Worldwide Epidemiology of Atrial Fibrillation: A Global Burden of Disease 2010 Study Sumeet S. Chugh, Rasmus Havmoeller, Kumar Narayanan, David Singh, Michiel Rienstra, Emelia J. Benjamin, Richard F. Gillum, Young-Hoon Kim, John H. McAnulty, Jr, Zhi-Jie Zheng, Mohammad H. Forouzanfar, Mohsen Naghavi, George A. Mensah, Majid Ezzati and Christopher J.L. Murray Circulation. 2014;129:837-847; originally published online December 17, 2013; doi: 10.1161/CIRCULATIONAHA.113.005119 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2013 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
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Arrhythmia/Electrophysiology Worldwide Epidemiology of Atrial Fibrillation A Global Burden of Disease 2010 Study Sumeet S. Chugh, MD; Rasmus Havmoeller, MD, PhD; Kumar Narayanan, MD; David Singh, MD; Michiel Rienstra, MD, PhD; Emelia J. Benjamin, MD, ScM; Richard F. Gillum, MD; Young-Hoon Kim, MD; John H. McAnulty, Jr, MD; Zhi-Jie Zheng, MD, PhD; Mohammad H. Forouzanfar, MD; Mohsen Naghavi, MD; George A. Mensah, MD; Majid Ezzati, PhD; Christopher J.L. Murray, MD Background—The global burden of atrial fibrillation (AF) is unknown. Methods and Results—We systematically reviewed population-based studies of AF published from 1980 to 2010 from the 21 Global Burden of Disease regions to estimate global/regional prevalence, incidence, and morbidity and mortality related to AF (DisModMR software). Of 377 potential studies identified, 184 met prespecified eligibility criteria. The estimated number of individuals with AF globally in 2010 was 33.5 million (20.9 million men [95% uncertainty interval (UI), 19.5–22.2 million] and 12.6 million women [95% UI, 12.0–13.7 million]). Burden associated with AF, measured as disability-adjusted life-years, increased by 18.8% (95% UI, 15.8–19.3) in men and 18.9% (95% UI, 15.8–23.5) in women from 1990 to 2010. In 1990, the estimated age-adjusted prevalence rates of AF (per 100 000 population) were 569.5 in men (95% UI, 532.8–612.7) and 359.9 in women (95% UI, 334.7–392.6); the estimated age-adjusted incidence rates were 60.7 per 100 000 person-years in men (95% UI, 49.2–78.5) and 43.8 in women (95% UI, 35.9–55.0). In 2010, the prevalence rates increased to 596.2 (95% UI, 558.4–636.7) in men and 373.1 (95% UI, 347.9–402.2) in women; the incidence rates increased to 77.5 (95% UI, 65.2–95.4) in men and 59.5 (95% UI, 49.9–74.9) in women. Mortality associated with AF was higher in women and increased by 2-fold (95% UI, 2.0–2.2) and 1.9-fold (95% UI, 1.8–2.0) in men and women, respectively, from 1990 to 2010. There was evidence of significant regional heterogeneity in AF estimations and availability of population-based data. Conclusions—These findings provide evidence of progressive increases in overall burden, incidence, prevalence, and AF-associated mortality between 1990 and 2010, with significant public health implications. Systematic, regional surveillance of AF is required to better direct prevention and treatment strategies. (Circulation. 2014;129:837-847.) Key Words: atrial fibrillation ◼ epidemiology ◼ incidence ◼ prevalence ◼ risk factors, prevention
A
trial fibrillation (AF) is the most common arrhythmia of clinical significance.1 In adjusted models, AF is associated with increased morbidity, especially stroke and heart failure, and increased mortality.2–5 AF constitutes a significant public health problem, and estimates suggest that this condition accounts for 1% of the National Health Service budget in the United Kingdom6 and $16 to 26 billion of annual US expenses.7,8
Editorial see p 829 Clinical Perspective on p 847
Several regional studies suggest a rising prevalence and incidence of AF.9–13 These secular trends may be explained in part by the demographic transition to an inverted age pyramid because frequency of AF increases with advancing age. Others have demonstrated an increase in AF incidence after age adjustment, which is probably a reflection of comorbidities and cardiovascular risk factors, in addition to other factors such as lifestyle changes.14,15 In the United States, it is estimated that the number of adults with AF will more than double by the year 2050;16 even higher increases have been predicted.14
Received July 22, 2013; accepted November 12, 2013. From the Cedars-Sinai Heart Institute, Los Angeles, CA (S.S.C., R.H., K.N., D.S.); Karolinska Institute, Stockholm, Sweden (R.H.); University of Groningen, University Medical Center Groningen, Groningen, the Netherlands (M.R.); Framingham Heart Study and Boston University School of Medicine and Public Health, Boston, MA (E.J.B.); Department of Medicine, Howard University College of Medicine, Washington, DC (R.F.G.); Korea University College of Medicine, Seoul, Republic of Korea (Y.-H.K.); Legacy Good Samaritan Medical Center, Portland, OR (J.H.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (Z.-J.Z., G.A.M.); Institute for Health Metrics and Evaluation, University of Washington, Seattle (M.H.F., M.N., C.J.L.M.); and Harvard School of Public Health, Boston, MA (M.E.). Guest Editor for this article was Mercedes Carnethon, PhD. The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA. 113.005119/-/DC1. Correspondence to Sumeet S. Chugh, MD, The Heart Institute, AHSP Ste A3300, Cedars-Sinai Medical Center, 127 S San Vicente Blvd, Los Angeles, CA 90048. E-mail [email protected] © 2013 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.113.005119
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838 Circulation February 25, 2014 In view of the emergence of AF as a growing epidemic,15,17 an assessment of the global burden of AF is warranted. We therefore conducted a comparative assessment of the burden of AF across defined time periods based on available epidemiological data from the 21 Global Burden of Disease (GBD) regions.
Methods The GBD Study Our analysis was performed within the framework of the latest Global Burden of Disease, Injuries, and Risk Factors Study (GBD 2010 Study).18 The GBD 2010 Study is a collaborative effort led by a consortium that includes Harvard University, the Institute for Health Metrics and Evaluation at the University of Washington, Johns Hopkins University, the University of Queensland, the University of Tokyo, Imperial College London, and the World Health Organization. It follows on the original GBD 1990 Study commissioned by the World Bank in 1991 and aims to systematically assess global data on all diseases and injuries. GBD 2010 provides a common instrument for assessing mortality and morbidity. The goal was to provide comparable estimates at different time periods with analysis of secular trends. Detailed information about the data, techniques, and methods for estimation of different disease parameters has been published elsewhere.19–21
Search Strategy and Data Sources As a subcommittee of the GBD 2010 Committee on Cardiovascular Disease and following the GBD 2010 protocol, the GBD Arrhythmias Panel performed a systematic review of the available literature (Appendix I in the online-only Data Supplement) to identify epidemiological studies of AF (1980–2010) that were population based. For the initial identification of published studies, we used the following search terms: atrial fibrillation, atrial flutter, epidemiology, incidence, prevalence, mortality, and case fatality rate. MEDLINE, EMBASE, and LILACS were queried for studies published between 1980 and 2010 (for LILACS, the time period was 1982–2010). There were no restrictions based on language of publication. Details of the search are outlined in Appendix II in the online-only Data Supplement. The initial search (phase 1) generated abstracts that were reviewed (phase 2) on the basis of prespecified inclusion and exclusion criteria (Appendix III in the online-only Data Supplement). Whereas all studies on AF epidemiology in the general population were included, studies conducted on selected clinical subgroups such as inpatients or those with heart failure were excluded to arrive at accurate estimates of AF burden at a population-wide level. The selected abstracts underwent full text reviews (phase 3) to confirm eligibility, generating
a final list of publications selected for abstraction. Each publication was assigned to 1 of 21 epidemiological regions as designated in GBD 2005. To minimize potential bias resulting from inconsistent case definitions of AF, all published studies of paroxysmal, persistent, or permanent/chronic AF and atrial flutter were included.
Statistical Methods Incidence rate was defined as the annual number of new cases with AF divided by the population at midyear. Prevalence rate was defined as the overall number of cases with the total population as denominator. Prevalence and incidence rates were age adjusted. Rates were presented per 100 000 persons or person-years with 95% uncertainty intervals (UIs). The denominators were derived from the United Nations population database (http://www.un.org/esa/population/), and classifications of countries, regions, and groups (eg, developed and developing countries) followed the definitions of the World Bank (http://data.worldbank.org/about/country-classifications) and GBD core team decisions.22
Modeling of AF as a Cause of Death Mortality associated with AF was estimated by use of an integrated method, with information on several country-level covariates used to inform the analysis.19 All combinations of the covariates with a significant coefficient (P75, Diabetes mellitus, and prior Stroke or transient ischemic attack (CHADS2) risk stratification scheme. Am Heart J 2008 July;156(1):57-64. Gandolfo C, Balestrino M, Burrone A, Del SM, Finocchi C. Stroke due to atrial fibrillation and the attitude to prescribing anticoagulant prevention in Italy. A prospective study of a consecutive stroke population
admitted to a comprehensive stroke unit. J Neurol 2008
Cameron AC, Jenkins SM, Dunn FG. The burden of atrial fibrillation in unselected acute medical admissions. Scott Med J 2008 May;53(2):42-7. Borzecki AM, Bridgers DK, Liebschutz JM, Kader B, Kazis LE, Berlowitz DR. Racial differences in the prevalence of atrial fibrillation among males. J Natl Med Assoc 2008 February;100(2):237-45. Lip GY, Frison L, Grind M. Stroke event rates in anticoagulated patients with paroxysmal atrial fibrillation. J Intern Med 2008 July;264(1):50-61. Guize L, Thomas F, Bean K, Benetos A, Pannier B. [Atrial fibrillation: prevalence, risk factors and mortality in a large French population with 15 years of follow-up]. Bull Acad Natl Med 2007 April;191(4-5):791-803. Kannel WB, Benjamin EJ. Status of the epidemiology of atrial fibrillation. Med Clin North Am 2008 January;92(1):17-40, ix Dabdoob WA, Bener A, Al-Mohannadi D, Numan MT, Al-Binali HA, Al-Suwaidi J. Epidemiology of atrial fibrillation among Qatari patients admitted with various cardiovascular disorder. A population-based study. Saudi Med J 2007 September;28(9):1457-9. Lee CH, Liu PY, Tsai LM et al. Characteristics of hospitalized patients with atrial fibrillation in Taiwan: a nationwide observation. Am J Med 2007 September;120(9):819-7. Cea-Calvo L, Redon J, Lozano JV et al. [Prevalence of atrial fibrillation in the Spanish population aged 60 years or more. The PREV-ICTUS study]. Rev Esp Cardiol 2007 June;60(6):616-24.
