Socioeconomic status and the incidence of atrial fibrillation in whites and blacks: the Atherosclerosis Risk in Communities (ARIC) study

Social drivers in atrial fibrillation occurrence, screening, treatment, and outcomes: systematic-narrative hybrid review

The importance of social drivers of health (SDOH) in the occurrence, detection, treatment, and outcome of atrial fibrillation (AF) has attracted increasing attention. Addressing SDOH factors may suggest opportunities to prevent AF and its complications. We aimed to conduct a structured narrative review and summarize current knowledge on the association between race and ethnicity, SDOH, including rural vs. urban habitation, education, income, and neighbourhood, and the risk of AF, its management, and complications. We identified 537 references in PubMed and 473 references in Embase. After removal of duplicates, we screened the abstracts of 975 references, resulting in 113 references that were examined for eligibility. Subsequently, 34 references were excluded leaving 79 references for the review. Evidence of a social gradient in AF incidence and prevelance were conflicting. However, we found substantial evidence indicating social inequities in the detection of AF, access to treatment, and outcomes such as healthcare utilization, bleeding, heart failure, stroke, dementia, work disability, and death. Inequities are reported across various health care systems and constitute a global problem affecting several continents, although data from Africa and South America are lacking. Given the documented social inequities in AF detection, management, and outcomes, there is an urgent need for healthcare systems, policymakers, and society to identify and implement effective interventions that can reduce inequities and improve outcomes in individuals with AF.

Are Socioeconomic Factors Associated With Atrial Fibrillation Sex-Dependent? A Narrative Review

Atrial fibrillation (AF), the most prevalent cardiac arrhythmia, poses a significant public health and economic burden. Although socioeconomic factors such as income and education have been implicated in AF incidence and outcomes, the potential sex-specific associations remained underexplored. This narrative review aimed to fill this gap by synthesizing existing literature on the sex-specific impact of socioeconomic factors on AF incidence, treatment, and outcome. Among these socioeconomic factors, we identified income and education as the most frequently cited determinants. Nevertheless, the magnitude and direction of these sex differences remained inconsistent across studies. The review uncovered that many studies did not include sex in the analysis when assessing the impact of socioeconomic factors on AF. We highlighted that there is a paucity of studies employing sex-stratified reporting and sex interaction analyses, thereby hindering a deeper understanding of these relationships.

Educational status and the risk of adverse outcomes in Asian patients with atrial fibrillation: a report from the prospective APHRS-AF Registry

BACKGROUND

The aim of this study was to evaluate the impact of educational status (ES) on the clinical course of Asian patients with atrial fibrillation (AF).

METHODS

We used data from the prospective APHRS-AF Registry. ES was classified as follows: low (primary school), medium (secondary), and high (University). The primary outcome was a composite of all-cause death, thromboembolic events, acute coronary syndrome, and heart failure. Secondary outcomes were each component of the primary outcome, cardiovascular death, and major bleeding. The one-year risk of primary and secondary outcomes was assessed through Cox-regressions. Adherence to the Atrial fibrillation Better Care (ABC) pathway was assessed.

RESULTS

Among 2697 AF patients (69±12 years, 34.8% females), 34.6% had low ES; 37.3% had medium ES; and 28.1% had high ES. Compared to patients with medium-high ES, patients with low ES were older, more often females, with a higher prevalence of cardiovascular risk factors, and a lower ABC pathway adherence (30.4% vs. 40.2%, P<0.001). On multivariable analysis, low ES was associated with a higher risk for the primary outcome (HR 1.52,95%CI 1.11-2.06) and all-cause death (HR 1.76,95%CI 1.10-2.83) than medium-high ES. A significant interaction was found for the risk of composite outcome among the different age strata, with the higher risk in the elderly (P for int=0.008), whereas the beneficial effect of the ABC pathway was irrespective of ES (P for int=0.691).

CONCLUSIONS

In Asian AF patients, low ES is associated with high mortality. Efforts to improve education and include ES evaluation in the integrated care approach for AF are necessary to reduce the cardiovascular burden in these patients.

Ten-year trends in incidence and prevalence of atrial fibrillation and flutter in Denmark according to demographics, ethnicity, educational level, and area of residence (2009-2018)

BACKGROUND

Atrial fibrillation is the most common cardiac arrhythmia and a major global health burden. Updated trends in the epidemiology of atrial fibrillation or flutter (AF) are needed.

METHODS

Using the Danish Heart Statistics, we investigated nationwide trends 2009-2018 in incidence rate and prevalence of AF according to age as well as age-standardized incidence rate (ASIR) and prevalence (ASP) of AF according to sex, ethnicity, educational level, and area of residence. Comparing year 2018 to 2009, we calculated stratum-specific ASIR ratios (ASIRR) and changes in ASP.

RESULTS

During 2009-2015 the ASIR for AF increased for both men and women, followed by a decline from 2015-2018. Overall, this resulted in a 9% increase among men (ASIRR: 1.09, 95% CI: 1.06-1.12), but no change among women (ASIRR: 1.00, 95% CI: 0.97-1.04). The ASP increased by 29% among men and 26% among women. An increase in ASIR was observed in all ethnic groups except men of Far Eastern ethnicity. Lower educational level was associated with greater increases in both ASIR and ASP. ASIR and ASP differed slightly between the Danish regions but increased in all of them.

CONCLUSIONS

During 2009-2018 the incidence and prevalence of AF in Denmark increased although the increase in incidence was transient among women. Factors associated with higher incidence were male sex, higher age, Danish and Western ethnicity as well as Middle Eastern/North African ethnicity among women, and lower educational level. Within Denmark, we observed only minor regional differences in AF incidence and prevalence.

Hypothetical interventions and risk of atrial fibrillation by sex and education: application of the parametric g-formula in the Tromsø Study

AIMS

To use the parametric g-formula to estimate the long-term risk of atrial fibrillation (AF) by sex and education under hypothetical interventions on six modifiable risk factors.

METHODS AND RESULTS

We estimated the risk reduction under hypothetical risk reduction strategies for smoking, physical activity, alcohol intake, body mass index, systolic, and diastolic blood pressure in 14 923 women and men (baseline mean age 45.8 years in women and 47.8 years in men) from the population-based Tromsø Study with a maximum of 22 years of follow-up (1994-2016). The estimated risk of AF under no intervention was 6.15% in women and 13.0% in men. This cumulative risk was reduced by 41% (95% confidence interval 17%, 61%) in women and 14% (-7%, 30%) in men under joint interventions on all risk factors. The most effective intervention was lowering body mass index to ≤ 25 kg/m2, leading to a 16% (4%, 25%) lower risk in women and a 14% (6%, 23%) lower risk in men. We found significant sex-differences in the relative risk reduction by sufficient physical activity, leading to a 7% (-4%, 18%) lower risk in women and an 8% (-2%, -13%) increased risk in men. We found no association between the level of education and differences in risk reduction by any of the interventions.

CONCLUSION

The population burden of AF could be reduced by modifying lifestyle risk factors. Namely, these modifications could have prevented 41% of AF cases in women and 14% of AF cases in men in the municipality of Tromsø, Norway during a maximum 22-year follow-up period.

Risk of atrial fibrillation in individuals with dysglycemia and diabetes

OBJECTIVE

Diabetes is a risk factor for atrial fibrillation (AF), and increases the risk of thromboembolic events in persons with AF. However, the link between the two conditions is not fully elucidated. Few studies have investigated the association of dysglycemia and incident AF. We investigated the risk of incident AF and prognosis according to diabetes status.

RESEARCH DESIGN AND METHODS

The Copenhagen Primary Care Laboratory Database was merged with data on medical prescriptions, in- and outpatient contacts and vital status. The risk of AF according to diabetes status was investigated by use of Cox regression models.

