Racial and ethnic differences in atrial fibrillation risk factors and predictors in women: Findings from the Women's Health Initiative

Inequities in Atrial Fibrillation Trials: An Analysis of Participant Race, Ethnicity, and Sex Over Time

BACKGROUND

Despite the importance of racial and ethnic representation in clinical trials, limited data exist regarding the enrollment trends of these groups in atrial fibrillation (AF) trials over time.

OBJECTIVES

The purpose of this study is to examine the characteristics of contemporary AF clinical trials and evaluate their association with race and ethnicity over time.

METHODS

We performed a systematic search of all completed AF trials registered in ClinicalTrials.gov between conception to December 31, 2023 and manually extracted composition of race/ethnicity. We stratified trials by study characteristics, including impact factor, publication status, funding source, and location. We calculated the participation prevalence ratio (PPR) by dividing the percentage of non-White participants by the percentage of non-White participants among the disease population (PPR 0.8-1.2 suggests proportional representation) over time.

RESULTS

We identified 277 completed AF trials encompassing a total of 1,933,441 adults, with a median proportion of non-White at 12% (IQR: 6-27), 121 (43.7%) device-focused, and 184 (66.4%) funded by industry. Only 36.1% of trials reported comprehensive race information. Overall, non-White participants were underrepresented (PPR = 0.511; P < 0.001), including Black (PPR = 0.263) and Hispanic (PPR = 0.337) participants. The proportion of non-White participants did not change significantly between 2000 and 2023 (11% vs 9%; P = 0.343).

CONCLUSION

Despite greater awareness, race/ethnicity reporting and representation of non-White groups in AF clinical trials are poor and have not improved significantly over time. These findings demand additional recruitment efforts and novel recruitment policies to ensure adequate representation of these demographic subgroups in future AF clinical trials.

Regional and Demographic Disparities in Atrial Fibrillation Mortality in the USA

BACKGROUND

Despite the burden of atrial fibrillation/flutter (AF/AFL) in the USA, an assessment of contemporary mortality trends is scarce in the literature. This study aimed to assess the temporal trends in AF/AFL deaths among US adults by age, sex, race/ethnicity, and census region from 1999 to 2020.

METHODS

National mortality data was abstracted from the National Center for Health Statistics to identify decedents whose underlying cause of death was cardiovascular disease and multiple cause of death, AF/AFL. Joinpoint regression assessed mortality trends, and we calculated the average percentage changes (APC) and average annual percentage changes in mortality rates. Results were presented as effect estimates and 95% confidence intervals (95% CI).

RESULTS

Between 1999 and 2020, 657,126 adults died from AF/AFL in the USA. Contemporary trends have worsened overall except among individuals from the Northeast region for whom the rates have remained stationary since 2015 (APC = 0.1; 95% CI, - 1.0, 1.1). Regional and demographic disparities were observed, with higher rates noted among younger persons below 65 years of age, women (APC = 2.1; 95% CI, 1.7, 2.5), and non-Hispanic Blacks (APC = 4.5; 95% CI, 3.9, 5.2).

CONCLUSIONS

The temporal trends in AF/AFL mortality in the USA have exhibited a worsening pattern in recent years, with regional and demographic disparities. Further investigations are warranted to explore the determinants of AF/AFL mortality in the US population and identify factors that may explain the observed differences. Understanding these factors will facilitate efforts to promote improved and equitable health outcomes for the population.

Is the Pattern Changing? Atrial Fibrillation and Screening with Holter Electrocardiograms among Ischemic Stroke Patients in Greenland from 2016 to 2021

A standardized examination regime for ischemic stroke (IS) patients was implemented in Greenland in 2010. Prevalence of atrial fibrillation (AF) of 32% was found among discharged IS patients from 2011 to 2012, and our study aims to estimate the use of Holter ECGs for AF diagnostics and the current prevalence of AF among IS patients in Greenland. Patients discharged from Queen Ingrid's Hospital in Nuuk between 2016 and 2021 with an ICD-10 diagnosis of IS or stroke without specification were included. Data on Holter recordings, age, gender, medical treatment with rivaroxaban or warfarin, and ICD-10 and ICPC codes for AF were extracted for each patient. The overall incidence of IS from 2016 to 2021 was 133/100,000 and unchanged since 2012. Sixty-eight of the study's IS patients (14.5%) had AF, and 46% of IS patients with Holter data accessible had a recording according to international recommendations. Our results indicate that fewer IS patients in Greenland have AF than previously. However, the insufficient use of Holter as a diagnostic tool may explain part of the drop, as well as improved preventive treatment with rivaroxaban among AF patients in Greenland. Regardless, IS remains common, and a focus on diagnostics and preventable risk factors should be maintained.

Racial, ethnic, and sex disparities in atrial fibrillation management: rate and rhythm control

BACKGROUND

Atrial fibrillation (AF) affects around 6 million Americans. AF management involves pharmacologic therapy and/or interventional procedures to control rate and rhythm, as well as anticoagulation for stroke prevention. Different populations may respond differently to distinct management strategies. This review will describe disparities in rate and rhythm control and their impact on outcomes among women and historically underrepresented racial and/or ethnic groups.