Hylek EM, Evans-Molina C, Shea C, Henault LE, Regan S. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation 2007 May 29;115(21):2689-96. McDonald AJ, Pelletier AJ, Ellinor PT, Camargo CA, Jr. Increasing US emergency department visit rates and subsequent hospital admissions for atrial fibrillation from 1993 to 2004. Ann Emerg Med 2008 January;51(1):58-65. Suzuki S, Yamashita T, Kato T et al. Incidence of major bleeding complication of warfarin therapy in Japanese patients with atrial fibrillation. Circ J 2007 May;71(5):761-5. Santini M, Ricci RP. The worldwide social burden of atrial fibrillation: what should be done and where do we go? J Interv Card Electrophysiol 2006 December;17(3):183-8. Chen LY, Shen WK. Epidemiology of atrial fibrillation: a current perspective. Heart Rhythm 2007 March;4(3 Suppl):S1-S6. Uyarel H, Onat A, Yuksel H, Can G, Ordu S, Dursunoglu D. [Incidence, prevalence, and mortality estimates for chronic atrial fibrillation in Turkish adults]. Turk Kardiyol Dern Ars 2008 June;36(4):214-22. Miyasaka Y, Barnes ME, Gersh BJ et al. Changing trends of hospital utilization in patients after their first episode of atrial fibrillation. Am J Cardiol 2008 September 1;102(5):568-72. Origasa H, Goto S, Uchiyama S, Shimada K, Ikeda Y. The Japan Thrombosis Registry for Atrial Fibrillation, Coronary or Cerebrovascular Events (J-TRACE): a nation-wide, prospective large cohort study; the study design. Circ J 2008 June;72(6):991-7. Suzuki S, Yamashita T, Ohtsuka T et al. Prevalence and prognosis of patients with atrial fibrillation in Japan: a prospective cohort of Shinken Database 2004. Circ J
2008 June;72(6):914-20. Iguchi Y, Kimura K, Aoki J et al. Prevalence of atrial fibrillation in community-dwelling Japanese aged 40 years or older in Japan: analysis of 41,436 non-employee residents in Kurashiki-city. Circ J 2008 June;72(6):90913. Yang JF, Liu B, Liu DG, Luo Y, Fang F. Prevalence and risk factors of atrial fibrillation in preterminal inpatients aged 60 years and over. Chin Med J (Engl ) 2008 October;121(20):2046-9. Lakshminarayan K, Anderson DC, Herzog CA, Qureshi AI. Clinical epidemiology of atrial fibrillation and related cerebrovascular events in the United States. Neurologist 2008 May;14(3):143-50. Fang MC, Go AS, Chang Y et al. Death and disability from warfarin-associated intracranial and extracranial hemorrhages. Am J Med 2007 August;120(8):700-5 Yap KB, Ng TP, Ong HY. Low prevalence of atrial fibrillation in community-dwelling Chinese aged 55 years or older in Singapore: a population-based study. J Electrocardiol 2008 March;41(2):94-8. Reynolds MR, Essebag V, Zimetbaum P, Cohen DJ. Healthcare resource utilization and costs associated with recurrent episodes of atrial fibrillation: the FRACTAL registry. J Cardiovasc Electrophysiol 2007 June;18(6):628-33. Miyasaka Y, Barnes ME, Bailey KR et al. Mortality trends in patients diagnosed with first atrial fibrillation: a 21-year community-based study. J Am Coll Cardiol 2007 March 6;49(9):986-92. Frost L, Andersen LV, Vestergaard P, Husted S, Mortensen LS. Trend in mortality after stroke with atrial fibrillation. Am J Med 2007 January;120(1):47-53.
Andersen KK, Olsen TS. Reduced poststroke mortality in patients with stroke and atrial fibrillation treated with anticoagulants: results from a Danish quality-control registry of 22,179 patients with ischemic stroke. Stroke 2007 February;38(2):259-63. Fornari LS, Calderaro D, Nassar IB et al. Misuse of antithrombotic therapy in atrial fibrillation patients: frequent, pervasive and persistent. J Thromb Thrombolysis 2007 February;23(1):65-71. Cheng TO. Global epidemic of atrial fibrillation including China. Int J Cardiol 2007 November 15;122(2):160. Burton C, Isles C, Norrie J, Hanson R, Grubb E. The safety and adequacy of antithrombotic therapy for atrial fibrillation: a regional cohort study. Br J Gen Pract 2006 September;56(530):697-702. Boriani G, Diemberger I, Martignani C, Biffi M, Branzi A. The epidemiological burden of atrial fibrillation: a challenge for clinicians and health care systems. Eur Heart J 2006 April;27(8):893-4. DeWilde S, Carey IM, Emmas C, Richards N, Cook DG. Trends in the prevalence of diagnosed atrial fibrillation, its treatment with anticoagulation and predictors of such treatment in UK primary care. Heart 2006 August;92(8):1064-70. Atar I, Konas D, Acikel S et al. Frequency of atrial fibrillation and factors related to its development in dialysis patients. Int J Cardiol 2006 January 4;106(1):4751. Rho RW, Page RL. Asymptomatic atrial fibrillation. Prog Cardiovasc Dis 2005 September;48(2):79-87. Burkiewicz JS. Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation. Pharmacotherapy 2005
August;25(8):1062-7. Tsang TS, Miyasaka Y, Barnes ME, Gersh BJ. Epidemiological profile of atrial fibrillation: a contemporary perspective. Prog Cardiovasc Dis 2005 July;48(1):1-8. Frost L, Vestergaard P, Mosekilde L, Mortensen LS. Trends in incidence and mortality in the hospital diagnosis of atrial fibrillation or flutter in Denmark, 1980-1999. Int J Cardiol 2005 August 3;103(1):78-84. Go AS. The epidemiology of atrial fibrillation in elderly persons: the tip of the iceberg. Am J Geriatr Cardiol 2005 March;14(2):56-61. Anderson DR, Gardner MJ, Putnam W et al. Populationbased evaluation of the management of antithrombotic therapy for atrial fibrillation. Can J Cardiol 2005 March;21(3):257-66 Jeong JH. Prevalence of and risk factors for atrial fibrillation in Korean adults older than 40 years. J Korean Med Sci 2005 February;20(1):26-30. de LS, van VJ, Hague N, Thana L, Dzregah B, Chan T. Preventing stroke in people with atrial fibrillation: a cross-sectional study. J Public Health (Oxf) 2005 March;27(1):85-92. Dang D, Patel R, Haywood LJ. Atrial fibrillation in a multiethnic inpatient population of a large public hospital. J Natl Med Assoc 2004 November;96(11):143844. Candel FJ, Matesanz M, Cogolludo F et al. [Prevalence of atrial fibrillation and relationed factors in a population in the centre Madrid]. An Med Interna 2004 October;21(10):477-82. Conway DS, Lip GY. Ethnicity in relation to atrial fibrillation and stroke (the West Birmingham Stroke
Project). Am J Cardiol 2003 December 15;92(12):1476-9. Bordin P, Mazzone C, Pandullo C, Goldstein D, Scardi S. Morbidity and mortality in 229 elderly patients with nonrheumatic atrial fibrillation. A five-year follow-up. Ital Heart J 2003 August;4(8):537-43. Buechner JS. Deaths and hospitalizations related to atrial fibrillation, 1999-2001. Med Health R I 2003 June;86(6):183-5. Tsang TS, Petty GW, Barnes ME et al. The prevalence of atrial fibrillation in incident stroke cases and matched population controls in Rochester, Minnesota: changes over three decades. J Am Coll Cardiol 2003 July 2;42(1):93-100. Atrial fibrillation as a contributing cause of death and Medicare hospitalization--United States, 1999. MMWR Morb Mortal Wkly Rep 2003 February 21;52(7):128, 13028, 131. Thomson R. How can epidemiological studies help us to prevent stroke? The example of atrial fibrillation. Age Ageing 2002 November;31 Suppl 3:9-16.:9-16. Sack S. [Epidemiology of atrial fibrillation]. Herz 2002 June;27(4):294-300. Ageno W, Ambrosini F, Nardo B et al. Atrial fibrillation and antithrombotic treatment in Italian hospitalized patients: a prospective, observational study. J Thromb Thrombolysis 2001 December;12(3):225-30. Carroll K, Majeed A. Comorbidity associated with atrial fibrillation: a general practice-based study. Br J Gen Pract 2001 November;51(472):884-91. Gonzalez-Peredo R, Munoz-Esteban C, mado-Fernandez C, Riancho JA. [Known and concealed auricular fibrillation in the population consulting in a health area]. Aten Primaria 2007 February;39(2):106-7.
Murphy NF, Simpson CR, Jhund PS et al. A national survey of the prevalence, incidence, primary care burden and treatment of atrial fibrillation in Scotland. Heart 2007 May;93(5):606-12. Gersh BJ, Tsang TS, Seward JB. The changing epidemiology and natural history of nonvalvular atrial fibrillation: clinical implications. Trans Am Clin Climatol Assoc 2004;115:149-60.:149-60. Roquer J, Rodriguez-Campello A, Gomis M et al. Comparison of the impact of atrial fibrillation on the risk of early death after stroke in women versus men. J Neurol 2006 November;253(11):1484-9. Lewalter T. [Epidemiology of atrial fibrillation and relevance of underlying cardiovascular disease]. Dtsch Med Wochenschr 2006 August 25;131(34-35 Suppl 4):S99-102. Cheng HY. Is age a risk factor for warfarin-related major bleeds in elderly patients with atrial fibrillation? J Am Geriatr Soc 2006 July;54(7):1155. Miyasaka Y, Barnes ME, Gersh BJ et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 2006 July 11;114(2):119-25. Lakshminarayan K, Solid CA, Collins AJ, Anderson DC, Herzog CA. Atrial fibrillation and stroke in the general medicare population: a 10-year perspective (1992 to 2002). Stroke 2006 August;37(8):1969-74. Frost L, Vukelic AL, Mortensen LS, Dethlefsen C. Seasonal variation in stroke and stroke-associated mortality in patients with a hospital diagnosis of nonvalvular atrial fibrillation or flutter. A populationbased study in Denmark. Neuroepidemiology 2006;26(4):220-5. Ref ID: 1187
Frost L, Vukelic AL, Vestergaard P, Husted S, Mortensen LS. Trends in risk of stroke in patients with a hospital diagnosis of nonvalvular atrial fibrillation: National Cohort Study in Denmark, 1980-2002. Neuroepidemiology 2006;26(4):212-9. Bush D, Martin LW, Leman R, Chandler M, Haywood LJ. Atrial fibrillation among African Americans, Hispanics and Caucasians: clinical features and outcomes from the AFFIRM trial. J Natl Med Assoc 2006 March;98(3):330-9. Heeringa J, van der Kuip DA, Hofman A et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J 2006 April;27(8):949-53. Swanson DR. Atrial fibrillation in athletes: implicit literature-based connections suggest that overtraining and subsequent inflammation may be a contributory mechanism. Med Hypotheses 2006;66(6):1085-92. Ref ID: 1224 Sojo L, Corcoy R. Seasonal variation in morbidity and mortality related to atrial fibrillation--could thyroid function contribute? Int J Cardiol 2006 February 15;107(2):281. Ref ID: 1244 Miyasaka Y, Barnes ME, Gersh BJ et al. Incidence and mortality risk of congestive heart failure in atrial fibrillation patients: a community-based study over two decades. Eur Heart J 2006 April;27(8):936-41. Ref ID: 1248 Keating RJ, Gersh BJ, Hodge DO et al. Effect of atrial fibrillation pattern on survival in a community-based cohort. Am J Cardiol 2005 November 15;96(10):1420-4. Wen-Hang QI. Retrospective investigation of hospitalised patients with atrial fibrillation in mainland China. Int J Cardiol 2005 December 7;105(3):283-7.
