Modifiable risk factors predict incident atrial fibrillation and heart failure

Heart failure (HF) frequently complicates atrial fibrillation (AF) and significantly increases mortality risk. Limited data exist on the modifiable risk factors associated with development of HF in AF patients.

We examined two large, prospective, population-based cohorts without prior AF or HF at baseline: Malmö Preventive Project (MPP, n=32 625) and Malmö Diet and Cancer Study (MDCS, n=27 695). Using Lunn-McNeil competing risks, multivariable Cox models were constructed to determine hazard ratios (HR) and 95% confidence intervals (CI) of risk factors for incident HF with AF, and AF alone.

Mean follow-up in MPP and MDCS was 27.6±8.4 and 17.7±5.3 years. In MPP, body mass index (HR 1.11, 95% CI 1.09 to 1.13 vs HR 1.05, 95% CI 1.04 to 1.06 per kg/m²), systolic blood pressure (HR 1.20, 95% CI 1.24 to 1.26 vs HR 1.08, 95% CI 1.06 to 1.10 per 10 mm Hg) and current cigarette smoking (HR 1.73, 95% CI 1.54 to 1.95 vs HR 1.23, 95% CI 1.15 to 1.32) had stronger associations with incident AF with HF compared with AF alone (all p for difference <0.0001). Similar results were observed in MDCS (all p for difference <0.009). These three risk factors and diabetes accounted for 51.8% and 54.1% of the population attributable risk (PAR) for AF with HF in MPP and MDCS, respectively, compared with 20.1% and 27.0% for AF alone.

Obesity, hypertension and active smoking preferentially associated with AF with HF, compared with AF alone, and accounted for >50% of the PAR. Randomised trials are needed to assess whether risk factor modification can reduce the incidence of AF with HF and reduce mortality.