METHODS

This is a narrative review exploring the topic of sex and racial and/or ethnic disparities in rate and rhythm management of AF. We describe basic terminology, summarize AF epidemiology, discuss diversity in clinical research, and review landmark clinical trials.

RESULTS

Despite having higher rates of traditional AF risk factors, Black and Hispanic adults have lower risk of AF than non-Hispanic White (NHW) patients, although those with AF experience more severe symptoms and report lower quality-of-life scores than NHW patients with AF. NHW patients receive antiarrhythmic drugs, cardioversions, and invasive therapies more frequently than Black and Hispanic patients. Women have lower rates of AF than men, but experience more severe symptoms, heart failure, stroke, and death after AF diagnosis. Women and people from diverse racial and ethnic backgrounds are inadequately represented in AF trials; prevalence findings may be a result of underdetection.

CONCLUSION

Race, ethnicity, and gender are social determinants of health that may impact the prevalence, evolution, and management of AF. This impact reflects differences in biology as well as disparities in treatment and representation in clinical trials.

Sex and ethnicity modified high 1-year mortality in patients in Singapore with newly diagnosed atrial fibrillation

INTRODUCTION

We investigated sex and ethnic differences in the incidence, clinical characteristics and 1-year mortality of patients with newly diagnosed AF in a multi-ethnic population.

METHOD

This retrospective cohort study of patients diagnosed with AF from 2008 to 2015 was based on medical claims, casemix and subvention data submitted to the Ministry of Health. Patients with AF were matched with controls without AF for age (3-year bands), sex and ethnicity, and categorised as middle-aged (45-64 years) or elderly (≥65 years) among major ethnic groups in Singapore (Chinese, Malay and Indian).

RESULTS

Among 40,602 adults with AF (elderly 74%), Malays had the highest age-standardised incidence rate of AF, followed by Chinese and Indians; and the rate was higher in men. Despite having the worst cardiovascular risk profile, Indians had the lowest prevalence and incidence of AF. The 1-year mortality rate after newly diagnosed AF was 22-26 deaths per 100 people. Newly diagnosed AF was independently associated with increased 1-year all-cause mortality among middle-aged (adjusted odds ratio [AOR] 9.08, 95% confidence interval [CI] 7.36-11.20) and elderly adults (AOR 3.60, 95% CI 3.40-3.80) compared with those without AF. Sex differences in mortality among patients with AF were limited to elderly adults (men: AOR 1.17, 95% CI 1.11-1.24), while Indians were associated with a 30% increased odds of mortality compared with Chinese regardless of age (middle-aged: AOR 1.27, 95% CI 1.09-1.548 elderly: AOR 1.33, 95% CI 1.22-1.45).

CONCLUSION

Variations in incidence, clinical profile and 1-year mortality of patients with AF in a nationwide cohort were influenced by sex and ethnicity. Newly diagnosed AF portends a worse prognosis and is a marker of high mortality within the first year.

Contributions of the Women's Health Initiative to Cardiovascular Research: JACC State-of-the-Art Review

The WHI (Women's Health Initiative) enrolled 161,808 racially and ethnically diverse postmenopausal women, ages 50-79 years, from 1993 to 1998 at 40 clinical centers across the United States. In its clinical trial component, WHI evaluated 3 randomized interventions (menopausal hormone therapy; diet modification; and calcium/vitamin D supplementation) for the primary prevention of major chronic diseases, including cardiovascular disease, in older women. In the WHI observational study, numerous clinical, behavioral, and social factors have been evaluated as predictors of incident chronic disease and mortality. Although the original interventions have been completed, the WHI data and biomarker resources continue to be leveraged and expanded through ancillary studies to yield novel insights regarding cardiovascular disease prevention and healthy aging in women.

Unique Cardiovascular Disease Risk Factors in Hispanic Individuals

Purpose of Review

This review summarizes contemporary data on unique cardiovascular disease (CVD) risk factors in Hispanic individuals in the USA, and how addressing these factors is important in addressing health equity.

Recent Findings

Recent studies have shown high rates of traditional CVD risk factors in Hispanic individuals such as obesity, hypertension, diabetes, hyperlipidemia, and emerging CVD risk factors like hypertensive disorders of pregnancy, psychological stress, and occupational exposures. However, most studies fail to consider the significant heterogeneity in risk factor burden and outcomes in atherosclerotic CVD by Hispanic subgroup. Heart failure and rhythm disorders are less well studied in Hispanic adults, making risk assessment for these conditions difficult. High levels of CVD risk factors in Hispanic youth given an aging Hispanic population overall highlight the importance of risk mitigation among these individuals.

Summary

In brief, these data highlight the significant, unique burden of CVD risk among Hispanic individuals in the USA and predict a rising burden of disease among this growing and aging population. Future CVD research should focus on including robust, diverse Hispanic cohorts as well as specifically delineating results for disaggregated Hispanic groups across CVDs. This will allow for better risk assessment, prevention, and treatment decisions to promote health equity for Hispanic patients.