Fuster V. Atrial fibrillation: an epidemiologic, scientific and clinical challenge. Nat Clin Pract Cardiovasc Med 2005 May;2(5):225 Miyasaka Y, Barnes ME, Gersh BJ et al. Time trends of ischemic stroke incidence and mortality in patients diagnosed with first atrial fibrillation in 1980 to 2000: report of a community-based study. Stroke 2005 November;36(11):2362-6. Hohler H. [Atrial fibrillation]. Med Klin (Munich) 2005 October 15;100(10):636-49. Habibzadeh F, Yadollahie M, Roshanipoor M, Haghighi AB. Prevalence of atrial fibrillation in a primary health care centre in Fars Province, Islamic Republic of Iran. East Mediterr Health J 2004 January;10(1-2):147-51. Ohsawa M, Okayama A, Sakata K et al. Rapid increase in estimated number of persons with atrial fibrillation in Japan: an analysis from national surveys on cardiovascular diseases in 1980, 1990 and 2000. J Epidemiol 2005 September;15(5):194-6. Fang MC, Singer DE, Chang Y et al. Gender differences in the risk of ischemic stroke and peripheral embolism in atrial fibrillation: the AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) study. Circulation 2005 September;112(12):1687-91. Flaker GC, Belew K, Beckman K et al. Asymptomatic atrial fibrillation: demographic features and prognostic information from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Am Heart J 2005 April;149(4):657-63. Marini C, De SF, Sacco S et al. Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study. Stroke 2005 June;36(6):1115-9. Alpert JS. Atrial fibrillation: now one of the most common causes for hospitalization. Curr Cardiol Rep
2005 May;7(3):149-50. Kerr CR, Humphries KH, Talajic M et al. Progression to chronic atrial fibrillation after the initial diagnosis of paroxysmal atrial fibrillation: results from the Canadian Registry of Atrial Fibrillation. Am Heart J 2005 March;149(3):489-96. Ref ID: 1396 Ridha M, Al-Sayed AA, Saleh SA et al. The prevalence of atrial fibrillation among acute medical admissions in Kuwait. Med Princ Pract 2005 May;14(3):136-9. Kimura K, Minematsu K, Yamaguchi T. Atrial fibrillation as a predictive factor for severe stroke and early death in 15,831 patients with acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2005 May;76(5):679-83 Scalvini S, Piepoli M, Zanelli E, Volterrani M, Giordano A, Glisenti F. Incidence of atrial fibrillation in an Italian population followed by their GPs through a telecardiology service. Int J Cardiol 2005 February 15;98(2):215-20. Stewart S, MacIntyre K, MacLeod MM, Bailey AE, Capewell S, McMurray JJ. Trends in hospital activity, morbidity and case fatality related to atrial fibrillation in Scotland, 1986--1996. Eur Heart J 2001 April;22(8):693701. Sra J, Dhala A, Blanck Z, Deshpande S, Cooley R, Akhtar M. Atrial fibrillation: epidemiology, mechanisms, and management. Curr Probl Cardiol 2000 July;25(7):405-524 Ryder KM, Benjamin EJ. Epidemiology and significance of atrial fibrillation. Am J Cardiol 1999 November 4;84(9A):131R-8R. Iacovino JR. Mortality of atrial fibrillation in a population selected to be free of major cardiovascular impairments. J
Insur Med 1999;31(1):8-12. Bozinovic S, Vojvodic N, Stajkovic Z. [Atrial fibrillation in a defined population of elderly persons]. Vojnosanit Pregl 1999 January;56(1):21-5. Viitaniemi M, Eskola K, Kurunmaki H et al. Anticoagulant treatment of patients with atrial fibrillation in primary health care. Scand J Prim Health Care 1999 March;17(1):59-63. Kannel WB, Wolf PA, Benjamin EJ, Levy D. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol 1998 October 16;82(8A):2N-9N Guedon-Moreau L, Kouakam C, Kacet S. [Epidemiology of paroxysmal auricular fibrillation]. Arch Mal Coeur Vaiss 1998 January;91(1):67-71. Benjamin EJ, Wolf PA, D'Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation 1998 September 8;98(10):946-52. Perings C, Hennersdorf M, Vester EG, Weirich J, Strauer BE. [Pathophysiology, epidemiology and complications of atrial fibrillation]. Internist (Berl) 1998 January;39(1):2-11. Camm AJ, Obel OA. Epidemiology and mechanism of atrial fibrillation and atrial flutter. Am J Cardiol 1996 October 17;78(8A):3-11 Mitra R, Leatham EW. Admissions with atrial fibrillation: disease patterns and outcomes in a District General Hospital. QJM 2005 February;98(2):153-4. Lewalter T, Luderitz B. Atrial fibrillation: mortality, morbidity, and money; is that all? Importance and variability of burden measurement. Eur Heart J 2005 January;26(2):110-1
Patel PJ, Keating RJ, Gersh BJ, Hodge DO, Hammill SC, Shen WK. Outcome of patients with newly diagnosed atrial fibrillation at the Mayo Clinic and residing in that area. Am J Cardiol 2004 December 1;94(11):1379-82. Clua Espuny JL, mau Llorca MR, Aguilar MC. [Characteristics of oral anti-coagulation treatment in high-risk chronic auricular fibrillation]. Aten Primaria 2004 November 15;34(8):414-9. Friberg J, Scharling H, Gadsboll N, Truelsen T, Jensen GB. Comparison of the impact of atrial fibrillation on the risk of stroke and cardiovascular death in women versus men (The Copenhagen City Heart Study). Am J Cardiol 2004 October 1;94(7):889-94 Murphy NF, Stewart S, MacIntyre K, Capewell S, McMurray JJ. Seasonal variation in morbidity and mortality related to atrial fibrillation. Int J Cardiol 2004 November;97(2):283-8. Ref ID: 1613 Inoue H. Under-use of warfarin for patients with nonvalvular atrial fibrillation in Japan. Intern Med 2004 July;43(7):529-30. Khairallah F, Ezzedine R, Ganz LI, London B, Saba S. Epidemiology and determinants of outcome of admissions for atrial fibrillation in the United States from 1996 to 2001. Am J Cardiol 2004 August 15;94(4):500-4. Lloyd-Jones DM, Wang TJ, Leip EP et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation 2004 August 31;110(9):1042-6. Zhou ZQ, Hu DY, Chen J, Zhang RH, Li KB, Zhao XL. [An epidemiological survey of atrial fibrillation in China]. Zhonghua Nei Ke Za Zhi 2004 July;43(7):491-4. Humphries KH, Jackevicius C, Gong Y et al. Population rates of hospitalization for atrial fibrillation/flutter in Canada. Can J Cardiol 2004 July;20(9):869-76.
Santini M, De Ferrari GM, Pandozi C et al. Atrial fibrillation requiring urgent medical care. Approach and outcome in the various departments of admission. Data from the atrial Fibrillation/flutter Italian REgistry (FIRE). Ital Heart J 2004 March;5(3):205-13. Stewart S. Epidemiology and economic impact of atrial fibrillation. J Cardiovasc Nurs 2004 March;19(2):94-102. Steinberg JS, Sadaniantz A, Kron J et al. Analysis of cause-specific mortality in the Atrial Fibrillation Followup Investigation of Rhythm Management (AFFIRM) study. Circulation 2004 April 27;109(16):1973-80. Ref ID: 1728 Stewart S, Murphy NF, Walker A, McGuire A, McMurray JJ. Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK. Heart 2004 March;90(3):286-92. Molander U, Dey DK, Sundh V, Steen B. ECG abnormalities in the elderly: prevalence, time and generation trends and association with mortality. Aging Clin Exp Res 2003 December;15(6):488-93. Stollberger C, Chnupa P, Abzieher C et al. Mortality and rate of stroke or embolism in atrial fibrillation during long-term follow-up in the embolism in left atrial thrombi (ELAT) study. Clin Cardiol 2004 January;27(1):40-6. Ref ID: 1762 Le Heuzey JY, Paziaud O, Piot O et al. Cost of care distribution in atrial fibrillation patients: the COCAF study. Am Heart J 2004 January;147(1):121-6. Friberg J, Scharling H, Gadsboll N, Jensen GB. Sexspecific increase in the prevalence of atrial fibrillation (The Copenhagen City Heart Study). Am J Cardiol 2003 December 15;92(12):1419-23. Friberg J, Buch P, Scharling H, Gadsbphioll N, Jensen GB. Rising rates of hospital admissions for atrial
fibrillation. Epidemiology 2003 November;14(6):666-72. Freestone B, Rajaratnam R, Hussain N, Lip GY. Admissions with atrial fibrillation in a multiracial population in Kuala Lumpur, Malaysia. Int J Cardiol 2003 October;91(2-3):233-8. Wattigney WA, Mensah GA, Croft JB. Increasing trends in hospitalization for atrial fibrillation in the United States, 1985 through 1999: implications for primary prevention. Circulation 2003 August 12;108(6):711-6 Johnston JA, Cluxton RJ, Jr., Heaton PC, Guo JJ, Moomaw CJ, Eckman MH. Predictors of warfarin use among Ohio medicaid patients with new-onset nonvalvular atrial fibrillation. Arch Intern Med 2003 July 28;163(14):1705-10 Hu DY, Sun YH, Zhou ZQ et al. [Risk factors for stroke in Chinese with non valvular atrial fibrillation: a casecontrol study]. Zhonghua Nei Ke Za Zhi 2003 March;42(3):157-61. Ref ID: 1883 Gubler D, Martina B, Arpagaus M, Dieterle T. [Quality of anticoagulation management in ambulatory care of patients with atrial fibrillation]. Praxis (Bern 1994;92(21):991-5. Wang TJ, Larson MG, Levy D et al. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation 2003 June 17;107(23):2920-5. Ref ID: 1894 Singh BN. Atrial fibrillation: epidemiologic considerations and rationale for conversion and maintenance of sinus rhythm. J Cardiovasc Pharmacol Ther 2003 June;8 Suppl 1:S13-26.:S13-S26. Mattle HP. Long-term outcome after stroke due to atrial fibrillation. Cerebrovasc Dis 2003;16 Suppl 1:3-8.:3-8.
