶ of 18, 819 male physicians with self-reported chocolate consumption and mean follow-up of 9 years, there was no evidence of association between chocolate consumption and risk of AF. It is plausible, although there is a paucity of data, that excess chocolate consumption may also be linked to a higher risk of incident AF, given its association with incident diabetes.

QUESTION 4 >>

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4. Marijuana  

A. Reduced risk of AF

B. Increased risk of AF

C. No known association with AF

ANSWER>>

The correct answer is B. Increased risk

Several review studies have reported an increased association between marijuana smoking and incidence of atrial arrhythmias, particularly in predisposed patients. As the once illegal substance becomes more widely used, more associations between marijuana smoking and cardiovascular pathology (such as endothelial activation) are emerging.^7-9

QUESTION 5 >>

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5. Smoking/Tobacco Use   

A. Reduced risk of AF

B. Increased risk of AF

C. No known association with AF

ANSWER>>

The correct answer is B. Increased risk of AF

In the same JACC review that evaluated studies of alcohol and AF risk,¹ a review of studies of tobacco use found that current or former smoking increased AF by 51% and AF risk decreased after quitting smoking. Secondhand smoke is also associated with higher risk. It has been reported that up to 12% of incident AF cases in people who smoke could be avoided with smoking cessation.

QUESTION 6 >>

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5. Energy Drinks    

A. Reduced risk of AF

B. Increased risk of AF

C. No known association with AF

ANSWER>>

The correct answer is B. Increased risk of AF

There have been reports that the non-caffeinated components of energy drinks (herbal stimulants and supplements such as taurine, guarana, ginseng, ginkgo biloba, L-carnitine,  glucoronate, B vitamins) can have synergistic effects when combined with alcohol. Excess use of these substances can trigger AF in young, otherwise healthy patients. Usually, such dysrhythmias resolve within a few hours or convert easily with nodal agents, a similar response to that seen with “holiday heart.” ^10,11