Global burden of heart failure attributable to atrial fibrillation and flutter, insights from GBD 2021

The aim of this study was to systematically quantify the global, regional, and national burden of heart failure (HF) attributable to atrial fibrillation/flutter (AF/AFL) from 1990 to 2021, and project trends to 2040.

Using Global Burden of Disease (GBD) 2021 data, we analysed AF/AFL-attributed HF prevalence and years lived with disability (YLDs) across 204 countries, stratified by age, sex, and socio-demographic index (SDI). Joinpoint regression identified temporal inflection points; decomposition analysis quantified contributions from population growth, ageing, and epidemiological change; Bayesian age-period-cohort (BAPC) models forecasted burden to 2040. Globally, AF-attributed HF cases increased 3.4-fold, from 162 561 (95% UI: 120 008-213 951) in 1990 to 714 137 (95% UI: 520 543-940 901) in 2021, with age-standardized prevalence rates (ASPRs) rising from 5.36 to 8.85 per 100 000 (EAPC: 1.76%, 95% UI: 1.66-1.85%). YLDs increased more than four-fold, from 14 615 (95% UI: 8848-23 114) to 63 943 (95% UI: 39 058-96 196; EAPC: 1.76%, 95% CI: 1.67-1.85%). High-SDI regions exhibited the highest burden (ASPR: 13.97 (95% UI: 10.31 to 18.36) per 100 000), with epidemiological changes contributing 44% of the absolute increase in high-SDI regions to case growth. Women outnumbered men beyond age 65 (female-to-male ratio: 1.1 at age 65-69, widening to 2.4 at ≥95 years), yet age-standardized rates showed no significant sex difference (female ASPR: 8.91 vs. male ASPR: 8.78 per 100 000). Joinpoint analysis revealed accelerated growth during 1990-2007 (APC: 2.12%, P < .05), which decelerated during 2007-2018 (APC: 1.41%, P < .05) and plateaued during 2018-2021 (APC: -0.36%, P > .05). Projections indicate a near-doubling of global cases to 1 307 469 (95% UI: 661 547-1 953 391) by 2040, corresponding to an ASPR of 8.45 per 100 000 (95% UI: 4.28-12.63).

AF/AFL is a major and growing driver of global HF burden, projected to affect 1.3 million individuals by 2040, with disproportionate impact in older adults (≥65 years) and high-SDI regions. Integrating standardized AF management-including systematic screening, anticoagulation, and early rhythm control-into HF prevention pathways represents a critical strategy to mitigate projected increases.