Cisternino MD, Giaquinto S, Maiolo I, Palma E, Valeriani M, Vittoria E. On the outcome in stroke patients one year later: the role of atrial fibrillation. Eur J Neurol 2003 January;10(1):67-70. Padeletti L, Michelucci A, Colella A et al. [Paroxysmal atrial fibrillation: epidemiology and clinical relevance]. Cardiologia 1999 December;44 Suppl 1(Pt 2):893-5. Vidaillet H, Granada JF, Chyou PH et al. A populationbased study of mortality among patients with atrial fibrillation or flutter. Am J Med 2002 October 1;113(5):365-70. Stewart S, Hart CL, Hole DJ, McMurray JJ. A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/Paisley study. Am J Med 2002 October 1;113(5):359-64 Tomcsanyi J, Somloi M. [Patients admitted with atrial fibrillation to a regional hospital]. Orv Hetil 2002 September 8;143(36):2073-6. Vecht RJ. Epidemiology of atrial fibrillation. Lancet 2002 August 17;360(9332):572. Garcia-Acuna JM, Gonzalez-Juanatey JR, Alegria EE, Gonzalez M, I, Listerri JL. [Permanent atrial fibrillation in heart disease in Spain. The CARDIOTENS study 1999]. Rev Esp Cardiol 2002 September;55(9):943-52. Lew SJ, Lim JK. Stroke prevention in elderly patients with atrial fibrillation. Singapore Med J 2002 April;43(4):198-201. Ceresne L, Upshur RE. Atrial fibrillation in a primary care practice: prevalence and management. BMC Fam Pract 2002 May 24;3:11.:11. Upshaw CB, Jr. Reduced prevalence of atrial fibrillation in black patients compared with white patients attending an urban hospital: an electrocardiographic study. J Natl
Med Assoc 2002 April;94(4):204-8. Wattigney WA, Mensah GA, Croft JB. Increased atrial fibrillation mortality: United States, 1980-1998. Am J Epidemiol 2002 May 1;155(9):819-26. Ruigomez A, Johansson S, Wallander MA, Rodriguez LA. Incidence of chronic atrial fibrillation in general practice and its treatment pattern. J Clin Epidemiol 2002 April;55(4):358-63. Stewart S, MacIntyre K, Chalmers JW et al. Trends in case-fatality in 22968 patients admitted for the first time with atrial fibrillation in Scotland, 1986-1995. Int J Cardiol 2002 March;82(3):229-36. Ruigomez A, Johansson S, Wallander MA, Garcia Rodriguez LA. Risk of mortality in a cohort of patients newly diagnosed with chronic atrial fibrillation. BMC Cardiovasc Disord 2002;2:5. Epub@2002 Feb 26.:5. Wilhelmsen L, Rosengren A, Lappas G. Hospitalizations for atrial fibrillation in the general male population: morbidity and risk factors. J Intern Med 2001 November;250(5):382-9. Frost L, Johnsen SP, Pedersen L et al. Seasonal variation in hospital discharge diagnosis of atrial fibrillation: a population-based study. Epidemiology 2002 March;13(2):211-5. Ref ID: 2075 Labrador Garcia MS, Merino SR, Jimenez DC, Garcia SY, Segura FA, Hernandez LC. [Prevalence of auricular fibrillation in people over 65 years of age in a health area]. Aten Primaria 2001 December;28(10):648-51. Iuliano L, Micheletta F. [Atrial fibrillation. Epidemiology and physiopathology.]. Haematologica 2001 September;86(9 Suppl):1-4.
McCormick D, Gurwitz JH, Goldberg RJ et al. Prevalence and quality of warfarin use for patients with atrial fibrillation in the long-term care setting. Arch Intern Med 2001 November 12;161(20):2458-63. Stewart S, Hart CL, Hole DJ, McMurray JJ. Population prevalence, incidence, and predictors of atrial fibrillation in the Renfrew/Paisley study. Heart 2001 November;86(5):516-21. Masiaa R, Sala J, Marrugat J, Pena A. [Prevalence of atrial fibrillation in the province of Girona, Spain: the REGICOR study]. Rev Esp Cardiol 2001 October;54(10):1240. Majeed A, Moser K, Carroll K. Trends in the prevalence and management of atrial fibrillation in general practice in England and Wales, 1994-1998: analysis of data from the general practice research database. Heart 2001 September;86(3):284-8. Sacco RL, Boden-Albala B, Abel G et al. Race-ethnic disparities in the impact of stroke risk factors: the northern Manhattan stroke study. Stroke 2001 August;32(8):1725-31. Ref ID: 2138 Wandell PE. Five-year mortality in men and women with atrial fibrillation. Scand J Prim Health Care 2001 June;19(2):112-6. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001 June 13;285(22):2864-70. Ref ID: 2154 Humphries KH, Kerr CR, Connolly SJ et al. New-onset atrial fibrillation: sex differences in presentation, treatment, and outcome. Circulation 2001 May 15;103(19):2365-70.
Go AS, Hylek EM, Phillips KA et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001 May 9;285(18):2370-5. Goudevenos JA, Vakalis JN, Giogiakas V et al. An epidemiological study of symptomatic paroxysmal atrial fibrillation in northwest Greece. Europace 1999 October;1(4):226-33. Chugh SS, Blackshear JL, Shen WK, Hammill SC, Gersh BJ. Epidemiology and natural history of atrial fibrillation: clinical implications. J Am Coll Cardiol 2001 February;37(2):371-8. Lip GY, Zarifis J. Atrial fibrillation and stroke in patients admitted to a city centre hospital serving a multiethnic community. Int J Cardiol 2000 September 15;75(23):311-2. Lamassa M, Di CA, Pracucci G et al. Characteristics, outcome, and care of stroke associated with atrial fibrillation in Europe: data from a multicenter multinational hospital-based registry (The European Community Stroke Project). Stroke 2001 February;32(2):392-8. Scardi S, Mazzone C. [Impact of chronic atrial fibrillation on cardiovacular mortality]. Ital Heart J Suppl 2000 September;1(9):1117-22. Tomita F, Kohya T, Sakurai M et al. Prevalence and clinical characteristics of patients with atrial fibrillation: analysis of 20,000 cases in Japan. Jpn Circ J 2000 September;64(9):653-8. Filippi A, Bettoncelli G, Zaninelli A. Detected atrial fibrillation in north Italy: rates, calculated stroke risk and proportion of patients receiving thrombo-prophylaxis. Fam Pract 2000 August;17(4):337-9.
Bhatia A, Sra J. Atrial fibrillation: epidemiology, mechanisms and management. Indian Heart J 2000 March;52(2):129-64. Nakayama T, Yokoyama T, Yoshiike N et al. Population attributable fraction of stroke incidence in middle-aged and elderly people: contributions of hypertension, smoking and atrial fibrillation. Neuroepidemiology 2000 July;19(4):217-26 Scardi S, Mazzone C, Pandullo C, Goldstein D, Di LA, Chersevani D. Mortality and cause of death in patients with chronic non-rheumatic atrial fibrillation after a twoyear follow-up. G Ital Cardiol 1999 June;29(6):637-46. Olsson SB. [Atrial fibrillation--epidemiological and electrophysiological aspects]. Tidsskr Nor Laegeforen 1999 April 30;119(11):1601-4 Levy S, Maarek M, Coumel P et al. Characterization of different subsets of atrial fibrillation in general practice in France: the ALFA study. The College of French Cardiologists. Circulation 1999 June 15;99(23):3028-35. Jouven X, Desnos M, Guerot C, Ducimetiere P. Idiopathic atrial fibrillation as a risk factor for mortality. The Paris Prospective Study I. Eur Heart J 1999 June;20(12):896-9. Stewart FM, Singh Y, Persson S, Gamble GD, Braatvedt GD. Atrial fibrillation: prevalence and management in an acute general medical unit. Aust N Z J Med 1999 February;29(1):51-8. Gersh BJ, Solomon A. Lone atrial fibrillation: epidemiology and natural history. Am Heart J 1999 April;137(4 Pt 1):592-5 Shatoor AS, Ahmed ME, Said MA, Shabbir K, Cheema A, Kardash MO. Patterns of atrial fibrillation at a regional hospital in Saudi Arabia. Ethn Dis 1998;8(3):360-6.
Sudlow M, Thomson R, Thwaites B, Rodgers H, Kenny RA. Prevalence of atrial fibrillation and eligibility for anticoagulants in the community. Lancet 1998 October 10;352(9135):1167-71 Lip GY, Bawden L, Hodson R, Rutland E, Snatchfold J, Beevers DG. Atrial fibrillation amongst the Indo-Asian general practice population. The West Birmingham Atrial Fibrillation Project. Int J Cardiol 1998 July 1;65(2):18792. Wolf PA, Mitchell JB, Baker CS, Kannel WB, D'Agostino RB. Impact of atrial fibrillation on mortality, stroke, and medical costs. Arch Intern Med 1998 February 9;158(3):229-34. Psaty BM, Manolio TA, Kuller LH et al. Incidence of and risk factors for atrial fibrillation in older adults. Circulation 1997 October 7;96(7):2455-61. Lip GY, Golding DJ, Nazir M, Beevers DG, Child DL, Fletcher RI. A survey of atrial fibrillation in general practice: the West Birmingham Atrial Fibrillation Project. Br J Gen Pract 1997 May;47(418):285-9 Zarifis J, Beevers G, Lip GY. Acute admissions with atrial fibrillation in a British multiracial hospital population. Br J Clin Pract 1997 March;51(2):91-6. Langenberg M, Hellemons BS, van Ree JW et al. Atrial fibrillation in elderly patients: prevalence and comorbidity in general practice. BMJ 1996 December 14;313(7071):1534. Aronow WS, Ahn C, Gutstein H. Prevalence of atrial fibrillation and association of atrial fibrillation with prior and new thromboembolic stroke in older patients. J Am Geriatr Soc 1996 May;44(5):521-3. Wolf PA, Benjamin EJ, Belanger AJ, Kannel WB, Levy D, D'Agostino RB. Secular trends in the prevalence of atrial fibrillation: The Framingham Study. Am Heart J
1996 April;131(4):790-5. Krahn AD, Manfreda J, Tate RB, Mathewson FA, Cuddy TE. The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba Follow-Up Study. Am J Med 1995 May;98(5):476-84. Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Arch Intern Med 1995 March 13;155(5):469-73. Scardi S, Mazzone C, Goldstein D et al. [SFAAT: the study of nonrheumatic chronic atrial fibrillation in the Trieste area. Results of an enrollment study]. G Ital Cardiol 1995 February;25(2):173-82. Kaushal SS, DasGupta DJ, Prashar BS, Bhardwaj AK. Electrocardiographic manifestations of healthy residents of a tribal Himalayan village. J Assoc Physicians India 1995 January;43(1):15-6.
