Sex-Specific Prevalence, Incidence, and Mortality Associated With Atrial Fibrillation in Heart Failure

Prognostic Implications and Global Perspectives of Atrial Fibrillation in Patients Hospitalized for Heart Failure

BACKGROUND

Atrial fibrillation (AF) and heart failure (HF) each contributes to global disease burden and can coexist. The interplay of prior HF, prior AF, and presenting rhythm have not previously been jointly considered in prognostic implication.

OBJECTIVES

The authors sought to assess 1-year all-cause mortality according to permutations of prior HF, prior AF, and AF as presenting rhythm, in a global cohort of patients hospitalized for HF.

METHODS

REPORT-HF enrolled patients during hospitalization for acute HF from 44 countries over 6 continents. Cox proportional hazard models were used to compute HRs for the primary outcome of 1-year all-cause mortality.

RESULTS

Of 13,401 participants (median age 67 years, 61% men), 58% had prior HF. AF prevalence (prior or newly detected) at HF admission was 39%, varying by left ventricular ejection fraction and race subgroups. Compared with patients with no prior HF, no prior AF, and presenting in sinus rhythm, 1-year all-cause mortality was elevated in patients with prior HF, prior AF, and presenting in AF (adjusted HR: 1.54 [95% CI: 1.34-1.78]; P < 0.001) and in patients with prior HF, no prior AF, and presenting in AF (adjusted HR: 1.51 [95% CI: 1.20-1.90]; P < 0.001), but not in patients with no prior HF and with prior AF or presenting in AF. These results were conserved across left ventricular ejection fraction and race subgroups.

CONCLUSIONS

In a global cohort of patients hospitalized for HF, permutations of prior HF, prior AF, and AF as presenting rhythm differentiate outcome. History of prior HF influences the prognostic implications of AF in patients hospitalized for HF. (Global Noninterventional Heart Failure Disease Registry [REPORT-HF]; NCT02595814).

Global, regional, and national burden of atrial fibrillation and atrial flutter from 1990 to 2021: sex differences and global burden projections to 2046-a systematic analysis of the Global Burden of Disease Study 2021

AIMS

Atrial fibrillation and atrial flutter (AF/AFL) are critical global health concerns, yet studies on burden trends and sex differences remain limited. This study aims to investigate the global burden trends of AF/AFL, with an in-depth analysis of differences between sexes and future trends, in order to address gaps in the current research field.

METHODS AND RESULTS

This study utilized data from the Global Burden of Disease 2021 study, applying methods such as age-period-cohort analysis and joinpoint regression models to evaluate trends and sex differences in the incidence, prevalence, mortality, and disability-adjusted life years (DALYs) of AF/AFL among individuals aged 30 and above from 1990 to 2021, and employed Bayesian age-period-cohort (BAPC) analysis to predict future trends from 2022 to 2046. In 2021, AF/AFL affected around 52.6 million people globally, with significant increases in cases, deaths, and DALYs since 1990. While the age-standardized prevalence rate (ASPR) remained stable, the age-standardized incidence rate (ASIR) slightly declined, and the age-standardized mortality rate (ASMR) increased. Moreover, there were significant differences in the disease burden between male and female patients. Males had higher prevalence and DALYs, with older age contributing to higher rates. Key risk factors included high systolic blood pressure, body mass index (BMI), and alcohol use, with female patients exhibiting a higher age-standardized rates associated with elevated BMI compared with their male counterparts. Bayesian age-period-cohort predicted stable ASPR and ASIR in males but rising rates in females, with ASMR expected to decline for both sexes.

CONCLUSION

The global burden of AF/AFL is rising, particularly among women, and in low-socio-demographic index regions. This underscores the urgent need for targeted prevention strategies and optimized management of modifiable risk factors, with a specific focus on these vulnerable groups.

Heart Failure in Atrial Fibrillation Subtypes in Women and Men in the Tromsø Study

Background

Atrial fibrillation (AF) and heart failure (HF) often coexist and impact morbidity and mortality. There is limited knowledge on the association of AF subtypes with HF according to sex.