RESULTS

Of 354.807 individuals with a hemoglobin A1c (HbA1c) measurement, 28.541 (8 %) had known diabetes, 13.038 (4 %) had new onset diabetes and 27.754 (8 %) had prediabetes (HbA1c 42-47 mmol/mol). Persons with dysglycemia (HbA1c > 42 mmol/mol) and diabetes were older, more were men, they had lower level of education and were more likely to be living alone. We observed a gradual increase in risk of developing AF from HbA1c levels of 40 to 60 mmol/mol. In adjusted analyses we found a stepwise increase in hazard of AF from normoglycemia over prediabetes to persons with diabetes (no diabetes: 1.00 [ref.]; prediabetes: 1.12 [1.08-1.16]; new-onset diabetes: 1.16 [1.10-1.22]; known diabetes: 1.15 [1.11-1.20]). Persons with known diabetes had a significant higher hazard of stroke, cardiovascular and all-cause mortality.

CONCLUSION

Increasing levels of HbA1c were associated with an increased hazard of developing AF. Persons with new onset of diabetes and those with known diabetes had similar hazard of developing AF, however persons with known diabetes had a significant higher hazard of stroke, cardiovascular- and all-cause mortality.

Impact of Socioeconomic Status on Emergency Department Visits in Patients With Atrial Fibrillation: A Nationwide Population-Based Cohort Study

Background Socioeconomic status (SES) differences could influence management and clinical outcomes in patients with atrial fibrillation (AF), reflecting health inequalities. The authors aimed to investigate emergency department (ED) visits in patients with AF according to SES level. Methods and Results The authors performed a cross-sectional analysis of ED visits in patients with nonvalvular AF using the Korean National Health Insurance Service database in 2016. The patients were divided into health premium quartiles and medical aid groups, with quartile 4 the highest SES and medical aid the lowest SES. Among patients with AF, patients who had ≥1 ED visits in 2016 were identified. The prevalence and cause of ED visits, 30- and 90-day mortality, and rehospitalization risk after ED visits were evaluated. Among the total 371 017 AF patients, 99 306 patients visited the ED in 2016. The medical aid group showed the highest ED visit rate (n=11 833, 38.0%), and patients with the highest quartile of SES (quartile 4 group) showed the lowest ED visit rate (n=38 037, 30.0%). The most common cause of ED visits was cerebral infarction in all groups. The 30- and 90-day mortality rates and rehospitalization risk after ED visits was higher in groups with lower SES. Conclusions Patients with AF and with lower SES had a higher risk of ED visit rate, higher 30- and 90-day mortality rates, and rehospitalization risk after ED visit. Tailored AF management according to different SES levels in patients with AF is needed to improve clinical outcomes.

Association of chronic kidney disease with all-cause mortality in patients hospitalized for atrial fibrillation and impact of clinical and socioeconomic factors on this association

Background

Atrial fibrillation (AF) and chronic kidney disease (CKD) often co-occur, and many of the same clinical factors and indicators of socioeconomic status (SES) are associated with both diseases. The effect of the estimated glomerular filtration rate (eGFR) on all-cause mortality in AF patients and the impact of SES on this relationship are uncertain.

Materials and methods

This retrospective study examined 968 patients who were admitted for AF. Patients were divided into four groups based on eGFR at admission: eGFR-0 (normal eGFR) to eGFR-3 (severely decreased eGFR). The primary outcome was all-cause mortality. Cox regression analysis was used to identify the effect of eGFR on mortality, and subgroup analyses to determine the impact of confounding factors.

Results

A total of 337/968 patients (34.8%) died during follow-up. The average age was 73.70 ± 10.27 years and there were 522 males (53.9%). More than 39% of these patients had CKD (eGFR < 60 mL/min/1.73 m²), 319 patients with moderately decreased eGFR and 67 with severely decreased eGFR. After multivariate adjustment and relative to the eGFR-0 group, the risk for all-cause death was greater in the eGFR-2 group (HR = 2.416, 95% CI = 1.366-4.272, p = 0.002) and the eGFR-3 group (HR = 4.752, 95% CI = 2.443-9.242, p < 0.00001), but not in the eGFR-1 group (p > 0.05). Subgroup analysis showed that moderately to severely decreased eGFR only had a significant effect on all-cause death in patients with low SES.

Conclusion

Moderately to severely decreased eGFR in AF patients was independently associated with increased risk of all-cause mortality, especially in those with lower SES.

The impact of socioeconomic deprivation on the risk of atrial fibrillation in patients with diabetes mellitus: A nationwide population-based study

Objective

To evaluate the relationship between socioeconomic status and the risk of atrial fibrillation (AF) in patients with diabetes mellitus (DM).

Research design and methods

From the National Health Insurance Service (NHIS) database, we identified 2,429,610 diabetic patients who underwent national health check-ups between 2009 and 2012. Tracing back the subjects for 5 years from the date of health check-up, we determined the subjects’ income and whether they received medical aid (MA) during the past 5 years. Subjects were divided into six groups according to the number of years of receiving (MA groups 0 through 5) and into four groups according to socioeconomic status change during the past 5 years. We estimated the risk of AF for each group using the Cox proportional-hazards model.

Results

During a median follow-up of 7.2 ± 1.7 years, 80,257 were newly identified as AF. The MA groups showed a higher risk of AF than the non-MA group with the hazard ratios (HRs) and 95% confidence interval (CI) 1.32 (1.2–1.44), 1.33 (1.22–1.45), 1.23 (1.13–1.34), 1.28 (1.16–1.4), and 1.50 (1.39–1.63) for MA groups 1 through 5, respectively. Dividing subjects according to socioeconomic condition change, those who experienced worsening socioeconomic status (non-MA to MA) showed higher risk compared to the persistent non-MA group (HR 1.54; 95% CI 1.38–1.73).

Conclusion

Low socioeconomic status was associated with the risk of AF in patients with diabetes. More attention should be directed at alleviating health inequalities, targeting individuals with socioeconomic deprivation to provide timely management for AF.

Association Between Neighborhood-Level Poverty and Incident Atrial Fibrillation: a Retrospective Cohort Study

BACKGROUND

Atrial fibrillation (AF) is a leading cause of cardiovascular morbidity and mortality. While neighborhood-level factors, such as poverty, have been related to prevalence of AF risk factors, the association between neighborhood poverty and incident AF has been limited.

OBJECTIVE

Using a large cohort from a health system serving the greater Chicago area, we sought to determine the association between neighborhood-level poverty and incident AF.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Adults, aged 30 to 80 years, without baseline cardiovascular disease from January 1, 2005, to December 31, 2018.

MAIN MEASURES

We geocoded and matched residential addresses of all eligible patients to census-level poverty estimates from the American Community Survey. Neighborhood-level poverty (low, intermediate, and high) was defined as the proportion of residents in the census tract living below the federal poverty threshold. We used generalized linear mixed effects models with a logit link function to examine the association between neighborhood poverty and incident AF, adjusting for patient demographic and clinical AF risk factors.

KEY RESULTS

Among 28,858 in the cohort, patients in the high poverty group were more often non-Hispanic Black or Hispanic and had higher rates of AF risk factors. Over 5 years of follow-up, 971 (3.4%) patients developed incident AF. Of these, 502 (51.7%) were in the low poverty, 327 (33.7%) in the intermediate poverty, and 142 (14.6%) in the high poverty group. The adjusted odds ratio (aOR) of AF was higher for the intermediate poverty compared with that for the low poverty group (aOR 1.23 [95% CI 1.01-1.48]). The point estimate for the aOR of AF incidence was similar, but not statistically significant, for the high poverty compared with the low poverty group (aOR 1.25 [95% CI 0.98-1.59]).

CONCLUSION

In adults without baseline cardiovascular disease managed in a large, integrated health system, intermediate neighborhood poverty was significantly associated with incident AF. Understanding neighborhood-level drivers of AF disparities will help achieve equitable care.