Covariates and external validity of the ensemble model
SUPPLEMENTAL TABLES Supplemental Table 1a. Estimated age-standardized prevalence rates of Atrial Fibrillation with 95% Uncertainty Intervals (per 100,000) for all 21 GBD regions for males and females: 2010 Males
35+ years
20+ years
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Arrhythmia/Electrophysiology Worldwide Epidemiology of Atrial Fibrillation A Global Burden of Disease 2010 Study Sumeet S. Chugh, MD; Rasmus Havmoeller, MD, PhD; Kumar Narayanan, MD; David Singh, MD; Michiel Rienstra, MD, PhD; Emelia J. Benjamin, MD, ScM; Richard F. Gillum, MD; Young-Hoon Kim, MD; John H. McAnulty, Jr, MD; Zhi-Jie Zheng, MD, PhD; Mohammad H. Forouzanfar, MD; Mohsen Naghavi, MD; George A. Mensah, MD; Majid Ezzati, PhD; Christopher J.L. Murray, MD Background—The global burden of atrial fibrillation (AF) is unknown. Methods and Results—We systematically reviewed population-based studies of AF published from 1980 to 2010 from the 21 Global Burden of Disease regions to estimate global/regional prevalence, incidence, and morbidity and mortality related to AF (DisModMR software). Of 377 potential studies identified, 184 met prespecified eligibility criteria. The estimated number of individuals with AF globally in 2010 was 33.5 million (20.9 million men [95% uncertainty interval (UI), 19.5–22.2 million] and 12.6 million women [95% UI, 12.0–13.7 million]). Burden associated with AF, measured as disability-adjusted life-years, increased by 18.8% (95% UI, 15.8–19.3) in men and 18.9% (95% UI, 15.8–23.5) in women from 1990 to 2010. In 1990, the estimated age-adjusted prevalence rates of AF (per 100 000 population) were 569.5 in men (95% UI, 532.8–612.7) and 359.9 in women (95% UI, 334.7–392.6); the estimated age-adjusted incidence rates were 60.7 per 100 000 person-years in men (95% UI, 49.2–78.5) and 43.8 in women (95% UI, 35.9–55.0). In 2010, the prevalence rates increased to 596.2 (95% UI, 558.4–636.7) in men and 373.1 (95% UI, 347.9–402.2) in women; the incidence rates increased to 77.5 (95% UI, 65.2–95.4) in men and 59.5 (95% UI, 49.9–74.9) in women. Mortality associated with AF was higher in women and increased by 2-fold (95% UI, 2.0–2.2) and 1.9-fold (95% UI, 1.8–2.0) in men and women, respectively, from 1990 to 2010. There was evidence of significant regional heterogeneity in AF estimations and availability of population-based data. Conclusions—These findings provide evidence of progressive increases in overall burden, incidence, prevalence, and AF-associated mortality between 1990 and 2010, with significant public health implications. Systematic, regional surveillance of AF is required to better direct prevention and treatment strategies. (Circulation. 2014;129:837-847.) Key Words: atrial fibrillation ◼ epidemiology ◼ incidence ◼ prevalence ◼ risk factors, prevention
A
trial fibrillation (AF) is the most common arrhythmia of clinical significance.1 In adjusted models, AF is associated with increased morbidity, especially stroke and heart failure, and increased mortality.2–5 AF constitutes a significant public health problem, and estimates suggest that this condition accounts for 1% of the National Health Service budget in the United Kingdom6 and $16 to 26 billion of annual US expenses.7,8
Editorial see p 829 Clinical Perspective on p 847
Several regional studies suggest a rising prevalence and incidence of AF.9–13 These secular trends may be explained in part by the demographic transition to an inverted age pyramid because frequency of AF increases with advancing age. Others have demonstrated an increase in AF incidence after age adjustment, which is probably a reflection of comorbidities and cardiovascular risk factors, in addition to other factors such as lifestyle changes.14,15 In the United States, it is estimated that the number of adults with AF will more than double by the year 2050;16 even higher increases have been predicted.14
Received July 22, 2013; accepted November 12, 2013. From the Cedars-Sinai Heart Institute, Los Angeles, CA (S.S.C., R.H., K.N., D.S.); Karolinska Institute, Stockholm, Sweden (R.H.); University of Groningen, University Medical Center Groningen, Groningen, the Netherlands (M.R.); Framingham Heart Study and Boston University School of Medicine and Public Health, Boston, MA (E.J.B.); Department of Medicine, Howard University College of Medicine, Washington, DC (R.F.G.); Korea University College of Medicine, Seoul, Republic of Korea (Y.-H.K.); Legacy Good Samaritan Medical Center, Portland, OR (J.H.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (Z.-J.Z., G.A.M.); Institute for Health Metrics and Evaluation, University of Washington, Seattle (M.H.F., M.N., C.J.L.M.); and Harvard School of Public Health, Boston, MA (M.E.). Guest Editor for this article was Mercedes Carnethon, PhD. The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA. 113.005119/-/DC1. Correspondence to Sumeet S. Chugh, MD, The Heart Institute, AHSP Ste A3300, Cedars-Sinai Medical Center, 127 S San Vicente Blvd, Los Angeles, CA 90048. E-mail [email protected] © 2013 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.113.005119
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838 Circulation February 25, 2014 In view of the emergence of AF as a growing epidemic,15,17 an assessment of the global burden of AF is warranted. We therefore conducted a comparative assessment of the burden of AF across defined time periods based on available epidemiological data from the 21 Global Burden of Disease (GBD) regions.
Methods The GBD Study Our analysis was performed within the framework of the latest Global Burden of Disease, Injuries, and Risk Factors Study (GBD 2010 Study).18 The GBD 2010 Study is a collaborative effort led by a consortium that includes Harvard University, the Institute for Health Metrics and Evaluation at the University of Washington, Johns Hopkins University, the University of Queensland, the University of Tokyo, Imperial College London, and the World Health Organization. It follows on the original GBD 1990 Study commissioned by the World Bank in 1991 and aims to systematically assess global data on all diseases and injuries. GBD 2010 provides a common instrument for assessing mortality and morbidity. The goal was to provide comparable estimates at different time periods with analysis of secular trends. Detailed information about the data, techniques, and methods for estimation of different disease parameters has been published elsewhere.19–21
Search Strategy and Data Sources As a subcommittee of the GBD 2010 Committee on Cardiovascular Disease and following the GBD 2010 protocol, the GBD Arrhythmias Panel performed a systematic review of the available literature (Appendix I in the online-only Data Supplement) to identify epidemiological studies of AF (1980–2010) that were population based. For the initial identification of published studies, we used the following search terms: atrial fibrillation, atrial flutter, epidemiology, incidence, prevalence, mortality, and case fatality rate. MEDLINE, EMBASE, and LILACS were queried for studies published between 1980 and 2010 (for LILACS, the time period was 1982–2010). There were no restrictions based on language of publication. Details of the search are outlined in Appendix II in the online-only Data Supplement. The initial search (phase 1) generated abstracts that were reviewed (phase 2) on the basis of prespecified inclusion and exclusion criteria (Appendix III in the online-only Data Supplement). Whereas all studies on AF epidemiology in the general population were included, studies conducted on selected clinical subgroups such as inpatients or those with heart failure were excluded to arrive at accurate estimates of AF burden at a population-wide level. The selected abstracts underwent full text reviews (phase 3) to confirm eligibility, generating
a final list of publications selected for abstraction. Each publication was assigned to 1 of 21 epidemiological regions as designated in GBD 2005. To minimize potential bias resulting from inconsistent case definitions of AF, all published studies of paroxysmal, persistent, or permanent/chronic AF and atrial flutter were included.
Statistical Methods Incidence rate was defined as the annual number of new cases with AF divided by the population at midyear. Prevalence rate was defined as the overall number of cases with the total population as denominator. Prevalence and incidence rates were age adjusted. Rates were presented per 100 000 persons or person-years with 95% uncertainty intervals (UIs). The denominators were derived from the United Nations population database (http://www.un.org/esa/population/), and classifications of countries, regions, and groups (eg, developed and developing countries) followed the definitions of the World Bank (http://data.worldbank.org/about/country-classifications) and GBD core team decisions.22
Modeling of AF as a Cause of Death Mortality associated with AF was estimated by use of an integrated method, with information on several country-level covariates used to inform the analysis.19 All combinations of the covariates with a significant coefficient (P75, Diabetes mellitus, and prior Stroke or transient ischemic attack (CHADS2) risk stratification scheme. Am Heart J 2008 July;156(1):57-64. Gandolfo C, Balestrino M, Burrone A, Del SM, Finocchi C. Stroke due to atrial fibrillation and the attitude to prescribing anticoagulant prevention in Italy. A prospective study of a consecutive stroke population
admitted to a comprehensive stroke unit. J Neurol 2008
Cameron AC, Jenkins SM, Dunn FG. The burden of atrial fibrillation in unselected acute medical admissions. Scott Med J 2008 May;53(2):42-7. Borzecki AM, Bridgers DK, Liebschutz JM, Kader B, Kazis LE, Berlowitz DR. Racial differences in the prevalence of atrial fibrillation among males. J Natl Med Assoc 2008 February;100(2):237-45. Lip GY, Frison L, Grind M. Stroke event rates in anticoagulated patients with paroxysmal atrial fibrillation. J Intern Med 2008 July;264(1):50-61. Guize L, Thomas F, Bean K, Benetos A, Pannier B. [Atrial fibrillation: prevalence, risk factors and mortality in a large French population with 15 years of follow-up]. Bull Acad Natl Med 2007 April;191(4-5):791-803. Kannel WB, Benjamin EJ. Status of the epidemiology of atrial fibrillation. Med Clin North Am 2008 January;92(1):17-40, ix Dabdoob WA, Bener A, Al-Mohannadi D, Numan MT, Al-Binali HA, Al-Suwaidi J. Epidemiology of atrial fibrillation among Qatari patients admitted with various cardiovascular disorder. A population-based study. Saudi Med J 2007 September;28(9):1457-9. Lee CH, Liu PY, Tsai LM et al. Characteristics of hospitalized patients with atrial fibrillation in Taiwan: a nationwide observation. Am J Med 2007 September;120(9):819-7. Cea-Calvo L, Redon J, Lozano JV et al. [Prevalence of atrial fibrillation in the Spanish population aged 60 years or more. The PREV-ICTUS study]. Rev Esp Cardiol 2007 June;60(6):616-24.
