Greater attention to stroke and heart failure prevention strategies is required for patients with atrial fibrillation, with little improvement in the rates of these complications following a diagnosis over the last two decades, a study suggests.
The researchers identified that heart failure was the most frequent complication of atrial fibrillation with a lifetime risk of 41.2%, which was twice as high as stroke despite the historic focus on stroke in international guidelines.
The study, published in The BMJ [link here] and drawing from registry analyses of 3.5 million adults in Denmark, showed the lifetime atrial fibrillation risk increased from one in four people to one in three over the past two decades.
Participants with no history of atrial fibrillation at age 45 or older were followed over a 23 year period to determine who would go on to develop atrial fibrillation.
All 362,721 individuals with a new diagnosis of atrial fibrillation during this time (46% women and 54% men) but with no complications were subsequently followed until a diagnosis of heart failure, stroke or myocardial infection.
Potentially influential factors such as history of high blood pressure, diabetes, high cholesterol, heart failure, chronic lung and kidney disease, family income and educational attainment, were also taken into account.
Findings showed that the lifetime risk of atrial fibrillation increased from 24% in 2000-10 to 31% in 2011-22, with an absolute difference of 6.7%.
The increase was slightly higher among men and individuals with a history of heart failure, myocardial infarction, stroke, diabetes, and chronic kidney disease.
Among those with atrial fibrillation, the most common complication was heart failure with a lifetime risk showing little improvement over the 23-year period, 43% in 2000-10 and 42% in 2011-22.
This was twice as large as the lifetime risk of any stroke (21%) and four times greater than the lifetime risk of myocardial infarction (12%), the researchers noted.
There were also only slight 4-5% decreases in the lifetime risks of any stroke, ischaemic stroke, and myocardial infarction after atrial fibrillation, which were similar between the sexes, over the two decades.
Men showed a higher lifetime risk of complications after atrial fibrillation compared with women for heart failure (44% vs 33%) and myocardial infarction (12% vs 10%), while the lifetime risk of stroke after atrial fibrillation was slightly lower in men than in women (21% vs 23%).
Study limitations included potential missed diagnoses, lack of generalisability to other countries or settings and lack of information on ethnicity or lifestyle factors.
In an accompanying editorial [link here], UK researchers said interventions to prevent stroke have dominated atrial fibrillation research and guidelines, but no evidence suggested that these interventions could prevent incident heart failure.
“The neglect of heart failure as a complication of atrial fibrillation in international guidelines is conspicuous because, similar to stroke, heart failure is associated with functional limitations, decreased quality of life, and poor prognosis, and the subpopulation who have both atrial fibrillation and heart failure have a significantly increased risk of cardiovascular and all cause mortality,” they wrote.
They said further improvements to patient prognosis likely required a “broader perspective on atrial fibrillation management beyond prevention of stroke”.