Race, Body Mass Index, and the Risk of Atrial Fibrillation: The Multi-Ethnic Study of Atherosclerosis

Background

Higher body mass index (BMI) is associated with increased risk of incident atrial fibrillation (AF), but it is not known whether this relationship varies by race/ethnicity.

Methods and Results

Eligible participants (6739) from MESA (Multi‐Ethnic Study of Atherosclerosis) were surveilled for incident AF using MESA hospital surveillance, scheduled MESA study ECG, and Medicare claims data. After a median 13.8 years of follow‐up, 970 participants (14.4%) had incident AF. With BMI modeled categorically in a Cox proportional hazards model, only those with grade II and grade III obesity had increased risks of AF (hazard ratio [HR], 1.50; 95% CI, 1.14–1.98, P=0.004 for grade II obesity and HR, 2.13; 95% CI, 1.48–3.05, P<0.0001 for grade III obesity). The relationship between BMI and AF risk was J‐shaped. However, the risk of AF as a function of BMI varied substantially by race/ethnicity (P value for interaction=0.02), with Chinese‐American participants having a much higher risk of AF with higher BMI and Black participants having minimal increased risk of AF with higher BMI.

Conclusions

Obesity is associated with an increased risk of incident AF, but the relationship between BMI and the risk of AF is J‐shaped and this relationship differs by race/ethnicity, such that Chinese‐American participants have a more pronounced increased risk of AF with higher BMI, while Black participants have minimal increased risk. Further exploration of the differential effects of BMI by race/ethnicity on cardiovascular outcomes is needed.

Disparities in Cardiovascular Care and Outcomes for Women From Racial/Ethnic Minority Backgrounds

Purpose of review

Racial, ethnic, and gender disparities in cardiovascular care are well-documented. This review aims to highlight the disparities and impact on a group particularly vulnerable to disparities, women from racial/ethnic minority backgrounds.

Recent findings

Women from racial/ethnic minority backgrounds remain underrepresented in major cardiovascular trials, limiting the generalizability of cardiovascular research to this population. Certain cardiovascular risk factors are more prevalent in women from racial/ethnic minority backgrounds, including traditional risk factors such as hypertension, obesity, and diabetes. Female-specific risk factors including gestational diabetes and preeclampsia as well as non-traditional psychosocial risk factors like depressive and anxiety disorders, increased child care, and familial and home care responsibility have been shown to increase risk for cardiovascular disease events in women more so than in men, and disproportionately affect women from racial/ethnic minority backgrounds. Despite this, minimal interventions to address differential risk have been proposed. Furthermore, disparities in treatment and outcomes that disadvantage minority women persist. The limited improvement in outcomes over time, especially among non-Hispanic Black women, is an area that requires further research and active interventions.

Summary

Understanding the lack of representation in cardiovascular trials, differential cardiovascular risk, and disparities in treatment and outcomes among women from racial/ethnic minority backgrounds highlights opportunities for improving cardiovascular care among this particularly vulnerable population.

The epidemiology of atrial fibrillation in Chinese postmenopausal women and its association with age of menopause

OBJECTIVES

To investigate the epidemiology of atrial fibrillation (AF) in postmenopausal women and to evaluate the association between age of menopause and AF.

STUDY DESIGN

A total of 9117 postmenopausal women were selected from a cross-sectional study conducted among the general population of north-east China from September 2017 and March 2019.

MAIN OUTCOME MEASURES

AF was diagnosed according to self-reported medical history of AF and/or current ECG findings. The epidemiology of AF including prevalence, awareness, use of anticoagulants and cardiovascular risk factors in postmenopausal women were carefully assessed. The association between age of menopause and AF was evaluated by stepwise logistic regression.

RESULTS

The prevalence of AF was up to 1.1 % (95 % CI, 0.9 %-1.3 %) in postmenopausal women, but the awareness of it was 61.2 %. The proportion of AF patients requiring treatment with an oral anticoagulant (OAC) was as high as 87.8 % according to CHA₂DS₂-VASc score, while only 5.8 % of them received it. The prevalence of cardiovascular risks factors was high among postmenopausal women with AF, but awareness, treatment and control of these comorbidities were unacceptably low. Compared with the women with premature menopause (< 45 years), participants reporting onset of menopause at 50-54 years had a significantly lower risk of AF (OR 0.49, 95 % CI 0.27-0.91).

CONCLUSIONS

The widespread use of OAC and the control of cardiovascular risk factors in postmenopausal women with AF was of great significance in preventing AF-related stroke. The history of premature menopause provided a reliable opportunity for primary prevention of AF.

Ethnic differences in atrial fibrillation among patients with heart failure in Asia

AIMS

We aimed to characterize ethnic differences in prevalence, clinical correlates, and outcomes of atrial fibrillation (AF) in heart failure (HF) with preserved and reduced ejection fraction (HFpEF and HFrEF) across Asia.