Hylek EM, Evans-Molina C, Shea C, Henault LE, Regan S. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation 2007 May 29;115(21):2689-96. McDonald AJ, Pelletier AJ, Ellinor PT, Camargo CA, Jr. Increasing US emergency department visit rates and subsequent hospital admissions for atrial fibrillation from 1993 to 2004. Ann Emerg Med 2008 January;51(1):58-65. Suzuki S, Yamashita T, Kato T et al. Incidence of major bleeding complication of warfarin therapy in Japanese patients with atrial fibrillation. Circ J 2007 May;71(5):761-5. Santini M, Ricci RP. The worldwide social burden of atrial fibrillation: what should be done and where do we go? J Interv Card Electrophysiol 2006 December;17(3):183-8. Chen LY, Shen WK. Epidemiology of atrial fibrillation: a current perspective. Heart Rhythm 2007 March;4(3 Suppl):S1-S6. Uyarel H, Onat A, Yuksel H, Can G, Ordu S, Dursunoglu D. [Incidence, prevalence, and mortality estimates for chronic atrial fibrillation in Turkish adults]. Turk Kardiyol Dern Ars 2008 June;36(4):214-22. Miyasaka Y, Barnes ME, Gersh BJ et al. Changing trends of hospital utilization in patients after their first episode of atrial fibrillation. Am J Cardiol 2008 September 1;102(5):568-72. Origasa H, Goto S, Uchiyama S, Shimada K, Ikeda Y. The Japan Thrombosis Registry for Atrial Fibrillation, Coronary or Cerebrovascular Events (J-TRACE): a nation-wide, prospective large cohort study; the study design. Circ J 2008 June;72(6):991-7. Suzuki S, Yamashita T, Ohtsuka T et al. Prevalence and prognosis of patients with atrial fibrillation in Japan: a prospective cohort of Shinken Database 2004. Circ J
2008 June;72(6):914-20. Iguchi Y, Kimura K, Aoki J et al. Prevalence of atrial fibrillation in community-dwelling Japanese aged 40 years or older in Japan: analysis of 41,436 non-employee residents in Kurashiki-city. Circ J 2008 June;72(6):90913. Yang JF, Liu B, Liu DG, Luo Y, Fang F. Prevalence and risk factors of atrial fibrillation in preterminal inpatients aged 60 years and over. Chin Med J (Engl ) 2008 October;121(20):2046-9. Lakshminarayan K, Anderson DC, Herzog CA, Qureshi AI. Clinical epidemiology of atrial fibrillation and related cerebrovascular events in the United States. Neurologist 2008 May;14(3):143-50. Fang MC, Go AS, Chang Y et al. Death and disability from warfarin-associated intracranial and extracranial hemorrhages. Am J Med 2007 August;120(8):700-5 Yap KB, Ng TP, Ong HY. Low prevalence of atrial fibrillation in community-dwelling Chinese aged 55 years or older in Singapore: a population-based study. J Electrocardiol 2008 March;41(2):94-8. Reynolds MR, Essebag V, Zimetbaum P, Cohen DJ. Healthcare resource utilization and costs associated with recurrent episodes of atrial fibrillation: the FRACTAL registry. J Cardiovasc Electrophysiol 2007 June;18(6):628-33. Miyasaka Y, Barnes ME, Bailey KR et al. Mortality trends in patients diagnosed with first atrial fibrillation: a 21-year community-based study. J Am Coll Cardiol 2007 March 6;49(9):986-92. Frost L, Andersen LV, Vestergaard P, Husted S, Mortensen LS. Trend in mortality after stroke with atrial fibrillation. Am J Med 2007 January;120(1):47-53.
Andersen KK, Olsen TS. Reduced poststroke mortality in patients with stroke and atrial fibrillation treated with anticoagulants: results from a Danish quality-control registry of 22,179 patients with ischemic stroke. Stroke 2007 February;38(2):259-63. Fornari LS, Calderaro D, Nassar IB et al. Misuse of antithrombotic therapy in atrial fibrillation patients: frequent, pervasive and persistent. J Thromb Thrombolysis 2007 February;23(1):65-71. Cheng TO. Global epidemic of atrial fibrillation including China. Int J Cardiol 2007 November 15;122(2):160. Burton C, Isles C, Norrie J, Hanson R, Grubb E. The safety and adequacy of antithrombotic therapy for atrial fibrillation: a regional cohort study. Br J Gen Pract 2006 September;56(530):697-702. Boriani G, Diemberger I, Martignani C, Biffi M, Branzi A. The epidemiological burden of atrial fibrillation: a challenge for clinicians and health care systems. Eur Heart J 2006 April;27(8):893-4. DeWilde S, Carey IM, Emmas C, Richards N, Cook DG. Trends in the prevalence of diagnosed atrial fibrillation, its treatment with anticoagulation and predictors of such treatment in UK primary care. Heart 2006 August;92(8):1064-70. Atar I, Konas D, Acikel S et al. Frequency of atrial fibrillation and factors related to its development in dialysis patients. Int J Cardiol 2006 January 4;106(1):4751. Rho RW, Page RL. Asymptomatic atrial fibrillation. Prog Cardiovasc Dis 2005 September;48(2):79-87. Burkiewicz JS. Effect of access to anticoagulation management services on warfarin use in patients with atrial fibrillation. Pharmacotherapy 2005
August;25(8):1062-7. Tsang TS, Miyasaka Y, Barnes ME, Gersh BJ. Epidemiological profile of atrial fibrillation: a contemporary perspective. Prog Cardiovasc Dis 2005 July;48(1):1-8. Frost L, Vestergaard P, Mosekilde L, Mortensen LS. Trends in incidence and mortality in the hospital diagnosis of atrial fibrillation or flutter in Denmark, 1980-1999. Int J Cardiol 2005 August 3;103(1):78-84. Go AS. The epidemiology of atrial fibrillation in elderly persons: the tip of the iceberg. Am J Geriatr Cardiol 2005 March;14(2):56-61. Anderson DR, Gardner MJ, Putnam W et al. Populationbased evaluation of the management of antithrombotic therapy for atrial fibrillation. Can J Cardiol 2005 March;21(3):257-66 Jeong JH. Prevalence of and risk factors for atrial fibrillation in Korean adults older than 40 years. J Korean Med Sci 2005 February;20(1):26-30. de LS, van VJ, Hague N, Thana L, Dzregah B, Chan T. Preventing stroke in people with atrial fibrillation: a cross-sectional study. J Public Health (Oxf) 2005 March;27(1):85-92. Dang D, Patel R, Haywood LJ. Atrial fibrillation in a multiethnic inpatient population of a large public hospital. J Natl Med Assoc 2004 November;96(11):143844. Candel FJ, Matesanz M, Cogolludo F et al. [Prevalence of atrial fibrillation and relationed factors in a population in the centre Madrid]. An Med Interna 2004 October;21(10):477-82. Conway DS, Lip GY. Ethnicity in relation to atrial fibrillation and stroke (the West Birmingham Stroke
Project). Am J Cardiol 2003 December 15;92(12):1476-9. Bordin P, Mazzone C, Pandullo C, Goldstein D, Scardi S. Morbidity and mortality in 229 elderly patients with nonrheumatic atrial fibrillation. A five-year follow-up. Ital Heart J 2003 August;4(8):537-43. Buechner JS. Deaths and hospitalizations related to atrial fibrillation, 1999-2001. Med Health R I 2003 June;86(6):183-5. Tsang TS, Petty GW, Barnes ME et al. The prevalence of atrial fibrillation in incident stroke cases and matched population controls in Rochester, Minnesota: changes over three decades. J Am Coll Cardiol 2003 July 2;42(1):93-100. Atrial fibrillation as a contributing cause of death and Medicare hospitalization--United States, 1999. MMWR Morb Mortal Wkly Rep 2003 February 21;52(7):128, 13028, 131. Thomson R. How can epidemiological studies help us to prevent stroke? The example of atrial fibrillation. Age Ageing 2002 November;31 Suppl 3:9-16.:9-16. Sack S. [Epidemiology of atrial fibrillation]. Herz 2002 June;27(4):294-300. Ageno W, Ambrosini F, Nardo B et al. Atrial fibrillation and antithrombotic treatment in Italian hospitalized patients: a prospective, observational study. J Thromb Thrombolysis 2001 December;12(3):225-30. Carroll K, Majeed A. Comorbidity associated with atrial fibrillation: a general practice-based study. Br J Gen Pract 2001 November;51(472):884-91. Gonzalez-Peredo R, Munoz-Esteban C, mado-Fernandez C, Riancho JA. [Known and concealed auricular fibrillation in the population consulting in a health area]. Aten Primaria 2007 February;39(2):106-7.
Murphy NF, Simpson CR, Jhund PS et al. A national survey of the prevalence, incidence, primary care burden and treatment of atrial fibrillation in Scotland. Heart 2007 May;93(5):606-12. Gersh BJ, Tsang TS, Seward JB. The changing epidemiology and natural history of nonvalvular atrial fibrillation: clinical implications. Trans Am Clin Climatol Assoc 2004;115:149-60.:149-60. Roquer J, Rodriguez-Campello A, Gomis M et al. Comparison of the impact of atrial fibrillation on the risk of early death after stroke in women versus men. J Neurol 2006 November;253(11):1484-9. Lewalter T. [Epidemiology of atrial fibrillation and relevance of underlying cardiovascular disease]. Dtsch Med Wochenschr 2006 August 25;131(34-35 Suppl 4):S99-102. Cheng HY. Is age a risk factor for warfarin-related major bleeds in elderly patients with atrial fibrillation? J Am Geriatr Soc 2006 July;54(7):1155. Miyasaka Y, Barnes ME, Gersh BJ et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 2006 July 11;114(2):119-25. Lakshminarayan K, Solid CA, Collins AJ, Anderson DC, Herzog CA. Atrial fibrillation and stroke in the general medicare population: a 10-year perspective (1992 to 2002). Stroke 2006 August;37(8):1969-74. Frost L, Vukelic AL, Mortensen LS, Dethlefsen C. Seasonal variation in stroke and stroke-associated mortality in patients with a hospital diagnosis of nonvalvular atrial fibrillation or flutter. A populationbased study in Denmark. Neuroepidemiology 2006;26(4):220-5. Ref ID: 1187
Frost L, Vukelic AL, Vestergaard P, Husted S, Mortensen LS. Trends in risk of stroke in patients with a hospital diagnosis of nonvalvular atrial fibrillation: National Cohort Study in Denmark, 1980-2002. Neuroepidemiology 2006;26(4):212-9. Bush D, Martin LW, Leman R, Chandler M, Haywood LJ. Atrial fibrillation among African Americans, Hispanics and Caucasians: clinical features and outcomes from the AFFIRM trial. J Natl Med Assoc 2006 March;98(3):330-9. Heeringa J, van der Kuip DA, Hofman A et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J 2006 April;27(8):949-53. Swanson DR. Atrial fibrillation in athletes: implicit literature-based connections suggest that overtraining and subsequent inflammation may be a contributory mechanism. Med Hypotheses 2006;66(6):1085-92. Ref ID: 1224 Sojo L, Corcoy R. Seasonal variation in morbidity and mortality related to atrial fibrillation--could thyroid function contribute? Int J Cardiol 2006 February 15;107(2):281. Ref ID: 1244 Miyasaka Y, Barnes ME, Gersh BJ et al. Incidence and mortality risk of congestive heart failure in atrial fibrillation patients: a community-based study over two decades. Eur Heart J 2006 April;27(8):936-41. Ref ID: 1248 Keating RJ, Gersh BJ, Hodge DO et al. Effect of atrial fibrillation pattern on survival in a community-based cohort. Am J Cardiol 2005 November 15;96(10):1420-4. Wen-Hang QI. Retrospective investigation of hospitalised patients with atrial fibrillation in mainland China. Int J Cardiol 2005 December 7;105(3):283-7.
