Global variations in the prevalence, treatment, and impact of atrial fibrillation in a multi-national cohort of 153 152 middle-aged individuals

Abstract

Aims To compare the prevalence of electrocardiogram (ECG)-documented atrial fibrillation (or flutter) (AF) across eight regions of the world, and to examine anti-thrombotic use and clinical outcomes. Methods and Results Baseline ECGs were collected in 153,152 middle-aged participants (ages 35 to 70 years) to document AF in two community-based studies, spanning 20 countries. Medication use and clinical outcome data (mean follow up of 7.4 years) were available in one cohort. Cross sectional analyses were performed to document the prevalence of AF and medication use, and associations between AF and clinical events were examined prospectively. Mean age of participants was 52.1 years, and 57.7% were female. Age and sex-standardized prevalence of AF varied 12-fold between regions; with the highest in North America, Europe, China and Southeast Asia (270-360 cases per 100,000 persons); and lowest in the Middle East, Africa, and South Asia (30-60 cases per 100,000 persons)(p < 0.001). Compared with low-income countries (LICs), AF prevalence was 7-fold higher in middle-income countries (MICs) and 11-fold higher in high-income countries (HICs)(p < 0.001). Differences in AF prevalence remained significant after adjusting for traditional AF risk factors. In LICs/MICs, 24% of participants with AF and a CHADS2 score ≥1 received anti-thrombotic therapy, compared with 85% in HICs. AF was associated with an increased risk of stroke (hazard ratio [HR: 2.29; 95% confidence interval [CI] 1.49-3.52) and death (HR: 2.97; 95% CI 2.25-3.93); with similar rates in different country income levels. Conclusions Large variations in AF prevalence occur in different regions and country income settings, but this is only partially explained by traditional AF risk factors. Anti-thrombotic therapy is infrequently used in poorer countries despite the high risk of stroke associated with AF. Translational perspective We examined atrial fibrillation (AF) prevalence in 153,152 middle-aged participants spanning 20 countries. Age and sex-standardized prevalence of AF varied by as much as 12-fold between regions; highest in North America, Europe, China and Southeast Asia (270-360 cases per 100,000 persons); and lowest in the Middle East, Africa, and South Asia (30-60 cases per 100,000 persons)(p < 0.001); and by as much as 11-fold between groups of countries at different income levels (p < 0.001). Global variations were poorly explained by traditional AF risk factors. Future studies are needed to understand the predominant determinants driving the variation in AF burden across different regions of the world.

World Heart Federation Roadmap on Atrial Fibrillation – A 2020 Update

“…Similarly, comparative data are somewhat limited for South and Central America [ 34 35 36 37 ]. In one 2020 publication with 153,152 participants from 20 countries aged 35–70 (mean 52), using population sampling between 2004–2012, there was a 12-fold variation in prevalence between regions, highest in North America, Europe, then China and South-East Asia, lower in South America, and lowest in the Middle East, Africa and South Asia [ 38 ]. There was also a continuous gradient of AF prevalence from low- to middle- and high-income countries.…”

Atrial fibrillation in low- and middle-income countries: a narrative review

“…There were also differences between these country groups, with warfarin more commonly used in high-income countries and antiplatelet use more common in LMICs. 82 …”

Prevalence of First Diagnosed Atrial Fibrillation in Patients Admitted with Acute Coronary Syndrome and with Impaired Renal Function with and without Diabetes Mellitus

“…Increase in the risk factors of AF such as age more than 55 years, hypertension, diabetes mellitus, chronic obstructive pulmonary disease (COPD), CKD, CAD, and OSA is directly associated with increase in the burden of AF. Patients with multiple risk factors have >2.5 folds chance for the development of AF as compared with no risk factor or less than 2 risk factors [11][12][13][14]. The mean age of patient who experience AF without looking at their type of AF is around 66 years in developed country while in developing country it is >50 years and it is more common is women than men [15].…”