Thirty-Year Trends in the Incidence of Atrial Fibrillation: The ARIC Study

Background Long-term data to study recent trends in the incidence of atrial fibrillation (AF), overall and among sex and race groups, are scarce. We evaluated the 30-year trends in the incidence of AF in the ARIC (Atherosclerosis Risk in Communities) study cohort and explored race and sex differences in these trends. Methods and Results We included 15 343 men and women aged 45 to 64 years in 1987 to 1989 without AF from 4 US communities in the ARIC cohort. Incident AF was identified based on study ECGs, hospital discharge codes, and death certificates through 2017. We calculated age and period-specific incidence rates (IRs) of AF. We used Poisson regression to calculate IR ratios of AF over time adjusting for age, sex, and race. A total of 3241 AF cases were identified during a mean (SD) follow-up of 22 years (8.4 years) (599 in Black participants, 2642 in White participants, 1582 in women, and 1659 in men). Overall, the IR of AF in the ARIC cohort was 9.6 per 1000 person-years (6.9 in Black participants, 10.5 in White participants, 8.1 in women, and 11.6 in men). Age-specific IR by time period did not show significant changes over time. In a model adjusted for sex, race, and age group, the rate of AF did not change significantly from 1987 to 1991 compared with 2012 to 2017 (IR ratio, 1.10 [95% CI, 0.88-1.36] comparing 2012-2017 with 1987-1991). Similarly, no evidence of changes over time in AF rates were identified in men and women or White and Black participants separately. Conclusions Even though IRs of AF increase as age increases, our analysis provided evidence suggesting that the overall IRs of AF have not changed over time in a multicenter cohort of Black and White individuals in the United States from 1987 to 2017.

Machine learning-based identification of risk-factor signatures for undiagnosed atrial fibrillation in primary prevention and post-stroke in clinical practice

AIMS

Atrial fibrillation (AF) carries a substantial risk of ischemic stroke and other complications, and estimates suggest that over a third of cases remain undiagnosed. AF detection is particularly pressing in stroke survivors. To tailor AF screening efforts, we explored German health claims data for routinely available predictors of incident AF in primary care and post-stroke using machine learning methods.

METHODS AND RESULTS

We combined AF predictors in patients over 45 years of age using claims data in the InGef database (n = 1 476 391) for (i) incident AF and (ii) AF post-stroke, using machine learning techniques. Between 2013-2016, new-onset AF was diagnosed in 98 958 patients (6.7%). Published risk factors for AF including male sex, hypertension, heart failure, valvular heart disease, and chronic kidney disease were confirmed. Component-wise gradient boosting identified additional predictors for AF from ICD-codes available in ambulatory care. The area under the curve (AUC) of the final, condensed model consisting of 13 predictors, was 0.829 (95% confidence interval (CI) 0.826-0.833) in the internal validation, and 0.755 (95% CI 0.603-0.890) in a prospective validation cohort (n = 661). The AUC for post-stroke AF was of 0.67 (95% CI 0.651-0.689) in the internal validation data set, and 0.766 (95% CI 0.731-0.800) in the prospective clinical cohort.

CONCLUSION

ICD-coded clinical variables selected by machine learning can improve the identification of patients at risk of newly diagnosed AF. Using this readily available, automatically coded information can target AF screening efforts to identify high-risk populations in primary care and stroke survivors.

The association of education and household income with the lifetime risk of incident atrial fibrillation: The Framingham Heart study

Background

Methods

Results

Conclusion

Incidence and Complications of Atrial Fibrillation in a Low Socioeconomic and High Disability United States (US) Population: A Combined Statistical and Machine Learning Approach

BACKGROUND

Poor socioeconomic status coupled with individual disability is significantly associated with incident atrial fibrillation (AF) and AF-related adverse outcomes, with the information currently lacking for US cohorts. We examined AF incidence/complications and the dynamic nature of associated risk factors in a large socially disadvantaged US population.

METHODS

A large population representing a combined poor socioeconomic status/disability (Medicaid program) was examined from diverse geographical regions across the US continent. The target population was extracted from administrative databases with patients possessing medical/pharmacy benefits. This retrospective cohort study was conducted from Jan 1, 2016, to Sep 30, 2021, and was limited to 18- to 80-year age group drawn from the Medicaid program. Descriptive and inferential statistics (parametric: logistic regression and neural network) were applied to all computations using a combined statistical and machine learning (ML) approach.

RESULTS

A total of 617413 individuals participated in the study, with mean age of 41.7 years (standard deviation "SD" 15.2) and 65.6% female patients. Seven distinct groups were identified with different combinations of low socioeconomic status and disability constraints. The overall crude AF incidence rate was 0.49 cases/100 person-years (95% confidence limit "CI" 0.40-0.58), with the lowest rate for the younger group (temporary assistance for needy family "TANF") (0.20, 95%CI 0.18-0.21), the highest rates for the older groups (age, blindness, or disability "ABD" duals-1.51, 95% CI 1.31-1.58; long-term services and support "LTSS" duals-1.45, 95% CI 1.31-1.58), and the remaining four other groups in between the lower and upper rates. Based on independent effects after accounting for confounders in main effect modeling, the point estimates of odds ratios for AF status with various clinical outcomes were as follows: stroke (2.69, 95% CI 2.53-2.85); heart failure (6.18, 95% CI 5.86-6.52); myocardial infarction (3.71, 95% CI 3.49-3.94); major bleeding (2.26, 95% CI 2.14-2.38); and cognitive impairment (1.74, 95% CI 1.59-1.91). A logistic regression-based ML model produced excellent discriminant validity for high-risk AF outcomes (c "concordance" index based on training data 0.91, 95%CI 0.891-0.929), together with similar measures for external validity, calibration, and clinical utility. The performance measures for the ML models predicting associated complications with high-risk AF cases were good to excellent.

CONCLUSIONS

A combination of low socioeconomic status and disability contributes to AF incidence and complications, elevating risks to higher levels relative to the general population. ML algorithms can be used to identify AF patients at high risk of clinical events. While further research is definitely in need on this socially important issue, the reported investigation is unique in which it integrates the general case about the subject due to the different ethnic groups around the world under a unified culture stemming from residing in the US.

Depressive Symptoms, Cardiac Structure and Function, and Risk of Incident Heart Failure With Preserved Ejection Fraction and Heart Failure With Reduced Ejection Fraction in Late Life

Background Depressive symptoms are associated with heightened risk of heart failure (HF), but their association with cardiac function and with HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF) in late life is unclear. We aimed to determine the prevalence of depression in HFpEF and in HFrEF in late life, and the association of depressive symptoms with cardiac function and incident HFpEF and HFrEF. Methods and Results We studied 6025 participants (age, 75.3±5.1 years; 59% women; 20% Black race) in the ARIC (Atherosclerosis Risk in Communities) study at visit 5 who underwent echocardiography and completed the Center for Epidemiologic Studies Depression Scale questionnaire. Among HF-free participants (n=5086), associations of Center for Epidemiologic Studies Depression Scale score with echocardiography and incident adjudicated HFpEF and HFrEF were assessed using multivariable linear and Cox proportional hazards regression. Prevalent HFpEF, but not HFrEF, was associated with a higher prevalence of depression compared with HF-free participants (P<0.001 and P=0.59, respectively). Among HF-free participants, Center for Epidemiologic Studies Depression Scale score was not associated with cardiac structure and function after adjusting for demographics and comorbidities (all P>0.05). Over 5.5-year follow-up, higher Center for Epidemiologic Studies Depression Scale score was associated with heightened risk of incident HFpEF (hazard ratio [HR] [95% CI], 1.06 [1.04-1.12]; P=0.02), but not HFrEF (HR [95% CI], 1.02 [0.96-1.08]; P=0.54), independent of echocardiographic measures, NT-proBNP (N-terminal pro-B-type natriuretic peptide), troponin, and hs-CRP (high-sensitivity C-reactive protein) (HR [95% CI], 1.06 [1.00-1.12]; P=0.04). Conclusions Worse depressive symptoms predict incident HFpEF in late life, independent of common comorbidities, cardiac structure and function, and prognostic biomarkers. Further studies are necessary to understand the mechanisms linking depression to risk of HFpEF.