METHODS AND RESULTS

Among 5504 patients with HF prospectively recruited across 11 Asian regions using identical protocols in the Asian Sudden Cardiac Death in Heart Failure study (mean age 61 ± 13 years, 27% women, 83% HFrEF), 1383 (25%) had AF defined as a history of AF and/or AF/flutter on baseline electrocardiogram. Clinical correlates of AF were similar across ethnicities and included older age, prior stroke, higher NT-proBNP, and larger left atria. Diabetes was associated with lower odds of AF in HFrEF [adjusted odds ratio (AOR) 0.79, 95% CI 0.66-0.95] and HFpEF (AOR 0.58, 95% CI 0.39-0.84) regardless of ethnicity. Compared with Chinese ethnicity, Japanese/Koreans had higher odds of AF in HFrEF (AOR 1.76, 95% CI 1.40-2.21), while Indians had lower odds in HFrEF (AOR 0.18, 95% CI 0.13-0.24) and HFpEF (AOR 0.28, 95% CI 0.16-0.49) even after adjusting for clinical covariates. Interaction between ethnicity and region was observed among Indians, with Southeast Asian Indians having higher odds of AF (AOR 3.01, 95% CI 1.60-5.67) compared with South Asian Indians. AF was associated with poorer quality of life and increased risk of 1 year all-cause mortality or HF hospitalisation (adjusted hazard ratio 1.39, 95% CI 1.18-1.63) regardless of ethnicity.

CONCLUSIONS

Among patients with HF across Asia, clinical correlates and adverse outcomes associated with AF are similar across ethnicities; however, there are striking ethnic variations in the prevalence of AF that are not accounted for by known risk factors.

Lifestyle components: Self-reported physical activity, nutritional status, sleep quality and incident atrial fibrillation

•Incident AF was detected in 249 (0.3%) individuals of the Lifelines population.•Age, sex, body mass index, heart failure and stroke were associated with incident AF.•Physical activity, nutritional status and sleep quality were not associated with incident AF.

Cardioprotective diabetes drugs: what cardiologists need to know

In patients with diabetes, where cardiovascular morbidity is highly prevalent, recent cardiovascular outcomes trials have identified therapies in the modern glucagon-like peptide 1 receptor agonist (GLP-1RA) and sodium-glucose cotransporter 2 inhibitor (SGLT2i) classes that significantly reduce cardiovascular events. A number of drugs in both classes have demonstrated reductions in the risk of the composite outcome of major adverse cardiovascular events (myocardial infarction, stroke, and cardiovascular death). In addition, SGLT2i drugs have a substantial impact on hospitalization for heart failure. Because GLP-1RA and SGLT2i are effective in reducing cardiovascular events, independent of their effects on blood glucose, cardiologists should be familiar with how to use them. This review outlines the evidence of cardiovascular benefit for current GLP-1RA and SGLT2i drugs, practical information for prescribing them, and putative mechanisms, so that these therapies can be incorporated along with antihypertensives, statins, and antiplatelet therapies into the routine care of patients.

The prevalence of atrial fibrillation on 48-hour ambulatory electrocardiography in African Americans compared to Whites: The Atherosclerosis Risk in Communities (ARIC) study

BACKGROUND

A lower prevalence of atrial fibrillation (AF), but paradoxically higher burden of cardiovascular disease risk factors, has been observed among African Americans compared to Whites in studies of AF identified by mostly 12-lead electrocardiograms (ECGs) and clinically.

METHODS

We performed 48-hour ambulatory electrocardiography (aECG) in a biracial sample of 1,193 participants in the Atherosclerosis Risk in Communities (ARIC) (mean age = 78 years, 62% African Americans, 64% female). Atrial fibrillation was identified from aECG, study visit ECGs, and discharge codes from cohort hospitalizations. We used covariate-adjusted logistic regression to estimate prevalence odds ratios (ORs) for AF in African Americans versus Whites, with adjustment for sampling and nonresponse.

RESULTS

African Americans were more likely than Whites to have hypertension and diabetes but less likely to have coronary heart disease. The prevalence of AF detected by aECG or ARIC study ECG (adjusted for age and coronary heart disease) was lower in African Americans than Whites (2.7% vs 5.0%). White men had a higher (although not significant) AF prevalence of 7.8% compared to the other race and gender groups at 2.3%-2.8%. The adjusted OR for AF was 0.49 (0.24-0.99) comparing African Americans to Whites. Findings were similar when AF was defined to include prior AF hospitalizations (OR = 0.42, 0.25-0.72). There were no significant differences by race for asymptomatic or paroxysmal AF.

CONCLUSIONS

Atrial fibrillation was less prevalent in African American than white older adults, regardless of detection method. Although overall detection of new AF cases with aECG was low, future studies should consider longer-term monitoring to characterize AF by race.

Ethnic differences in atrial fibrillation in patients with heart failure from Asia-Pacific

OBJECTIVE

Ethnic differences in the prevalence of atrial fibrillation (AF) in heart failure (HF) remain unclear. We compared the prevalence and clinical correlates of AF among different ethnicities in an Asian-Pacific population with HF.

METHODS

Patients with validated HF were prospectively studied across Singapore and New Zealand (NZ).

