Modifiable Risk Factors in Atrial Fibrillation: Clinical Implications and Pathophysiological Insights

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide, and its growing prevalence is increasingly driven by modifiable lifestyle and clinical factors. Understanding how obesity, hypertension, diabetes, obstructive sleep apnoea (OSA), alcohol intake, and cardiorespiratory fitness each contribute to AF onset, progression, and recurrence is essential for developing comprehensive prevention and treatment strategies.

We performed a narrative review of the available literature assessing six key modifiable risk factors for AF. Evidence was synthesized regarding each factor's pathophysiological effects on atrial structure and electrophysiology, as well as the impact of targeted interventions on arrhythmia burden and procedural outcomes.

Every 1 kg/m² increase in body mass index (BMI) raises AF risk by 50%, with sustained weight loss reversing atrial remodeling and improving arrhythmia-free survival. Hypertension increases atrial pressure, electrical heterogeneity, and fibrosis; resistant cases may benefit from adjunctive renal denervation. Diabetes promotes oxidative stress, profibrotic signaling, and autonomic neuropathy, reducing cardioversion success and antiarrhythmic efficacy. OSA induces intermittent hypoxia and sympathetic surges, destabilizing atrial substrates; CPAP therapy reduces remodeling and halves recurrence after cardioversion or ablation. Alcohol exerts dose-dependent ion-channel alterations, structural changes, and autonomic disruption. Cardiorespiratory fitness shows a U-shaped relationship: moderate exercise is protective, whereas endurance extremes and inactivity foster atrial stretch, fibrosis, and ectopic triggers. Across all factors, shared mechanisms of fibrosis, inflammation, and autonomic imbalance emerge as key therapeutic targets.

Integrating risk-factor modification into AF rhythm-control protocols addresses fundamental disease mechanisms and enhances procedural efficacy, offering clinicians a framework for prevention and therapy.