Social determinants of atrial fibrillation

Atrial fibrillation affects almost 60 million adults worldwide. Atrial fibrillation is associated with a high risk of cardiovascular morbidity and death as well as with social, psychological and economic burdens on patients and their families. Social determinants - such as race and ethnicity, financial resources, social support, access to health care, rurality and residential environment, local language proficiency and health literacy - have prominent roles in the evaluation, treatment and management of atrial fibrillation. Addressing the social determinants of health provides a crucial opportunity to reduce the substantial clinical and non-clinical complications associated with atrial fibrillation. In this Review, we summarize the contributions of social determinants to the patient experience and outcomes associated with this common condition. We emphasize the relevance of social determinants and their important intersection with atrial fibrillation treatment and outcomes. In closing, we identify gaps in the literature and propose future directions for the investigation of social determinants and atrial fibrillation.

Paradoxical impact of socioeconomic factors on outcome of atrial fibrillation in Europe: trends in incidence and mortality from atrial fibrillation

AIMS

The aim of this study was to understand the changing trends in atrial fibrillation (AF) incidence and mortality across Europe from 1990 to 2017, and how socioeconomic factors and sex differences play a role.

METHODS AND RESULTS

We performed a temporal analysis of data from the 2017 Global Burden of Disease Database for 20 countries across Europe using Joinpoint regression analysis. Age-adjusted incidence, mortality, and mortality-to-incidence ratios (MIRs) to approximate case fatality rate are presented. Incidence and mortality trends were heterogenous throughout Europe, with Austria, Denmark, and Sweden experiencing peaks in incidence in the middle of the study period. Mortality rates were higher in wealthier countries with the highest being Sweden for both men and women (8.83 and 8.88 per 100 000, respectively) in 2017. MIRs were higher in women in all countries studied, with the disparity increasing the most over time in Germany (43.6% higher in women vs. men in 1990 to 74.5% higher in women in 2017).

CONCLUSION

AF incidence and mortality across Europe did not show a general trend, but unique patterns for some nations were observed. Higher mortality rates were observed in wealthier countries, potentially secondary to a survivor effect where patients survive long enough to suffer from AF and its complications. Outcomes for women with AF were worse than men, represented by higher MIRs. This suggests that there is widespread healthcare inequality between the sexes across Europe, or that there are biological differences between them in terms of their risk of adverse outcomes from AF.

World Heart Federation Roadmap on Atrial Fibrillation - A 2020 Update

The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world's population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them. Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow. This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great.

Effect modification of general and central obesity by sex and age on cardiovascular outcomes: Targeted maximum likelihood estimation in the atherosclerosis risk in communities study

BACKGROUND AND AIMS

To elucidate the effect modification of general and central obesity by sex and age on the risk of cardiovascular events.

METHODS

The analysis included 14,983 males and females aged 45-75 years from the Atherosclerosis Risk in Communities study. Obesity was defined with body mass index (BMI), waist-to-hip ratio (WHR) and body shape index (BSI) which categorized the participants as obese and non-obese. Targeted maximum likelihood estimation was used to estimate the risk ratio (RR) with the tmle package in R software.

RESULTS

After adjustment, the strongest effect of BMI on CHD was in females (RR (95%CI): 1.26 (1.11, 1.42)) and in age>54 (RR (95%CI): 1.16 (1.06, 1.27)) and for HF it was in age>54 (RR (95%CI): 1.18 (1.10, 1.26)) and in females (RR (95%CI): 1.17 (1.08, 1.28)). Regarding central obesity, WHR (RR (95%CI): 1.19 (1.05, 1.34)) had the strongest effects on CHD for males and BSI (RR (95%CI): 1.140 (1.02, 1.26)) for age ≤ 54, and for HF the WHR (RR (95%CI): 1.22 (1.10, 1.36)) and BSI (RR (95%CI): 1.18 (1.07, 1.30)) had the strongest effects for age≤54, respectively.

CONCLUSION

Among males and age≤54, WHR index was associated with a higher risk of CHD and HF while BMI was so for females and age>54.

Life Course Socioeconomic Status and Risk of Hospitalization for Heart Failure or Atrial Fibrillation in The Moli-Sani Study Cohort

We investigated the association of cumulative socioeconomic disadvantage (CSD) and socioeconomic (SES) trajectories across life course with the risk of first hospitalization for heart failure (HF) or atrial fibrillation (AF) and tested some biological mechanisms in explaining such associations. Longitudinal analysis on 21,756 HF- and AF-free subjects recruited in the Moli-sani Study (2005-2010; Italy) and followed up for 8.2 years. CSD was computed using childhood SES, education and adulthood SES indicators, and the same were used to define overall trajectories. High disadvantage across life course (CSD≥8) posed subjects at increased risk of HF (Hazard ratio [HR]=2.58; 95%CI 1.78, 3.74) or AF (HR=1.57;1.05,2.33), as compared to low CSD. All explanatory factors accounted for 18.5% and 24% of the excess of HF and AF risks, respectively, associated with CSD. For subjects with low childhood SES, advancements in education lowered risk of HF (HR=0.70;0.48, 1.02) or AF (HR=0.50;0.28, 0.89), whereas achievements of adulthood SES were unlikely to contribute to disease reduction. In conclusion, a life-course disadvantaged SES is an important predictor of first hospitalization for HF and AF; known risk factors partially explained the SES-disease gradient. Upwardly mobile groups are likely to mitigate the effect of poor childhood circumstances especially through educational advancement.

Ethical Challenges With Smartwatch-Based Screening for Atrial Fibrillation: Putting Users at Risk for Marketing Purposes?

Background: Atrial fibrillation is the most common persistent arrhythmia. It is associated with increased mortality and morbidity such as stroke. The early detection of atrial fibrillation can significantly reduce the risk of stroke through preventive anticoagulation. Smartwatches offer the opportunity to screen for atrial fibrillation in the general population. This paper aims to analyze the ethical challenges associated with screening for atrial fibrillation using smartwatches. Methods: This is an ethical analysis. The methodology is based on the principle-orientated approach of Beauchamp and Childress. The principles of beneficence, non-maleficence, justice, and autonomy have to be guaranteed given the influence of private companies, privacy protection, liability and doctor-patient-relationship. The work is based on a systematic literature research. Results: There is currently no evidence that screening for atrial fibrillation with smartwatches improves the outcome and reduces the number of adverse events. The high number of false-positive results can lead to harm. The principle of non-maleficence is violated. The over-reliance on and the lack of adequate education by smartwatches can worsen the doctor-patient relationship. However, the relationship can also be improved by the proactive participation of the patient, which leads to greater autonomy, compliance and in the end beneficence. Since smartwatches are consumer goods, there is a risk for greater disparities in the poor and rich population. There is also a risk of discrimination against ethnic minorities due to underrepresentation in training data and study cohorts. The principle of justice is violated. The storage of sensitive medical data by private companies also raises many ethical and legal concerns. Conclusion: This analysis has shown that the use of smartwatches to detect atrial fibrillation is currently in an ethical perspective problematic. The lack of evidence and the high number of false-positive results can lead to harm. As smartwatches provide only little information about the possible consequences, informed consent cannot be assumed. Ethical implementation could be archived if doctors provide smartwatches to patients who have been shown to benefit from them. The implementation and education should be managed by the doctor.

Association of psychosocial factors with all-cause hospitalizations in patients with atrial fibrillation

Background

A high burden of cardiovascular comorbidities puts patients with atrial fibrillation (AF) at high risk for hospitalizations, but the role of other factors is less clear.

Hypothesis

To determine the relationship between psychosocial factors and the risk of unplanned hospitalizations in AF patients.