RESULTS

Among 1746 patients with HF (62% Asian, 26% women, mean age 66 (SD 13) years, mean ejection fraction (EF) 37 (SD 16%), 39% had AF. The prevalence of AF was markedly lower in Singapore-Asians than NZ-Europeans (24% vs 63%; p<0.001), even after adjusting for age, clinical and echocardiographic covariates, regardless of EF group (p_interaction for EF=0.39). Patients with AF were older, had higher body mass index and were more likely to have a history of hypertension, stroke, peripheral vascular disease, renal disease, chronic respiratory disease and increased alcohol intake, but less likely to have diabetes. Clinical correlates were similar for Asians and NZ-Europeans, except diabetes: Asian diabetic patients with HF had less AF compared with Asian patients without diabetes (OR 0.66, 95% CI 0.50 to 0.88), whereas among NZ-Europeans there was no significant association between diabetes and AF (OR 1.22, 95% CI 0.85 to 1.75) (p_interaction for ethnicity=0.01). AF was associated with a higher crude composite outcome of mortality and HF hospitalisations at 2 years (HR 1.19, 95% CI 1.02 to 1.38).

CONCLUSION

There is a strikingly lower prevalence of AF among Asian compared with NZ-European patients with HF. The underlying mechanisms for the lower prevalence of AF among Asians, particularly in the presence of diabetes, deserve further study.

TRIAL REGISTRATION NUMBER

ACTRN12610000374066.

Clinical Overview of Obesity and Diabetes Mellitus as Risk Factors for Atrial Fibrillation and Sudden Cardiac Death

The epidemics of obesity and diabetes mellitus are associated with an increased incidence of both atrial fibrillation (AF), the most common sustained arrhythmia in adults, and sudden cardiac death (SCD). Obesity and DM are known to have adverse effects on cardiac structure and function. The pathologic mechanisms are thought to involve cardiac tissue remodeling, metabolic dysregulation, inflammation, and oxidative stress. Clinical data suggest that left atrial size, epicardial fat pad thickness, and other modifiable risk factors such as hypertension, glycemic control, and obstructive sleep apnea may mediate the association with AF. Data from human atrial tissue biopsies demonstrate alterations in atrial lipid content and evidence of mitochondrial dysfunction. With respect to ventricular arrhythmias, abnormalities such as long QT syndrome, frequent premature ventricular contractions, and left ventricular hypertrophy with diastolic dysfunction are commonly observed in obese and diabetic humans. The increased risk of SCD in this population may also be related to excessive cardiac lipid deposition and insulin resistance. While nutritional interventions have had limited success, perhaps due to poor long-term compliance, weight loss and improved cardiorespiratory fitness may reduce the frequency and severity of AF.

Diabetes and Arrhythmias: Pathophysiology, Mechanisms and Therapeutic Outcomes

The prevalence of diabetes is rapidly increasing and closely associated with cardiovascular morbidity and mortality. While the major cardiovascular complication associated with diabetes is coronary artery disease, it is becoming increasingly apparent that diabetes impacts the electrical conduction system in the heart, resulting in atrial fibrillation, and ventricular arrhythmias. The relationship between diabetes and arrhythmias is complex and multifactorial including autonomic dysfunction, atrial and ventricular remodeling and molecular alterations. This review will provide a comprehensive overview of the link between diabetes and arrhythmias with insight into the common molecular mechanisms, structural alterations and therapeutic outcomes.

Tobacco smoking and the risk of atrial fibrillation: A systematic review and meta-analysis of prospective studies

Background

Epidemiological studies on smoking and atrial fibrillation have been inconsistent, with some studies showing a positive association while others have found no association. It is also unclear whether there is a dose–response relationship between the number of cigarettes smoked or pack-years and the risk of atrial fibrillation. We conducted a systematic review and meta-analysis to clarify the association.

Design

Systematic review and meta-analysis.

Methods

We searched the PubMed and Embase databases for studies of smoking and atrial fibrillation up to 20 July 2017. Prospective studies and nested case–control studies within cohort studies reporting adjusted relative risk estimates and 95% confidence intervals (CIs) of atrial fibrillation associated with smoking were included. Summary relative risks (95% CIs) were estimated using a random effects model.

Results

Twenty nine prospective studies (22 publications) were included. The summary relative risk was 1.32 (95% CI 1.12–1.56, I2 = 84%, n = 11 studies) for current smokers, 1.09 (95% CI 1.00–1.18, I2 = 33%, n = 9) for former smokers and 1.21 (95% CI 1.12–1.31, I2 = 80%, n = 14) for ever smokers compared to never smokers. Comparing current versus non-current smokers the summary relative risk was 1.33 (95% CI 1.14–1.56, I2 = 78%, n = 10). The summary relative risk was 1.14 (95% CI 1.10–1.20, I2 = 0%, n = 3) per 10 cigarettes per day and 1.16 (95% CI 1.09–1.25, I2 = 49%, n = 2) per 10 pack-years and there was no evidence of a non-linear association for cigarettes per day, Pnon-linearity = 0.17.

Conclusions

The current meta-analysis suggests that smoking is associated with an increased risk of atrial fibrillation in a dose-dependent matter, but the association is weaker among former smokers compared to current smokers.