Fuster V. Atrial fibrillation: an epidemiologic, scientific and clinical challenge. Nat Clin Pract Cardiovasc Med 2005 May;2(5):225 Miyasaka Y, Barnes ME, Gersh BJ et al. Time trends of ischemic stroke incidence and mortality in patients diagnosed with first atrial fibrillation in 1980 to 2000: report of a community-based study. Stroke 2005 November;36(11):2362-6. Hohler H. [Atrial fibrillation]. Med Klin (Munich) 2005 October 15;100(10):636-49. Habibzadeh F, Yadollahie M, Roshanipoor M, Haghighi AB. Prevalence of atrial fibrillation in a primary health care centre in Fars Province, Islamic Republic of Iran. East Mediterr Health J 2004 January;10(1-2):147-51. Ohsawa M, Okayama A, Sakata K et al. Rapid increase in estimated number of persons with atrial fibrillation in Japan: an analysis from national surveys on cardiovascular diseases in 1980, 1990 and 2000. J Epidemiol 2005 September;15(5):194-6. Fang MC, Singer DE, Chang Y et al. Gender differences in the risk of ischemic stroke and peripheral embolism in atrial fibrillation: the AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) study. Circulation 2005 September;112(12):1687-91. Flaker GC, Belew K, Beckman K et al. Asymptomatic atrial fibrillation: demographic features and prognostic information from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Am Heart J 2005 April;149(4):657-63. Marini C, De SF, Sacco S et al. Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study. Stroke 2005 June;36(6):1115-9. Alpert JS. Atrial fibrillation: now one of the most common causes for hospitalization. Curr Cardiol Rep
2005 May;7(3):149-50. Kerr CR, Humphries KH, Talajic M et al. Progression to chronic atrial fibrillation after the initial diagnosis of paroxysmal atrial fibrillation: results from the Canadian Registry of Atrial Fibrillation. Am Heart J 2005 March;149(3):489-96. Ref ID: 1396 Ridha M, Al-Sayed AA, Saleh SA et al. The prevalence of atrial fibrillation among acute medical admissions in Kuwait. Med Princ Pract 2005 May;14(3):136-9. Kimura K, Minematsu K, Yamaguchi T. Atrial fibrillation as a predictive factor for severe stroke and early death in 15,831 patients with acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2005 May;76(5):679-83 Scalvini S, Piepoli M, Zanelli E, Volterrani M, Giordano A, Glisenti F. Incidence of atrial fibrillation in an Italian population followed by their GPs through a telecardiology service. Int J Cardiol 2005 February 15;98(2):215-20. Stewart S, MacIntyre K, MacLeod MM, Bailey AE, Capewell S, McMurray JJ. Trends in hospital activity, morbidity and case fatality related to atrial fibrillation in Scotland, 1986--1996. Eur Heart J 2001 April;22(8):693701. Sra J, Dhala A, Blanck Z, Deshpande S, Cooley R, Akhtar M. Atrial fibrillation: epidemiology, mechanisms, and management. Curr Probl Cardiol 2000 July;25(7):405-524 Ryder KM, Benjamin EJ. Epidemiology and significance of atrial fibrillation. Am J Cardiol 1999 November 4;84(9A):131R-8R. Iacovino JR. Mortality of atrial fibrillation in a population selected to be free of major cardiovascular impairments. J
Insur Med 1999;31(1):8-12. Bozinovic S, Vojvodic N, Stajkovic Z. [Atrial fibrillation in a defined population of elderly persons]. Vojnosanit Pregl 1999 January;56(1):21-5. Viitaniemi M, Eskola K, Kurunmaki H et al. Anticoagulant treatment of patients with atrial fibrillation in primary health care. Scand J Prim Health Care 1999 March;17(1):59-63. Kannel WB, Wolf PA, Benjamin EJ, Levy D. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol 1998 October 16;82(8A):2N-9N Guedon-Moreau L, Kouakam C, Kacet S. [Epidemiology of paroxysmal auricular fibrillation]. Arch Mal Coeur Vaiss 1998 January;91(1):67-71. Benjamin EJ, Wolf PA, D'Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation 1998 September 8;98(10):946-52. Perings C, Hennersdorf M, Vester EG, Weirich J, Strauer BE. [Pathophysiology, epidemiology and complications of atrial fibrillation]. Internist (Berl) 1998 January;39(1):2-11. Camm AJ, Obel OA. Epidemiology and mechanism of atrial fibrillation and atrial flutter. Am J Cardiol 1996 October 17;78(8A):3-11 Mitra R, Leatham EW. Admissions with atrial fibrillation: disease patterns and outcomes in a District General Hospital. QJM 2005 February;98(2):153-4. Lewalter T, Luderitz B. Atrial fibrillation: mortality, morbidity, and money; is that all? Importance and variability of burden measurement. Eur Heart J 2005 January;26(2):110-1
Patel PJ, Keating RJ, Gersh BJ, Hodge DO, Hammill SC, Shen WK. Outcome of patients with newly diagnosed atrial fibrillation at the Mayo Clinic and residing in that area. Am J Cardiol 2004 December 1;94(11):1379-82. Clua Espuny JL, mau Llorca MR, Aguilar MC. [Characteristics of oral anti-coagulation treatment in high-risk chronic auricular fibrillation]. Aten Primaria 2004 November 15;34(8):414-9. Friberg J, Scharling H, Gadsboll N, Truelsen T, Jensen GB. Comparison of the impact of atrial fibrillation on the risk of stroke and cardiovascular death in women versus men (The Copenhagen City Heart Study). Am J Cardiol 2004 October 1;94(7):889-94 Murphy NF, Stewart S, MacIntyre K, Capewell S, McMurray JJ. Seasonal variation in morbidity and mortality related to atrial fibrillation. Int J Cardiol 2004 November;97(2):283-8. Ref ID: 1613 Inoue H. Under-use of warfarin for patients with nonvalvular atrial fibrillation in Japan. Intern Med 2004 July;43(7):529-30. Khairallah F, Ezzedine R, Ganz LI, London B, Saba S. Epidemiology and determinants of outcome of admissions for atrial fibrillation in the United States from 1996 to 2001. Am J Cardiol 2004 August 15;94(4):500-4. Lloyd-Jones DM, Wang TJ, Leip EP et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation 2004 August 31;110(9):1042-6. Zhou ZQ, Hu DY, Chen J, Zhang RH, Li KB, Zhao XL. [An epidemiological survey of atrial fibrillation in China]. Zhonghua Nei Ke Za Zhi 2004 July;43(7):491-4. Humphries KH, Jackevicius C, Gong Y et al. Population rates of hospitalization for atrial fibrillation/flutter in Canada. Can J Cardiol 2004 July;20(9):869-76.
Santini M, De Ferrari GM, Pandozi C et al. Atrial fibrillation requiring urgent medical care. Approach and outcome in the various departments of admission. Data from the atrial Fibrillation/flutter Italian REgistry (FIRE). Ital Heart J 2004 March;5(3):205-13. Stewart S. Epidemiology and economic impact of atrial fibrillation. J Cardiovasc Nurs 2004 March;19(2):94-102. Steinberg JS, Sadaniantz A, Kron J et al. Analysis of cause-specific mortality in the Atrial Fibrillation Followup Investigation of Rhythm Management (AFFIRM) study. Circulation 2004 April 27;109(16):1973-80. Ref ID: 1728 Stewart S, Murphy NF, Walker A, McGuire A, McMurray JJ. Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK. Heart 2004 March;90(3):286-92. Molander U, Dey DK, Sundh V, Steen B. ECG abnormalities in the elderly: prevalence, time and generation trends and association with mortality. Aging Clin Exp Res 2003 December;15(6):488-93. Stollberger C, Chnupa P, Abzieher C et al. Mortality and rate of stroke or embolism in atrial fibrillation during long-term follow-up in the embolism in left atrial thrombi (ELAT) study. Clin Cardiol 2004 January;27(1):40-6. Ref ID: 1762 Le Heuzey JY, Paziaud O, Piot O et al. Cost of care distribution in atrial fibrillation patients: the COCAF study. Am Heart J 2004 January;147(1):121-6. Friberg J, Scharling H, Gadsboll N, Jensen GB. Sexspecific increase in the prevalence of atrial fibrillation (The Copenhagen City Heart Study). Am J Cardiol 2003 December 15;92(12):1419-23. Friberg J, Buch P, Scharling H, Gadsbphioll N, Jensen GB. Rising rates of hospital admissions for atrial
fibrillation. Epidemiology 2003 November;14(6):666-72. Freestone B, Rajaratnam R, Hussain N, Lip GY. Admissions with atrial fibrillation in a multiracial population in Kuala Lumpur, Malaysia. Int J Cardiol 2003 October;91(2-3):233-8. Wattigney WA, Mensah GA, Croft JB. Increasing trends in hospitalization for atrial fibrillation in the United States, 1985 through 1999: implications for primary prevention. Circulation 2003 August 12;108(6):711-6 Johnston JA, Cluxton RJ, Jr., Heaton PC, Guo JJ, Moomaw CJ, Eckman MH. Predictors of warfarin use among Ohio medicaid patients with new-onset nonvalvular atrial fibrillation. Arch Intern Med 2003 July 28;163(14):1705-10 Hu DY, Sun YH, Zhou ZQ et al. [Risk factors for stroke in Chinese with non valvular atrial fibrillation: a casecontrol study]. Zhonghua Nei Ke Za Zhi 2003 March;42(3):157-61. Ref ID: 1883 Gubler D, Martina B, Arpagaus M, Dieterle T. [Quality of anticoagulation management in ambulatory care of patients with atrial fibrillation]. Praxis (Bern 1994;92(21):991-5. Wang TJ, Larson MG, Levy D et al. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation 2003 June 17;107(23):2920-5. Ref ID: 1894 Singh BN. Atrial fibrillation: epidemiologic considerations and rationale for conversion and maintenance of sinus rhythm. J Cardiovasc Pharmacol Ther 2003 June;8 Suppl 1:S13-26.:S13-S26. Mattle HP. Long-term outcome after stroke due to atrial fibrillation. Cerebrovasc Dis 2003;16 Suppl 1:3-8.:3-8.