Methods

Prospective observational cohort study of 2378 patients aged 65 or older with previously diagnosed AF across 14 centers in Switzerland. Marital status and education level were defined as social factors, depression and health perception were psychological components. The pre‐defined outcome was unplanned all‐cause hospitalization.

Results

During a median follow‐up of 2.0 years, a total of 1713 hospitalizations occurred in 37% of patients. Compared to patients who were married, adjusted rate ratios (aRR) for all‐cause hospitalizations were 1.28 (95% confidence interval [CI], 0.97‐1.69) for singles, 1.31 (95%CI, 1.06‐1.62) for divorced patients, and 1.02 (95%CI, 0.82‐1.25) for widowed patients. The aRRs for all‐cause hospitalizations across increasing quartiles of health perception were 1.0 (highest health perception), 1.15 (95%CI, 0.84‐1.59), 1.25 (95%CI, 1.03‐1.53), and 1.66 (95%CI, 1.34‐2.07). No different hospitalization rates were observed in patients with a secondary or primary or less education as compared to patients with a college degree (aRR, 1.06; 95%CI, 0.91‐1.23 and 1.05; 95%CI, 0.83‐1.33, respectively). Presence of depression was not associated with higher hospitalization rates (aRR, 0.94; 95%CI, 0.68‐1.29).

Conclusions

The findings suggest that psychosocial factors, including marital status and health perception, are strongly associated with the occurrence of hospitalizations in AF patients. Targeted psychosocial support interventions may help to avoid unnecessary hospitalizations.

Trial registration

ClinicalTrials.gov Identifier NCT02105844.

Association of Atrial Fibrillation Without Cardiovascular Comorbidities and Stroke Risk: From the REGARDS Study

Background Atrial fibrillation (AF) is associated with a 5-fold increased stroke risk. While most patients with AF warrant anticoagulation, optimal treatment remains uncertain for patients with AF without cardiovascular comorbidities because the risk of stroke in this population has not been well-characterized. Methods and Results Participants (N=28 253; 55% women, mean age 64.6±9.4 years), from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study (2003-present) were classified into 1 of 4 groups based on the presence or absence of AF and the presence or absence of cardiovascular comorbidities. Cox proportional hazards analysis was used to compare the risk of stroke between groups. During 244 560 person-years of follow-up (median 8.7 years), 1206 strokes occurred. Compared with patients with neither AF nor cardiovascular comorbidities, we did not find an increased stroke risk (hazard ratio [HR], 1.23; 95% CI, 0.62-2.18 [P=0.511]) among participants with AF alone. Participants without AF but with cardiovascular comorbidities had both an elevated stroke risk (HR, 1.77; 95% CI, 1.48-2.18 [P<0.0001]) and an increased risk of cardioembolic stroke (HR, 2.34; 95% CI, 1.48-3.90 [P=0.0002]). Conclusions In this large cohort of participants with AF without cardiovascular comorbidities, we found that AF itself, without cardiovascular comorbidities, did not confer increased risk of stroke. Cardiovascular comorbidities, however, were associated with an increased risk of both stroke of any type and cardioembolic stroke, even in the absence of AF.

Association of household income and adverse outcomes in patients with atrial fibrillation

Background

Social determinants of health are relevant to cardiovascular outcomes but have had limited examination in atrial fibrillation (AF).

Objectives

The purpose of this study was to examine the association of annual household income and cardiovascular outcomes in individuals with AF.

Methods

We analysed administrative claims for individuals with AF from 2009 to 2015 captured by a health claims database. We categorised estimates of annual household income as <$40 000; $40–$59 999; $60–$74 999; $75–$99 999; and ≥$100 000. Covariates included demographics, education, cardiovascular disease risk factors, comorbid conditions and anticoagulation. We examined event rates by income category and in multivariable-adjusted models in reference to the highest income category (≥$100 000).

Results

Our analysis included 336 736 individuals (age 72.7±11.9 years; 44.5% women; 82.6% white, 8.4% black, 7.0% Hispanic and 2.1% Asian) with AF followed for median (25th and 75th percentile) of 1.5 (95% CI 0.6 to 3.0) years. We observed an inverse association between income and heart failure and myocardial infarction (MI) with evidence of progressive risk across decreased income categories. Individuals with household income <$40 000 had the greatest risk for heart failure (HR 1.17; 95% CI 1.05 to 1.30) and MI (HR 1.18; 95% CI 0.98 to 1.41) compared with those with income ≥$100 000.

Conclusions

We identified an association between lower household income and adverse outcomes in a large cohort of individuals with AF. Our findings support consideration of income in the evaluation of cardiovascular risk in individuals with AF.

Atrial Fibrillation, Brain Volumes, and Subclinical Cerebrovascular Disease (from the Atherosclerosis Risk in Communities Neurocognitive Study [ARIC-NCS])

The aim of the present study was to investigate the association between atrial fibrillation (AF) and total and regional brain volumes among participants in the community-based Atherosclerosis Risk in Communities Neurocognitive study (ARIC-NCS). A total of 1,930 participants (130 with AF) with a mean age of 76.3 ± 5.2, who underwent 3T brain MRI scans in 2011 to 2013 were included. Prevalent AF was ascertained from study ECGs and hospital discharge codes. Brain volumes were measured using FreeSurfer image analysis software. Markers of subclinical cerebrovascular disease included lobar microhemorrhages, subcortical microhemorrhages, cortical infarcts, subcortical infarcts, lacunar infarcts, and volume of white matter hyperintensities. Linear regression models were used to assess the associations between AF status and brain volumes. In adjusted analyses, AF was not associated with markers of subclinical cerebrovascular disease. However, AF was associated with smaller regional brain volumes (including temporal, occipital, and parietal lobes; deep gray matter; Alzheimer disease signature region; and hippocampus [all p <0.05]) after controlling for demographics, cardiovascular risk factors, prevalent cardiovascular disease, and markers of subclinical cerebrovascular disease. Subgroup analysis revealed a significant interaction between AF and total brain volume with respect to age (p = 0.02), with associations between AF and smaller brain volumes being stronger for older individuals. In conclusion, AF was associated with smaller brain volumes, and the association was stronger among older individuals. This finding may be related to the longer exposure period of the older population to AF or the possibility that older people are more susceptible to the effects of AF on brain volume.

How useful is the smartwatch ECG?

Apple launched a novel feature of the Apple Watch (Apple Inc.) series 4 that enables consumers to record a rhythm strip and assist with self-diagnosis of atrial fibrillation (AF). The watch is paired with an app that provides automatic classification of the rhythm. Ability of the algorithm to identify AF has received Food and Drug Administration clearance. Given increasing use of direct-to-consumer devices, important questions regarding the utilization of such devices and their features in clinical practice arise. It is unclear how the data obtained from these devices can be optimally incorporated in patient care and what it means for patients. Safety and security of using wearables are also of concern. Furthermore, whether data generated from the Electrocardiogram (ECG) feature will be beneficial to public health is to be determined. We discuss possible uses and challenges of Apple's (Apple Inc.) newly launched ECG feature and review an upcoming trial looking at clinical applications and outcomes using this technology. We also review the literature on the Kardia (AliveCor Inc.) mobile and smartwatch ECG technology and briefly discuss Apple Watch irregular heartbeat notifications along with the Apple Heart Study.

Socioeconomic position and risk of atrial fibrillation: a nationwide Danish cohort study

AIM

To examine the association between socioeconomic position and the risk of atrial fibrillation (AF) in different stages of life in a population of Danish citizens.

METHODS

Register-based study. We followed all individuals turning 35, 50, 65 or 80 years from 1 January 1996 to 31 December 2005 until AF, death, emigration or the end of study period (31 December 2015). Exposure was education and income. We used Cox regression for the HRs (95% CI) and the pseudo-observation method for the adjusted risk difference (RD) (%).