Lifetime Risk of Atrial Fibrillation by Race and Socioeconomic Status: ARIC Study (Atherosclerosis Risk in Communities)

BACKGROUND

Limited information exists on the lifetime risk of atrial fibrillation (AF) in African Americans and by socioeconomic status.

METHODS

We studied 15 343 participants without AF at baseline from the ARIC (Atherosclerosis Risk in Communities) cohort recruited in 1987 to 1989 from 4 communities in the United States when they were 45 to 64 years of age. Participants have been followed through 2014. Incidence rates of AF were calculated dividing the number of new cases by person-years of follow-up. Lifetime risk of AF was estimated by a modified Kaplan-Meier method considering death as a competing risk. Participants' family income and education were obtained at baseline.

RESULTS

We identified 2760 AF cases during a mean follow-up of 21 years. Lifetime risk of AF was 36% (95% confidence interval, 32%-38%) in white men, 30% (95% confidence interval, 26%-32%) in white women, 21% (95% confidence interval, 13%-24%) in African American men, and 22% (95% confidence interval, 16%-25%) in African American women. Regardless of race and sex, incidence rates of AF decreased from the lowest to the highest categories of income and education. In contrast, lifetime risk of AF increased in individuals with higher income and education in most sex-race groups. Cumulative incidence of AF was lower in those with higher income and education compared with their low socioeconomic status counterparts through earlier life but was reversed after age 80.

CONCLUSIONS

Lifetime risk of AF in the ARIC cohort was ≈1 in 3 among whites and 1 in 5 among African Americans. Socioeconomic status was inversely associated with cumulative incidence of AF before the last decades of life.

Fasting and post-glucose load measures of insulin resistance and risk of incident atrial fibrillation: The Cardiovascular Health Study

BACKGROUND AND AIMS

Existing literature in individuals without diabetes has not demonstrated a relationship between IR and incident AF; however, data are limited and only fasting glucose measures of IR were assessed. We evaluated the relationship of both fasting and post-glucose load IR measures with the development of atrial fibrillation in nondiabetic older adults.

METHODS AND RESULTS

Among Cardiovascular Health Study participants, a population-based cohort of 5888 adults aged 65 years or older enrolled in two waves (1989-1990 and 1992-1993), those without prevalent AF or diabetes and with IR measures at baseline were followed for the development of AF, identified by follow-up visit electrocardiograms, hospital discharge diagnosis coding, or Medicare claims data, through 2014. Fasting IR was determined by the homeostatic model of insulin resistance (HOMA-IR) and post-glucose load IR was determined by the Gutt index. Cox proportional hazards models were used to determine the association of IR with risk of AF. Analyses included 3601 participants (41% men) with a mean age of 73 years. Over a median follow-up of 12.3 years, 1443 (40%) developed AF. After multivariate adjustment, neither HOMA-IR nor the Gutt index was associated with risk of developing AF [hazard ratios (95% confidence intervals): 0.96 (0.90, 1.03) for 1-SD increase in HOMA-IR and 1.03 (0.97, 1.10) for 1-SD decrease in the Gutt index].

CONCLUSIONS

We found no evidence of an association between either fasting or post-glucose load IR measures and incident AF.

Diabetes mellitus, blood glucose and the risk of atrial fibrillation: A systematic review and meta-analysis of cohort studies

BACKGROUND

Diabetes and elevated blood glucose have been associated with increased risk of atrial fibrillation in a number of epidemiological studies, however, the findings have not been entirely consistent. We conducted a systematic review and meta-analysis to clarify the association.

MATERIAL AND METHODS

We searched the PubMed and Embase databases for studies of diabetes and blood glucose and atrial fibrillation up to July 18th 2017. Cohort studies were included if they reported relative risk (RR) estimates and 95% confidence intervals (CIs) of atrial fibrillation associated with a diabetes diagnosis, prediabetes or blood glucose. Summary RRs were estimated using a random effects model.

RESULTS

Thirty four studies were included in the meta-analysis of diabetes, pre-diabetes or blood glucose and atrial fibrillation. Thirty two cohort studies (464,229 cases, >10,244,043 participants) were included in the analysis of diabetes mellitus and atrial fibrillation. The summary RR for patients with diabetes mellitus versus patients without diabetes was 1.30 (95% CIs: 1.03-1.66), however, there was extreme heterogeneity, I² = 99.9%) and evidence of publication bias with Begg's test, p < 0.0001. After excluding a very large and outlying study the summary RR was 1.28 (95% CI: 1.22-1.35, I² = 90%, n = 31, 249,772 cases, 10,244,043 participants). The heterogeneity was mainly due to differences in the size of the association between studies and the results persisted in a number of subgroup and sensitivity analyses. The summary RR was 1.20 (95% CI: 1.03-1.39, I² = 30%, n = 4, 2392 cases, 58,547 participants) for the association between prediabetes and atrial fibrillation. The summary RR was 1.11 (95% CI: 1.04-1.18, I² = 61%, n = 4) per 20 mg/dl increase of blood glucose in relation to atrial fibrillation (3385 cases, 247,447 participants) and there was no evidence of nonlinearity, p_nonlinearity = 0.34.