Objectives

The purpose of this study was to explore sex-specific associations between AF subtypes and subsequent HF, identifying HF risk factors in participants with AF, and exploring the combined impact on mortality.

Methods

14,790 women and 13,181 men from the Tromsø Study were enrolled between 1994 and 2008 and followed for incident AF and HF through 2016. Cox regression was conducted to provide HRs and 95% CIs.

Results

Those with AF had higher risk of subsequent HF in both sexes compared to those without AF. Women with permanent AF had higher relative risk of HF than men (HR: 10.52; 95% CI: 8.72-12.70, and HR: 7.65; 95% CI: 6.40-9.15, respectively). Risk factors for HF in participants with AF included smoking in all, higher diastolic blood pressure and hypertension in women, underweight, obesity, and low alcohol consumption in men. All-cause mortality was higher in women with both subtypes (paroxysmal/persistent: HR: 2.10; 95% CI: 1.78-2.48, permanent: HR: 1.40, 95% CI: 1.14-1.72) and in men with paroxysmal/persistent AF (HR: 1.66; 95% CI: 1.40-1.96). Subsequent HF increased risk of mortality in both sexes.

Conclusions

All AF subtypes were associated with increased risk of HF. Smoking was a shared risk factor, while diastolic blood pressure and hypertension were specific to women, and underweight, obesity, and low alcohol intake were specific to men. Subsequent HF increased mortality risk in all.

Sex differences in clinical characteristics, management, and outcomes in patients admitted for ventricular tachycardia: 2016-2018

INTRODUCTION

The concurrent data on sex disparities in VT management and outcomes have remained unclear. Therefore, our objective was to determine the impact of sex on ventricular tachycardia (VT) management and outcomes in patients admitted with VT, dervied from the US National Inpatient Sample database (NIS).

METHODS

We used data from the US NIS to identify hospitalized adult patients who were admitted with VT between 2016 and 2018. Regression analysis was conducted to evaluate the impact of sex on VT management, in-hospital mortality, complications, length of stay, and hospitalization costs.

RESULTS

Of the database, a total of 146 070 patients, who were primarily hospitalized for VT, were approximated. Among these, women comprised 25.5%; they were significantly younger and had fewer comorbidities. Of procedural aspects, women were less likely to receive an angiogram, mechanical support, implantable cardioverter-defibrillator implantation, and VT ablation compared to men. Notably, women were associated with higher do-not-resuscitate rates and in-hospital cardiac arrests than men. No differences in in-hospital mortality and cardiogenic shock were observed between men and women (p > .05). Length of stay was significantly longer for women, while no differences in hospital costs were observed in both sexes.

CONCLUSION

Significant sex disparities in management and outcomes were observed in admitted patients with VT. Our results reflect the need for further studies to explore factors causing such diversities.

Prognostic Importance of Atrial Fibrillation and Anticoagulation in Alcoholic Versus Dilated Cardiomyopathy

AIMS

Limited data exist to describe the prognostic impact of atrial fibrillation (AF) and oral anticoagulation on patients with alcoholic cardiomyopathy (ACM) compared with dilated cardiomyopathy (DCM) and were investigated in this study.

METHODS

Using Danish nationwide registries, a cohort analysis was conducted to assess the prognostic differences for patients with a first diagnosis of ACM versus DCM with and without AF 1994-2018 (followed until end 2019). Our study also assessed differences in mortality following initiation of anticoagulation in both populations.

RESULTS

Totally, 1237 patients with ACM (33% with AF) and 17,211 individuals with DCM (33% with AF) were included. Those with ACM were more often men (89 versus 71%) and younger than patients with DCM (mean age 56 versus 64 years). Cumulative 5-year mortality was greater among patients with ACM, compared with DCM, regardless of AF (ACM with AF 49% [95% CI: 44-54%], ACM without AF 48% [45-53%], DCM with AF 41% [39-42%], DCM without AF 30% [29-31%], P < 0.0001). The prognosis associated with AF was statistically significantly different in people with ACM and DCM (adjusted hazards ratio 0.85 [95% CI: 0.74-0.98] versus 1.04 [1.00-1.09] in ACM and DCM, P < 0.0001). The mortality associated with oral anticoagulation was similar in ACM and DCM (hazards ratio 0.81 [0.61-1.07] versus 0.87 [0.80-0.94], P = 0.49).