RESULTS

A total of 2 173 857 participants were enrolled and 151 340 incident cases of AF occurred over a median of 13.6 years of follow-up. Adjusted HR (95% CI) of incident AF for the youngest age group with the highest education (ref lowest) was 0.62 (0.50 to 0.77) (women) and 0.85 (0.76 to 0.96) (men). The associations attenuated with increasing age, that is, HRs for the oldest age group were 1.04 (0.97 to 1.10) and 0.98 (0.96 to 1.04), respectively. The corresponding adjusted RDs (%) were: -0.28 (-0.43 to -0.14), -0.18 (-0.36 to -0.01), 3.04 (-0.55 to 6.64) and -0.74 (-3.38 to 2.49), respectively. Similar but weaker associations were found for income.

CONCLUSION

Higher level of education and income was associated with a lower risk of being diagnosed with AF in young individuals but the association decreased with increasing age and was almost absent for the oldest age cohort. However, since AF is relatively rare in the youngest the RDs were low.

Atrial fibrillation in immigrants under the age of 45 y in Sweden

AIM

To study association between country of birth and risk of first-onset atrial fibrillation (AF) in first- and second-generation immigrants to Sweden under 45 y of age.

METHODS

The study population included all individuals (n = 3 248 457) under the age of 45 y in Sweden, including immigrants (n = 722 249). AF was defined as first registered diagnosis in the National Patient Register. Association between country of birth and risk of AF was assessed by Cox regression, calculating HRs and 95% CIs, using Swedish-born individuals as referents. All models were stratified by sex, and in different models were adjusted for age, area of residence in Sweden, educational level, marital status, neighbourhood socioeconomic status and co-morbidity(ies).

RESULTS

A higher fully adjusted HR of incident AF was found in the total sample of first-generation immigrants, 1.44 (95% CI 1.35 to 1.54), in males born in Denmark, Lebanon and Iraq, and in females born in Turkey and Iraq. Lower HRs were found in male and female immigrants from Latin America and Iran, and female immigrants from Finland. Among second-generation immigrants, the fully adjusted HR was significantly lower, 0.70 (95% CI 0.58 to 0.83).

CONCLUSIONS

Clinicians may show a greater awareness of AF in some groups of younger immigrants to enable early diagnosis.

Association of income and health-related quality of life in atrial fibrillation

Objective

Health-related quality of life (HRQoL) is a patient-centred benchmark promoted by clinical guidelines in atrial fibrillation (AF). Income is associated with health outcomes, but how income effects HRQoL in AF has limited investigation.

Methods

We enrolled a convenience cohort with AF receiving care at a regional healthcare system and assessed demographics, medical history, AF treatment, income, education and health literacy. We defined income as a categorical variable (<$20 000; $20 000-$49 999; $50 000-$99 999; >$100 000). We used two complementary HRQoL measures: (1) the atrial fibrillation effect on quality of life (AFEQT), measuring composite and domain scores (daily activity, symptoms, treatment concerns, treatment satisfaction; range 0-100); (2) the 12-item Short Form Survey (SF-12), measuring general HRQoL with physical and mental health domains (range 0-100). We related income to HRQoL and adjusted for relevant covariates.

Results

In 295 individuals with AF (age 71±10, 40% women), we observed significant differences in HRQoL by income. Higher mean composite AFEQT scores were observed for higher income groups: participants with income <$20 000 had the lowest HRQoL (n=35, 68.2±21.4), and those with income >$100 000 had the highest HRQoL (n=64, 81.9±17.0; p=0.04). We also observed a significant difference by income in the AFEQT daily activity domain (p=0.02). Lower income was also associated with lower HRQoL in the mental health composite score of the SF-12 (59.7±21.5, income <$20 000 vs 79.3±16.3, income >$100 000; p<0.01).

Conclusion

We determined that income was associated with HRQoL in a cohort with prevalent AF. Given the marked differences, we consider income as essential for understanding patient-centred outcomes in AF.

Associations between socioeconomic status, atrial fibrillation, and outcomes: a systematic review

BACKGROUND

Atrial fibrillation (AF) is a growing epidemic and evidence of a relationship to socioeconomic status (SES) is inconsistent. We aimed to summarize the literature about SES and AF and defined two objectives: (1) To examine the association between SES and the risk of AF; (2) To examine the association between SES and AF-related outcomes in an AF-population.

METHODS

We performed a separate search for each objective in Ovid-MEDLINE and Ovid-Embase. For objective 1, the population included was healthy participants and outcome of interest was AF. For objective 2, the population included were patients with AF and outcome of interest was mortality, treatment, ablation for AF, knowledge about AF, and morbidity.

RESULTS

For objective 1, 12 studies were included. No consistent pattern for an association between SES and the risk of AF was discovered. For objective 2, 39 studies comprising 42 outcomes were included. The majority of studies showed an association between low SES and increased mortality and morbidity.

CONCLUSION

Low SES was associated with poorer outcomes when AF was present. These findings may imply that health-care professionals and policy interventions should focus on the promotion of AF-education and management among patients with AF and low SES.

ReAl-life Multicenter Survey Evaluating Stroke prevention strategies in non-valvular atrial fibrillation (RAMSES study)

Objective:

Data regarding stroke prevention strategies in non-valvular atrial fibrillation (NVAF) are limited to vitamin K antagonists (VKAs). This study aimed to evaluate real-life stroke prevention strategies for NVAF patients in the era of non-VKA oral anticoagulants (NOACs).

Methods:

We established a cross-sectional, multicenter, nationwide registry of NVAF patients. All consecutive atrial fibrillation (AF) patients and without mechanical heart valves or rheumatic mitral stenosis (but including those with any degree of mitral regurgitation) were enrolled in the ReAl-life Multicenter Survey Evaluating Stroke Prevention Strategies (RAMSES Study; ClinicalTrials.gov identifier NCT02344901) in Turkey. Baseline demographic data, medical history, and medications prescribed for NVAF treatment were collected. Univariate analyses were performed for continuous variables, and the chi-square test was used for categorical variables.

Results:

In total, 6273 patients from 29 provinces of Turkey were enrolled in the study between February and May 2015, with the contribution of 83 investigators. The mean age was 69.6±10.7 years; 56% of the patients were females, and one-fifth of the patients had at least one comorbid disease, the most common being hypertension (69%). The mean CHA₂DS₂–VASc and HAS-BLED scores were 3.3±1.6 and 1.6±1.1, respectively. The rate of oral anticoagulant (OAC) therapy use was 72% (37% NOAC and 35% VKA).

Conclusion:

The RAMSES study showed a higher prevalence of OAC use among NVAF patients than that reported in previous studies. Although NOACs were preferred over VKAs in daily cardiology practice, there is a need for improved OAC therapies for NVAF patients.

Atrial fibrillation in an African-American cohort: The Jackson Heart Study

BACKGROUND

Atrial fibrillation (AF) is an important public health problem across race/ethnic groups. Data from US cohort studies initiated in the 1980s suggest a higher prevalence of AF risk factors among African-Americans (AAs) than whites, but lower AF incidence. The Jackson Heart Study (JHS) is a community-based study of 5306 AAs recruited starting in 2000.

HYPOTHESIS

Demographic, anthropometric, cardiovascular, and/or electrocardiographic factors are associated with AF incidence in JHS.

METHODS

Using baseline participant characteristics and incident AF identified through hospital surveillance, study electrocardiogram, and Medicare claims, we estimated age- and sex-specific AF incidence rates, compared them with rates in AA participants in the Multi-Ethnic Study of Atherosclerosis (MESA) and Cardiovascular Health Study (CHS), and examined associations of cardiovascular risk factors with AF.

RESULTS

A total of 66 participants had prevalent AF at baseline. Over an average follow-up of 8.5 years, 242 cases of incident AF were identified. Age- and sex-specific AF incidence rates in JHS were similar to those among AAs in MESA and appeared slightly lower than those among AAs in CHS. In an age- and sex-adjusted model, associations with incident AF were observed for modifiable risk factors: high body weight (HR = 1.23 per 15 kg, 95%CI 1.13-1.35), systolic blood pressure (HR = 1.29 per 20 mmHg, 95%CI 1.13-1.47), and current smoking (HR = 1.80, 95%CI 1.27-2.55). Risk estimates associated with these risk factors were only slightly attenuated after multivariable adjustments.