Cisternino MD, Giaquinto S, Maiolo I, Palma E, Valeriani M, Vittoria E. On the outcome in stroke patients one year later: the role of atrial fibrillation. Eur J Neurol 2003 January;10(1):67-70. Padeletti L, Michelucci A, Colella A et al. [Paroxysmal atrial fibrillation: epidemiology and clinical relevance]. Cardiologia 1999 December;44 Suppl 1(Pt 2):893-5. Vidaillet H, Granada JF, Chyou PH et al. A populationbased study of mortality among patients with atrial fibrillation or flutter. Am J Med 2002 October 1;113(5):365-70. Stewart S, Hart CL, Hole DJ, McMurray JJ. A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/Paisley study. Am J Med 2002 October 1;113(5):359-64 Tomcsanyi J, Somloi M. [Patients admitted with atrial fibrillation to a regional hospital]. Orv Hetil 2002 September 8;143(36):2073-6. Vecht RJ. Epidemiology of atrial fibrillation. Lancet 2002 August 17;360(9332):572. Garcia-Acuna JM, Gonzalez-Juanatey JR, Alegria EE, Gonzalez M, I, Listerri JL. [Permanent atrial fibrillation in heart disease in Spain. The CARDIOTENS study 1999]. Rev Esp Cardiol 2002 September;55(9):943-52. Lew SJ, Lim JK. Stroke prevention in elderly patients with atrial fibrillation. Singapore Med J 2002 April;43(4):198-201. Ceresne L, Upshur RE. Atrial fibrillation in a primary care practice: prevalence and management. BMC Fam Pract 2002 May 24;3:11.:11. Upshaw CB, Jr. Reduced prevalence of atrial fibrillation in black patients compared with white patients attending an urban hospital: an electrocardiographic study. J Natl
Med Assoc 2002 April;94(4):204-8. Wattigney WA, Mensah GA, Croft JB. Increased atrial fibrillation mortality: United States, 1980-1998. Am J Epidemiol 2002 May 1;155(9):819-26. Ruigomez A, Johansson S, Wallander MA, Rodriguez LA. Incidence of chronic atrial fibrillation in general practice and its treatment pattern. J Clin Epidemiol 2002 April;55(4):358-63. Stewart S, MacIntyre K, Chalmers JW et al. Trends in case-fatality in 22968 patients admitted for the first time with atrial fibrillation in Scotland, 1986-1995. Int J Cardiol 2002 March;82(3):229-36. Ruigomez A, Johansson S, Wallander MA, Garcia Rodriguez LA. Risk of mortality in a cohort of patients newly diagnosed with chronic atrial fibrillation. BMC Cardiovasc Disord 2002;2:5. Epub@2002 Feb 26.:5. Wilhelmsen L, Rosengren A, Lappas G. Hospitalizations for atrial fibrillation in the general male population: morbidity and risk factors. J Intern Med 2001 November;250(5):382-9. Frost L, Johnsen SP, Pedersen L et al. Seasonal variation in hospital discharge diagnosis of atrial fibrillation: a population-based study. Epidemiology 2002 March;13(2):211-5. Ref ID: 2075 Labrador Garcia MS, Merino SR, Jimenez DC, Garcia SY, Segura FA, Hernandez LC. [Prevalence of auricular fibrillation in people over 65 years of age in a health area]. Aten Primaria 2001 December;28(10):648-51. Iuliano L, Micheletta F. [Atrial fibrillation. Epidemiology and physiopathology.]. Haematologica 2001 September;86(9 Suppl):1-4.
McCormick D, Gurwitz JH, Goldberg RJ et al. Prevalence and quality of warfarin use for patients with atrial fibrillation in the long-term care setting. Arch Intern Med 2001 November 12;161(20):2458-63. Stewart S, Hart CL, Hole DJ, McMurray JJ. Population prevalence, incidence, and predictors of atrial fibrillation in the Renfrew/Paisley study. Heart 2001 November;86(5):516-21. Masiaa R, Sala J, Marrugat J, Pena A. [Prevalence of atrial fibrillation in the province of Girona, Spain: the REGICOR study]. Rev Esp Cardiol 2001 October;54(10):1240. Majeed A, Moser K, Carroll K. Trends in the prevalence and management of atrial fibrillation in general practice in England and Wales, 1994-1998: analysis of data from the general practice research database. Heart 2001 September;86(3):284-8. Sacco RL, Boden-Albala B, Abel G et al. Race-ethnic disparities in the impact of stroke risk factors: the northern Manhattan stroke study. Stroke 2001 August;32(8):1725-31. Ref ID: 2138 Wandell PE. Five-year mortality in men and women with atrial fibrillation. Scand J Prim Health Care 2001 June;19(2):112-6. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001 June 13;285(22):2864-70. Ref ID: 2154 Humphries KH, Kerr CR, Connolly SJ et al. New-onset atrial fibrillation: sex differences in presentation, treatment, and outcome. Circulation 2001 May 15;103(19):2365-70.
Go AS, Hylek EM, Phillips KA et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001 May 9;285(18):2370-5. Goudevenos JA, Vakalis JN, Giogiakas V et al. An epidemiological study of symptomatic paroxysmal atrial fibrillation in northwest Greece. Europace 1999 October;1(4):226-33. Chugh SS, Blackshear JL, Shen WK, Hammill SC, Gersh BJ. Epidemiology and natural history of atrial fibrillation: clinical implications. J Am Coll Cardiol 2001 February;37(2):371-8. Lip GY, Zarifis J. Atrial fibrillation and stroke in patients admitted to a city centre hospital serving a multiethnic community. Int J Cardiol 2000 September 15;75(23):311-2. Lamassa M, Di CA, Pracucci G et al. Characteristics, outcome, and care of stroke associated with atrial fibrillation in Europe: data from a multicenter multinational hospital-based registry (The European Community Stroke Project). Stroke 2001 February;32(2):392-8. Scardi S, Mazzone C. [Impact of chronic atrial fibrillation on cardiovacular mortality]. Ital Heart J Suppl 2000 September;1(9):1117-22. Tomita F, Kohya T, Sakurai M et al. Prevalence and clinical characteristics of patients with atrial fibrillation: analysis of 20,000 cases in Japan. Jpn Circ J 2000 September;64(9):653-8. Filippi A, Bettoncelli G, Zaninelli A. Detected atrial fibrillation in north Italy: rates, calculated stroke risk and proportion of patients receiving thrombo-prophylaxis. Fam Pract 2000 August;17(4):337-9.
Bhatia A, Sra J. Atrial fibrillation: epidemiology, mechanisms and management. Indian Heart J 2000 March;52(2):129-64. Nakayama T, Yokoyama T, Yoshiike N et al. Population attributable fraction of stroke incidence in middle-aged and elderly people: contributions of hypertension, smoking and atrial fibrillation. Neuroepidemiology 2000 July;19(4):217-26 Scardi S, Mazzone C, Pandullo C, Goldstein D, Di LA, Chersevani D. Mortality and cause of death in patients with chronic non-rheumatic atrial fibrillation after a twoyear follow-up. G Ital Cardiol 1999 June;29(6):637-46. Olsson SB. [Atrial fibrillation--epidemiological and electrophysiological aspects]. Tidsskr Nor Laegeforen 1999 April 30;119(11):1601-4 Levy S, Maarek M, Coumel P et al. Characterization of different subsets of atrial fibrillation in general practice in France: the ALFA study. The College of French Cardiologists. Circulation 1999 June 15;99(23):3028-35. Jouven X, Desnos M, Guerot C, Ducimetiere P. Idiopathic atrial fibrillation as a risk factor for mortality. The Paris Prospective Study I. Eur Heart J 1999 June;20(12):896-9. Stewart FM, Singh Y, Persson S, Gamble GD, Braatvedt GD. Atrial fibrillation: prevalence and management in an acute general medical unit. Aust N Z J Med 1999 February;29(1):51-8. Gersh BJ, Solomon A. Lone atrial fibrillation: epidemiology and natural history. Am Heart J 1999 April;137(4 Pt 1):592-5 Shatoor AS, Ahmed ME, Said MA, Shabbir K, Cheema A, Kardash MO. Patterns of atrial fibrillation at a regional hospital in Saudi Arabia. Ethn Dis 1998;8(3):360-6.
Sudlow M, Thomson R, Thwaites B, Rodgers H, Kenny RA. Prevalence of atrial fibrillation and eligibility for anticoagulants in the community. Lancet 1998 October 10;352(9135):1167-71 Lip GY, Bawden L, Hodson R, Rutland E, Snatchfold J, Beevers DG. Atrial fibrillation amongst the Indo-Asian general practice population. The West Birmingham Atrial Fibrillation Project. Int J Cardiol 1998 July 1;65(2):18792. Wolf PA, Mitchell JB, Baker CS, Kannel WB, D'Agostino RB. Impact of atrial fibrillation on mortality, stroke, and medical costs. Arch Intern Med 1998 February 9;158(3):229-34. Psaty BM, Manolio TA, Kuller LH et al. Incidence of and risk factors for atrial fibrillation in older adults. Circulation 1997 October 7;96(7):2455-61. Lip GY, Golding DJ, Nazir M, Beevers DG, Child DL, Fletcher RI. A survey of atrial fibrillation in general practice: the West Birmingham Atrial Fibrillation Project. Br J Gen Pract 1997 May;47(418):285-9 Zarifis J, Beevers G, Lip GY. Acute admissions with atrial fibrillation in a British multiracial hospital population. Br J Clin Pract 1997 March;51(2):91-6. Langenberg M, Hellemons BS, van Ree JW et al. Atrial fibrillation in elderly patients: prevalence and comorbidity in general practice. BMJ 1996 December 14;313(7071):1534. Aronow WS, Ahn C, Gutstein H. Prevalence of atrial fibrillation and association of atrial fibrillation with prior and new thromboembolic stroke in older patients. J Am Geriatr Soc 1996 May;44(5):521-3. Wolf PA, Benjamin EJ, Belanger AJ, Kannel WB, Levy D, D'Agostino RB. Secular trends in the prevalence of atrial fibrillation: The Framingham Study. Am Heart J
1996 April;131(4):790-5. Krahn AD, Manfreda J, Tate RB, Mathewson FA, Cuddy TE. The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba Follow-Up Study. Am J Med 1995 May;98(5):476-84. Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Arch Intern Med 1995 March 13;155(5):469-73. Scardi S, Mazzone C, Goldstein D et al. [SFAAT: the study of nonrheumatic chronic atrial fibrillation in the Trieste area. Results of an enrollment study]. G Ital Cardiol 1995 February;25(2):173-82. Kaushal SS, DasGupta DJ, Prashar BS, Bhardwaj AK. Electrocardiographic manifestations of healthy residents of a tribal Himalayan village. J Assoc Physicians India 1995 January;43(1):15-6.
Covariates and external validity of the ensemble model
SUPPLEMENTAL TABLES Supplemental Table 1a. Estimated age-standardized prevalence rates of Atrial Fibrillation with 95% Uncertainty Intervals (per 100,000) for all 21 GBD regions for males and females: 2010 Males
35+ years
20+ years