CONCLUSIONS

This meta-analysis suggest that prediabetes and diabetes increase the risk of atrial fibrillation by 20% and 28%, respectively, and there is a dose-response relationship between increasing blood glucose and atrial fibrillation. Any further studies should clarify whether the association between diabetes and blood glucose and atrial fibrillation is independent of adiposity.

Usefulness of the American Heart Association's Life Simple 7 to Predict the Risk of Atrial Fibrillation (from the REasons for Geographic And Racial Differences in Stroke [REGARDS] Study)

The American Heart Association has identified metrics of ideal cardiovascular (CV) health known as Life's Simple 7 (LS7). We determined the prospective relationship between the LS7 and the incident atrial fibrillation (AF) in a biracial cohort. The REasons for Geographic And Racial Differences in Stroke (REGARDS) study enrolled non-Hispanic black and white adults 45 years or older. This analysis included 9,576 REGARDS participants (mean age 63 ± 8.4 years; 57% women; 30% black) who were free of AF at baseline and completed a follow-up examination 9.4 years later. An overall LS7 score was calculated at baseline as the sum of the LS7 component scores and classified as inadequate (0 to 4), average (5 to 9), or optimal (10 to 14) CV health. The primary outcome was incident AF, identified at follow-up by either electrocardiogram or a self-reported medical history of a physician diagnosis. A total of 725 incident AF cases were detected. Compared with the inadequate category (n = 534), participants in the optimal category (n = 1,953) had a 32% lower odds of developing AF (odds ratio 0.68; 95% confidence interval 0.47, 0.99) in a logistic regression model adjusted for demographic characteristics, alcohol use, left ventricular hypertrophy, coronary heart disease, and stroke. A 1-point higher LS7 score was associated with a 5% lower odds of incident AF (odds ratio  = 0.95; 95% confidence interval 0.91, 0.99). In conclusion, better CV health, as defined by the LS7 score, is associated with a reduction in development of AF.

Atrial Fibrillation in Heart Failure: a Therapeutic Challenge of Our Times

Atrial fibrillation (AF) and heart failure (HF) are growing cardiovascular disease epidemics worldwide. There has been an exponential increase in the prevalence of AF and HF correlating with an increased burden of cardiac risk factors and improved survival rates in patients with structural heart disease. AF is associated with adverse prognostic outcomes in HF and is most evident in mild-to-moderate left ventricular (LV) dysfunction where the loss of "atrial kick" translates into poorer quality of life and increased mortality. In the absence of underlying structural heart disease, arrhythmia can independently contribute to the development of cardiomyopathy. Together, these 2 conditions carry a high risk of thromboembolism due to stasis, inflammation and cellular dysfunction. Stroke prevention with oral anticoagulation (OAC) remains a mainstay of treatment. Pharmacologic rate and rhythm control remain limited by variable efficacy, intolerance and adverse reactions. Catheter ablation for AF has resulted in a paradigm shift with evidence indicating superiority over medical therapy. While its therapeutic success is high for paroxysmal AF, it remains suboptimal in persistent AF. A better mechanistic understanding of AF as well as innovations in ablation technology may improve patient outcomes in the future. Refractory cases may benefit from atrioventricular junction ablation and biventricular pacing. The value of risk factor modification, especially with regard to obesity, sleep apnea, hypertension and diabetes, cannot be emphasized enough. Close interdisciplinary collaboration between HF specialists and electrophysiologists is an essential component of good long-term outcomes in this challenging population.

Increased Risk of Atrial Fibrillation and Thromboembolism in Patients with Severe Psoriasis: a Nationwide Population-based Study

Psoriasis increases the risk of atrial fibrillation (AF) and thromboembolic events (TE). There is limited information on the effect of psoriasis severity on AF and TE. In this study, psoriasis patients were enrolled from the Korean National Insurance Service-National Sample Cohort (2004–2008). Diagnosis and disease severity were determined from claims data. Newly diagnosed non-valvular AF and TE were identified during a 9.6-year follow-up. The effect of psoriasis severity on AF and TE was evaluated. We identified 13,385 psoriasis patients (1,947 with severe psoriasis). Severe psoriasis significantly increased the risk of AF (adjusted hazard ratio [HR_adjust] 1.44 [95% confidence interval (CI) 1.14–1.82], p = 0.002) and TE (HR_adjust 1.26 [95% CI 1.07–1.47], p = 0.005); mild psoriasis did not show any significant effects. Results were similar after propensity-score matching. Risk increments of AF and TE were prominent in patients with greater cardiovascular risk. A possible limitation of our study is that it has a retrospective design, and the effect of unmeasured confounders and risk of misclassification could bias the results. To conclude, our results showed that severe, but not mild, psoriasis significantly increased AF and TE risk. AF surveillance and active stroke prevention would be beneficial in such cases.