CONCLUSIONS

These findings underscore the potential additional benefits of interventions for weight management, control of hypertension, and smoking cessation for the prevention of AF among AAs.

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.

Prevalence of Non-valvular Atrial Fibrillation Based on Geographical Distribution and Socioeconomic Status in the Entire Korean Population

BACKGROUND AND OBJECTIVES

Prevalence of atrial fibrillation (AF) varies based on geographical location and socioeconomic status. We aimed to evaluate the prevalence of AF and utilization of antithrombotic therapy based on geographical regions and income levels in the entire Korean population.

METHODS

We performed a cross-sectional analysis of Korean adults (aged ≥20 years) using the 2015 National Health Insurance Service database (n=41,505,679). The study population was stratified into 17 geographical regions and 21 income levels.

RESULTS

We identified 276,842 patients diagnosed with AF. Overall prevalence of AF in suburban/rural regions was significantly higher than that observed in urban regions (0.72% vs. 0.61%, respectively, p<0.001). Elderly patients (age ≥75 years) showed a higher prevalence of AF and comorbidities related to AF development showed a higher prevalence among the population residing in suburban/rural regions. Among AF patients with a CHA₂DS₂-VASc score ≥2, oral anticoagulation (OAC) therapy utilization was lower in the suburban/rural regions than that observed in the urban regions (48.2% vs. 51.8%, respectively, p<0.001). The relationship between income levels and AF prevalence showed a J-shaped curve. The OAC prescription rate showed a positive correlation with income levels. Non-vitamin K antagonist oral anticoagulants tended to be more commonly prescribed among the higher income groups.

CONCLUSIONS

Geographical location of residence and income levels were closely associated with the prevalence of AF and antithrombotic therapy utilization. This information may provide further insights for more effective surveillance of AF and stroke prevention for improved clinical outcomes.

Associations of Lipoprotein(a) Levels With Incident Atrial Fibrillation and Ischemic Stroke: The ARIC (Atherosclerosis Risk in Communities) Study

Background

Lipoprotein(a) (Lp[a]) is proatherosclerotic and prothrombotic, causally related to coronary disease, and associated with other cardiovascular diseases. The association of Lp(a) with incident atrial fibrillation (AF) and with ischemic stroke among individuals with AF remains to be elucidated.

Methods and Results

In the community‐based ARIC (Atherosclerosis Risk in Communities) study cohort, Lp(a) levels were measured by a Denka Seiken assay at visit 4 (1996–1998). We used multivariable‐adjusted Cox models to compare AF and ischemic stroke risk across Lp(a) levels. First, we evaluated incident AF in 9908 participants free of AF at baseline. AF was ascertained by electrocardiography at study visits, hospital International Statistical Classification of Diseases, 9th Revision (ICD‐9) codes, and death certificates. We then evaluated incident ischemic stroke in 10 127 participants free of stroke at baseline. Stroke was identified by annual phone calls, hospital ICD‐9 Revision codes, and death certificates. The baseline age was 62.7±5.6 years. Median Lp(a) levels were 13.3 mg/dL (interquartile range, 5.2–39.7 mg/dL). Median follow‐up was 13.9 and 15.8 years for AF and stroke, respectively. Lp(a) was not associated with incident AF (hazard ratio, 0.98; 95% confidence interval, 0.82–1.17), comparing those with Lp(a) ≥50 with those with Lp(a) <10 mg/dL. High Lp(a) was associated with a 42% relative increase in stroke risk among participants without AF (hazard ratio, 1.42; 95% confidence interval, 1.07–1.90) but not in those with AF (hazard ratio, 1.06; 95% confidence interval, 0.70–1.61 [P interaction for AF=0.25]). There were no interactions by race or sex. No association was found for cardioembolic stroke subtype.

Conclusions

High Lp(a) levels were not associated with incident AF. Lp(a) levels were associated with increased ischemic stroke risk, primarily among individuals without AF but not in those with AF.

Atrial ectopy as a mediator of the association between race and atrial fibrillation

BACKGROUND

Blacks have a lower risk of atrial fibrillation (AF) despite having more AF risk factors, but the mechanism remains unknown. Premature atrial contraction (PAC) burden is a recently identified risk factor for AF.

OBJECTIVE

The purpose of this study was to determine whether the burden of PACs explains racial differences in AF risk.

METHODS

PAC burden (number per hour) was assessed by 24-hour ambulatory electrocardiographic (ECG) monitoring in a randomly selected subset of patients in the Cardiovascular Health Study. Participants were followed prospectively for the development of AF, diagnosed by study ECG and hospital admission records.

RESULTS

Among 938 participants (median age 73 years; 34% black; 58% female), 206 (22%) developed AF over a median follow-up of 11.0 years (interquartile range 6.1-13.4). After adjusting for age, sex, body mass index, coronary disease, congestive heart failure, diabetes, hypertension, alcohol consumption, smoking status, and study site, black race was associated with a 42% lower risk of AF (hazard ratio 0.58, 95% confidence interval [CI] 0.40-0.85; P = .005). The baseline PAC burden was 2.10 times (95% CI 1.57-2.83; P <.001) higher in whites than blacks. There was no detectable difference in premature ventricular contraction (PVC) burden by race. PAC burden mediated 19.5% (95% CI 6.3-52.5) of the adjusted association between race and AF.

CONCLUSION

On average, whites exhibited more PACs than blacks, and this difference statistically explains a modest proportion of the differential risk of AF by race. The differential PAC burden, without differences in PVCs, by race suggests that identifiable common exposures or genetic influences might be important to atrial pathophysiology.

Past alcohol consumption and incident atrial fibrillation: The Atherosclerosis Risk in Communities (ARIC) Study

Background

Although current alcohol consumption is a risk factor for incident atrial fibrillation (AF), the more clinically relevant question may be whether alcohol cessation is associated with a reduced risk.

Methods and results

We studied participants enrolled in the Atherosclerosis Risk in Communities Study (ARIC) between 1987 and 1989 without prevalent AF. Past and current alcohol consumption were ascertained at baseline and at 3 subsequent visits. Incident AF was ascertained via study ECGs, hospital discharge ICD-9 codes, and death certificates. Of 15,222 participants, 2,886 (19.0%) were former drinkers. During a median follow-up of 19.7 years, there were 1,631 cases of incident AF, 370 occurring in former consumers. Former drinkers had a higher rate of AF compared to lifetime abstainers and current drinkers. After adjustment for potential confounders, every decade abstinent from alcohol was associated with an approximate 20% (95% CI 11–28%) lower rate of incident AF; every additional decade of past alcohol consumption was associated with a 13% (95% CI 3–25%) higher rate of AF; and every additional drink per day during former drinking was associated with a 4% (95% CI 0–8%) higher rate of AF.

Conclusions

Among former drinkers, the number of years of drinking and the amount of alcohol consumed may each confer an increased risk of AF. Given that a longer duration of abstinence was associated with a decreased risk of AF, earlier modification of alcohol use may have a greater influence on AF prevention.