CONCLUSIONS

Patients with ACM had a worse prognosis when compared with patients with DCM, but this did not appear to be driven by AF. Patients with ACM were observed to have similar associated risk benefits of oral anticoagulation as DCM.

Sex Differences in Atrial Fibrillation Risk: The VITAL Rhythm Study

Importance

Women have a lower incidence of atrial fibrillation (AF) compared with men in several studies, but it is unclear whether this sex difference is independent of sex differences in prevalent cardiovascular disease (CVD), body size, and other risk factors.

Objective

To examine sex differences in AF incidence and whether AF risk factors differ by sex in a contemporary cohort of men and women without prevalent CVD.

Design, Setting, and Participants

This was a prospective cohort analysis within the Vitamin D and Omega-3 Trial (VITAL) Rhythm Study, a randomized trial that examined the effect of vitamin D and ω-3 fatty acid supplementation on incident AF among men 50 years or older and women 55 years or older without a prior history of prevalent AF, CVD, or cancer at baseline. Data were analyzed from September 29, 2020, to June 29, 2021.

Exposures

Sex, height, weight, body mass index (BMI), body surface area (BSA), and other AF risk factors at study enrollment.

Main Outcomes and Measures

Incident AF confirmed by medical record review.

Results

A total of 25 119 individuals (mean [SD] age, 67.0 [7.1] years; 12 757 women [51%]) were included in this study. Over a median (IQR) follow-up of 5.3 (5.1-5.7) years, 900 confirmed incident AF events occurred among 12 362 men (495 events, 4.0%) and 12 757 women (405 events, 3.2%). After adjustment for age and treatment assignment, women were at lower risk for incident AF than men (hazard ratio [HR], 0.68; 95% CI, 0.59-0.77; P < .001). The inverse association between female sex and AF persisted after adjustment for race and ethnicity, smoking, alcohol intake, hypertension, diabetes (type 1, type 2, gestational), thyroid disease, exercise, and BMI (HR, 0.73; 95% CI, 0.63-0.85; P <.001). However, female sex was positively associated with AF when height (HR, 1.39; 95% CI, 1.14-1.72; P = .001), height and weight (HR 1.49, 95% CI, 1.21-1.82; P <.001), or BSA (HR, 1.25; 95% CI, 1.06-1.49; P = .009) were substituted for BMI in the multivariate model. In stratified models, risk factor associations with incident AF were similar for women and men.

Conclusions and Relevance

In this cohort study, findings suggest that after controlling for height and/or body size, women without CVD at baseline were at higher risk for AF than men, suggesting that sex differences in body size account for much of the protective association between female sex and AF. These data underscore the importance of AF prevention in women.

Temporal and geographical trends in women operators of electrophysiology procedures in the United States

BACKGROUND

Cardiac electrophysiology (EP) has few women physicians.

OBJECTIVE

The purpose of this study was to determine temporal and geographical trends in the proportion of women EP operators in the United States.

METHODS

We extracted data from the Medicare Provider Utilization and Payment Database from 2013 to 2019 using procedure codes for atrial fibrillation (AF) ablation, supraventricular tachycardia/atrial flutter (SVT/AFL) ablation, and cardiac device implantation. The Medicare Provider Utilization and Payment Database excludes operators who perform ≤10 procedures annually for a given individual procedure code. The proportion of women operators was compared across the 7-year period.

RESULTS

On average annually between 2013 and 2019, 5% (n = 187) of the 3524 EP operators were women. Procedure-specific analyses demonstrated a similarly low proportion of women EP operators across each procedure type. Despite a 137% increase in the total number of AF ablationists over the 7-year period, the proportion of women remained unchanged (P = .3966). The number of SVT/AFL ablationists and device operators remained constant over time as did the proportion of women operators (P = .9709 and .3583, respectively). In 2019, 10 states (20%) had no women EP operators who performed >10 of any given EP procedure annually, 20 states (39%) had no women who performed >10 of either AF or SVT/AFL ablation procedures annually, and 10 states (20%) had no women device operators who performed >10 of any given type of device implantation annually.