Sex Differences in Outcomes among Stroke Survivors with Non-Valvular Atrial Fibrillation in China

Atrial fibrillation (AF) significantly increases the risk of stroke and disease burden and is an established predictor of poor outcomes after stroke. However, data regarding sex differences in long-term outcomes following stroke in patients with AF are scarce. We thus aimed to assess these differences. We recruited 951 consecutive patients with acute ischemic stroke and non-valvular atrial fibrillation (NVAF) treated at three hospitals in Tianjin, China, from January 2006 to September 2014. Information regarding stroke subtype, severity, risk factors, and outcomes (mortality, dependency, and recurrence) at 3, 12, and 36 months after stroke was recorded. The prevalence of NVAF was 8.4% overall, with a higher frequency in women than in men (11.3 vs. 6.9%, P < 0.001). Among patients with NVAF, women were older than men. Women were more likely than men to have severe stroke (38.8 vs. 29.5%, P < 0.001), high levels of total cholesterol and high- and low-density lipoprotein cholesterol (all P < 0.001), hypertension (69.1 vs. 61.2%, P = 0.012), dyslipidemia (29.8 vs. 20.7%, P = 0.001), and obesity (18.5 vs. 11.6%, P = 0.003); they were less likely than men to be current smokers (12.2 vs. 33.6%, P < 0.001) and to consume alcohol (0.9 vs. 13.9%, P < 0.001). There were greater risks of dependency and recurrence at 36 months after stroke in women than in men [odds ratios (95% confidence intervals), 1.64 (1.02–2.64) for dependency, P = 0.043; and 2.03 (1.28–3.20) for recurrence, P = 0.002] after adjustment for stroke subtype, severity, and risk factors. These findings suggest that it is crucial to emphasize the need for individualized stroke prevention education and promotion of healthy lifestyles in order to improve NVAF-related stroke outcomes and reduce disease burden in women.

Distinct risk factors of atrial fibrillation in patients with and without coronary artery disease: a cross-sectional analysis of the BOREAS-CAG Registry data

Objective

Although risk factors of atrial fibrillation (AF) in the general population have been characterised, their impacts on patients with specific diseases are unclear. Our aim was to determine whether risk factors of AF are different in patients with and those without coronary artery disease (CAD).

Methods

We enrolled 1871 consecutive patients who underwent coronary angiography for evaluation of symptoms suggestive of CAD in the BOREAS-CAG Registry between August 2014 and January 2015. After exclusion of patients with valvular heart disease or a history of PCI/cardiac surgery, 1150 patients contributed to multivariate logistic regression analysis to identify risk factors of AF. We also retrieved data for 361 consecutive patients with CAD admitted to Sapporo Medical University Hospital between April 2013 and July 2014 and analysed data for 166 patients using the same inclusion and exclusion criteria as those in the BOREAS-CAG Registry.

Results

Unexpectedly, CAD was independently associated with the absence of AF. The patients were then divided into a non-CAD group (n=576) and a CAD group (n=574) for further analysis. The brain natriuretic peptide level showed a strong association with AF regardless of the presence or absence of CAD. In the non-CAD group, lack of statin use was independently associated with AF, whereas high serum uric acid level was an independent explanatory variable of AF in the CAD group. The association of AF with uric acid was confirmed in a separate group of patients (n=166) enrolled in the CAD cohort in Sapporo Medical University Hospital.

Conclusions

Major risk factors of AF are different in patients with CAD and those without CAD. Patients with CAD are more likely to develop AF when the serum uric acid level is high, whereas no statin administration predicts development of AF in patients without CAD.

Differential Impact of Risk Factors in Blacks and Whites in the Development of Atrial Fibrillation: the Reasons for Geographic And Racial Differences in Stroke (REGARDS) Study

BACKGROUND

Despite a higher prevalence of risk factors, atrial fibrillation (AF) is less prevalent in blacks than whites. To address this paradox, we examined racial differences in the magnitude of AF risk associated with common risk factors.

METHODS

Participants (13,688; mean age = 63 ± 8.4 years; 56 % female; 37 % black) from the Reasons for Geographic And Racial Differences in Stroke study who were free of baseline AF were included. Incident AF was identified at a follow-up examination by electrocardiogram and self-reported medical history. Poisson regression was used to compute relative risk (RR) and 95 % confidence intervals (CI) for the association between risk factors and incident AF in blacks and whites, separately. Age- and sex-adjusted population attributable fractions (PAFs) of modifiable AF risk factors were computed.

RESULTS

After median follow-up of 9.4 years, 997 (7.3 %) incident AF cases were detected. Black race was associated with a lower risk of AF (RR = 0.46, 95 % CI = 0.39, 0.53). Significant risk factors for AF were age, male sex, hypertension, obesity, and cardiovascular disease. A differential association was detected for smoking by race, with the association being stronger in blacks (RR = 1.41, 95 % CI = 1.07, 1.85) compared with whites (RR = 1.01, 95 % CI = 0.88, 1.16; P interaction = 0.030). The PAFs for hypertension (blacks = 27.4 %, whites = 19.4 %), obesity (blacks = 16.9 %, whites = 11.8 %), and smoking (blacks = 17.9 %, whites = 2.5 %) were higher for blacks than whites.

CONCLUSION

Modifiable risk factors are important in AF development among blacks despite a lower risk of the arrhythmia. Racial differences in the magnitude of the association of individual AF risk factors do not explain the AF paradox.