Atrial fibrillation in immigrant groups: a cohort study of all adults 45 years of age and older in Sweden

To study the association between country of birth and incident atrial fibrillation (AF) in several immigrant groups in Sweden. The study population included all adults (n = 3,226,752) aged 45 years and older in Sweden. AF was defined as having at least one registered diagnosis of AF in the National Patient Register. The incidence of AF in different immigrant groups, using Swedish-born as referents, was assessed by Cox regression, expressed in hazard ratios (HRs) and 95% confidence intervals (CI). All models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, and neighbourhood socioeconomic status. Compared to their Swedish-born counterparts, higher incidence of AF [HR (95% CI)] was observed among men from Bosnia 1.74 (1.56–1.94) and Latvia 1.29 (1.09–1.54), and among women from Iraq 1.96 (1.67–2.31), Bosnia 1.88 (1.61–1.94), Finland 1.14 (1.11–1.17), Estonia 1.14 (1.05–1.24) and Germany 1.08 (1.03–1.14). Lower incidence of AF was noted among men (HRs ≤ 0.60) from Iceland, Southern Europe (especially Greece, Italy and Spain), Latin America (especially Chile), Africa, Asia (including Iraq, Turkey, Lebanon and Iran), and among women from Nordic countries (except Finland), Southern Europe, Western Europe (except Germany), Africa, North America, Latin America, Iran, Lebanon and other Asian countries (except Turkey and Iraq). In conclusion, we observed substantial differences in incidence of AF between immigrant groups and the Swedish-born population. A greater awareness of the increased risk of AF development in some immigrant groups may enable for a timely diagnosis, treatment and prevention of its debilitating complications, such as stroke.

Socioeconomic status and the development of atrial fibrillation in Hispanics, African Americans and non-Hispanic whites

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia and is associated with significant morbidity and mortality. Despite having a higher burden of traditional AF risk factors, African American and Hispanic minorities have a lower incidence of AF when compared to non-Hispanic whites, referred to as the "racial paradox."

HYPOTHESIS

Lower SES among Hispanics and African Americans may help to explain the lower incidence rates of AF compared to non-Hispanic whites.

METHODS

An electrocardiogram/electronic medical records database in New York State was interrogated for individuals free of AF for development of subsequent AF from 2000 to 2013. SES was assessed per zip code via a composite of 6 measures Z-scored to the New York State average. SES was reclassified into decile groups. Cox regression analysis controlling for all baseline differences was used to estimate the independent predictive ability of SES for AF.

RESULTS

We identified 48 631 persons (43% Hispanic, 37% African Americans, and 20% non-Hispanic white; mean age 59 years; mean follow-up of 3.2 years) of which 4556 AF cases occurred. Hispanics and African Americans had lower AF risk than whites in all SES deciles (P < 0.001 by log-rank test). Higher SES was borderline associated with lower AF risk (hazard ratio: 0.990, 95% confidence interval: 0.980-1.001, P = 0.061). P trend analysis was not significant by any race/ethnic group by SES deciles for AF.

CONCLUSIONS

Our study suggests that non-Hispanic whites were at higher risk for AF compared to nonwhites, and this was independent of SES.

Are cardiovascular risk factors also associated with the incidence of atrial fibrillation? A systematic review and field synopsis of 23 factors in 32 population-based cohorts of 20 million participants

Established primary prevention strategies of cardiovascular diseases are based on understanding of risk factors, but whether the same risk factors are associated with atrial fibrillation (AF) remains unclear. We conducted a systematic review and field synopsis of the associations of 23 cardiovascular risk factors and incident AF, which included 84 reports based on 28 consented and four electronic health record cohorts of 20,420,175 participants and 576,602 AF events. We identified 3-19 reports per risk factor and heterogeneity in AF definition, quality of reporting, and adjustment. We extracted relative risks (RR) and 95 % confidence intervals [CI] and visualised the number of reports with inverse (RR [CI]<1.00), or direct (RR [CI]>1.00) associations. For hypertension (13/17 reports) and obesity (19/19 reports), there were direct associations with incident AF, as there are for coronary heart disease (CHD). There were inverse associations for non-White ethnicity (5/5 reports, with RR from 0.35 to 0.84 [0.82-0.85]), total cholesterol (4/13 reports from 0.76 [0.59-0.98] to 0.94 [0.90-0.97]; 8/13 reports with non-significant inverse associations), and diastolic blood pressure (2/11 reports from 0.87 [0.78-0.96] to 0.92 [0.85-0.99]; 5/11 reports with non-significant inverse associations), and direct associations for taller height (7/10 reports from 1.03 [1.02-1.05] to 1.92 [1.38-2.67]), which are in the opposite direction of known associations with CHD. A systematic evaluation of the available evidence suggests similarities as well as important differences in the risk factors for incidence of AF as compared with other cardiovascular diseases, which has implications for the primary prevention strategies for atrial fibrillation.

Educational inequalities in mortality of patients with atrial fibrillation in Norway

OBJECTIVES

We explored the educational gradient in mortality in atrial fibrillation (AF) patients.

DESIGN

We prospectively followed patients hospitalized with AF as primary discharge diagnosis in the Cardiovascular Disease in Norway 2008-2012 project. The average length of follow-up was 2.4 years. Mortality by educational level was assessed by Cox proportional hazard models. Population attributable fractions (PAF) were calculated. Analyses stratified by age (≤75 and >75 years of age), and adjusted for age, gender, medical intervention, and Charlson Comorbidity Index.

RESULTS

Of 42,138 AF patients, 16% died by end of 2012. Among younger patients, those with low education (≤10 years) had a HR of 2.3 (95% confidence interval 2.0, 2.6) for all-cause mortality relative to those with any college or university education. Similar results were observed for cardiovascular mortality. Disparities in mortality were greater among younger than older patients. A PAF of 35.9% (95% confidence interval 27.9, 43.1) was observed for an educational level of high school/vocational school or less versus higher education in younger patients.

CONCLUSIONS

Increasing educational level associated with better prognosis suggesting underlying education-related behavioral and medical determinants of mortality. A considerable proportion of mortality within 5 years following hospital discharge could be prevented.

Impact of sex and ethnicity on arrhythmic risk

Substantial differences in the risk of common arrhythmia syndromes exist between men and women, as well as in varying ethnic/racial groups. For example, despite an overall lower risk of sudden death and atrial fibrillation in women compared with men, women have longer QT intervals and a higher risk of torsades de pointes due to antiarrhythmic drugs and worse outcomes associated with atrial fibrillation. An ethnicity-related paradox in atrial fibrillation epidemiology is apparent; despite a higher prevalence of medical comorbidities such as hypertension, diabetes, and prolonged PR interval, blacks, Hispanics, and Asians have a lower risk of atrial fibrillation than whites. In this promising era of genomic medicine, an improved understanding of epidemiology and phenotype holds the potential for revealing novel therapeutic targets and preventing disease.

Validation of the Framingham Heart Study and CHARGE-AF Risk Scores for Atrial Fibrillation in Hispanics, African-Americans, and Non-Hispanic Whites

A risk score for atrial fibrillation (AF) has been developed by the Framingham Heart Study and Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE)-AF consortium. However, validation of these risk scores in an inner-city population is uncertain. Thus, a validation model was built using the Framingham Risk Score for AF and CHARGE-AF covariates. An in and outpatient electrocardiographic database was interrogated from 2000 to 2013 for the development of AF. Patients were included if their age was >45 and <95 years, had <10-year follow-up, if their initial electrocardiogram was without AF, had ≥ 2 electrocardiograms, and declared a race and/or ethnicity as non-Hispanic white, African-American, or Hispanic. For the Framingham Heart Study, 49,599 patients met inclusion criteria, of which 4,860 developed AF. Discrimination analysis using area under the curve (AUC) for original risk equations: non-Hispanic white AUC = 0.712 (95% confidence interval [CI] 0.694 to 0.731), African-American AUC = 0.733 (95% CI 0.716 to 0.751), and Hispanic AUC = 0.740 (95% CI 0.723 to 0.757). For the CHARGE-AF, 45,571 patients met inclusion criteria, of which 4,512 developed AF. Non-Hispanic white AUC = 0.673 (95% CI 0.652 to 0.694), African-American AUC = 0.706 (95% CI 0.685 to 0.727), and Hispanic AUC = 0.711 (95% CI 0.691 to 0.732). Calibration analysis showed qualitative similarities between cohorts. In conclusion, this is the first study to validate both the Framingham Heart Study and CHARGE-AF risk scores in both a Hispanic and African-American cohort. All models predicted AF well across all race and ethnic cohorts.