CONCLUSION

Women EP operators remain underrepresented, and the proportion of women is stagnant even in areas of major clinical growth such as AF ablation. One-fifth of states had no women operators who performed >10 of any given EP procedure annually.

Life-Years Lost After Newly Diagnosed Atrial Fibrillation in Patients with Heart Failure

Objective

Prior work estimated excess death rates associated with atrial fibrillation (AF) in heart failure (HF) with hazard ratios (HR). The aim was to estimate the life-years lost after newly diagnosed AF in HF patients.

Methods

Among patients diagnosed with HF in 2008–2018 in the nationwide Danish Heart Failure Registry, we compared patients with incident AF to referents matched on age, sex, and time since HF. We estimated the marginal hazard ratio (HR) for death and marginal difference in restricted mean survival times (RMST) between AF cases and referents at 10 years after AF diagnosis. We adjusted for sex, age at AF diagnosis, clinical and lifestyle risk factors, and medications.

Results

Among 4463 AF cases and 17,792 referents (mean age 73.7 years, 29% women), the HR was 1.41 (95% CI 1.38; 1.44) but there was evidence of non-proportional hazards. The difference in RMST was −18.2 months (95% CI −16.8; −19.6) at 10 years after AF diagnosis. There were differences in life-years lost between patients diagnosed with AF >1 year and ≤1 year after HF (−25.7 months, 95% CI −23.7; −27.7 vs −10.4 months, 95% CI −8.2; −12.5, p < 0.001), women and men (−20.3 months, 95% CI −17.7; −21.9 vs −17.2 months, 95% CI −15.5; −19.0, p = 0.05), patients with low, medium, and high CHA₂DS₂-VASc (10.3 months, 95% CI −4.6; −16.1 vs −18.5 months, 95% CI −16.7; −20.4 vs 22.1, 95% CI −18.8; −22.3, p = 0.002).

Conclusion

HF patients with incident AF lost on average 1.5 life-years over 10 years after AF. Life-years lost were larger among patients diagnosed with AF >1 year after HF, women, and patients with higher CHA₂DS₂-VASc.

The Influence of Atrial Fibrillation on In-Hospital Mortality in People with Hospital-Acquired Pneumonia: An Observational, Sex-Stratified Study

(1) Background: The study aimed to analyze the influence of atrial fibrillation (AF) prior to hospital admission (“prevalent”) and new-onset AF diagnosed during hospital admission (“incident”) on in-hospital mortality (IHM) in women and men who developed hospital-acquired pneumonia (HAP) in Spain (2016−2019). (2) Methods: We used the Spanish Register of Specialized Care-Basic Minimum Database. (3) Results: We analyzed 38,814 cases of HAP (34.6% women; 13.5% ventilator-associated). Prevalent AF was coded in 19.9% (n = 7742), and incident AF in 5.5% (n = 2136) of HAP. Crude IHM was significantly higher for prevalent AF (34.22% vs. 27.35%, p < 0.001) and for incident AF (35.81% vs. 28.31%, p < 0.001) compared to no AF. After propensity score matching, IHM among women and men with prevalent AF was higher than among women and men with no AF (among women, 32.89% vs. 30.11%, p = 0.021; among men, 35.05% vs. 32.46%, p = 0.008). Similarly, IHM among women and men with incident AF was higher than among women and men with no AF (among women, 36.23% vs. 29.90%, p = 0.013; among men, 35.62% vs. 30.47%; p = 0.003). Sex was associated with a higher IHM only in people with incident AF (for female, OR = 1.21; 95% CI: 1.01−1.57). (4) Conclusions: Both prevalent and incident AF were associated with higher IHM in people who developed HAP. Female sex was associated with a higher IHM in incident AF.