Rising Prevalence of Atrial Fibrillation in India: An Urgent Need for Early Diagnosis and Stroke Prevention

Dear Editor,

Atrial fibrillation (AF) is rapidly emerging as a major public health challenge in India, driven by demographic transitions, rising cardiovascular risk factors, and improved survival from acute cardiac events. Traditionally considered uncommon in South Asia, recent epidemiological data now indicate a steady rise in AF prevalence, particularly among older adults and individuals with comorbidities such as hypertension, diabetes mellitus, obesity, and coronary artery disease. This evolving landscape carries significant clinical implications, as AF accounts for nearly one-third of cardioembolic strokes, many of which result in severe disability or mortality. In India, community studies suggest an AF prevalence of about 0.1%-1.6% in the general adult population, rising to around 5% among older rural adults, whereas registry and hospital data indicate that approximately two-thirds of Indian AF patients have chronic (persistent or permanent) AF, with permanent AF in about 35%-45% of cases. ¹

Despite the growing burden, AF remains significantly underdiagnosed across India. A considerable proportion of patients first come to medical attention only after suffering an ischemic stroke—a scenario that highlights a critical missed opportunity for preventive care. Contributing factors include limited routine pulse checks in outpatient settings, inadequate use of handheld or ambulatory electrocardiography (ECG) devices, and low public awareness regarding arrhythmia symptoms. Given that paroxysmal AF is frequently asymptomatic, opportunistic screening in primary care becomes particularly essential. Wearable devices hold significant promise in India—especially as a first-line screening strategy for AF in at-risk and symptomatic persons. They could help close the gap in undiagnosed AF, allow earlier detection, and possibly prevent complications (stroke, heart failure) by prompting timely care. However, because of limitations in validation, real-world signal quality, healthcare infrastructure, and equity/access, they should not be used as a stand-alone diagnostic tool. Rather, their role should be complementary, prompting confirmatory diagnostics when they flag an irregular rhythm. ²

Another major challenge lies in the persistently low rates of anticoagulation, despite strong evidence supporting oral anticoagulants as the cornerstone of stroke prevention. Misconceptions about bleeding risks, physician hesitancy, and cost-related concerns often lead to underuse of anticoagulation even among high-risk individuals. This therapeutic inertia directly translates into preventable strokes, hospitalizations, and long-term disabilities that could largely be avoided with guideline-based care. ³

Addressing the rising AF burden requires a multipronged and system-level approach. Integrating routine pulse checks and opportunistic ECG screening in primary care can markedly increase early detection. Targeted screening of high-risk groups—such as older adults and individuals with hypertension or diabetes—should be standardized across community and tertiary settings. In parallel, physician training programs should emphasize systematic use of risk stratification tools like CHA2DS2-VASc and HAS-BLED scores to ensure informed decision-making. Public health initiatives focusing on anticoagulation literacy can further empower patients and counter prevalent misconceptions.^{4, 5}

In conclusion, the increasing prevalence of atrial fibrillation in India demands urgent attention. Prioritizing early detection strategies, improving access to evidence-based stroke prevention, and enhancing both clinician and patient awareness can significantly reduce AF-related morbidity and mortality across the country.