Lifetime risk of atrial fibrillation according to optimal, borderline, or elevated levels of risk factors: cohort study based on longitudinal data from the Framingham Heart StudyBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1453 (Published 26 April 2018) Cite this as: BMJ 2018;361:k1453
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Re: Lifetime risk of atrial fibrillation according to optimal, borderline, or elevated levels of risk factors: cohort study based on longitudinal data from the Framingham Heart Study
We read with great interest the results from the observational analysis by Staerk et al. (1) These investigators using data from 5338 participants from the Framingham Heart Study not only found that lifetime risk of developing atrial fibrillation (AF) is higher in men than in women; but also, AF risk increases even if only one risk factor is present, with obesity being the most prominent modifiable risk factor. (1) Based on these results, the investigators suggested that an aggressive primary prevention approach would probably be useful to reduce AF in an aging population. (1)
Multiple trials have linked AF to an increased risk of stroke, heart failure, and death. (2) In 1998, a sub-analysis of the Framingham Heart Study by Benjamin et al. demonstrated an excess in all-cause mortality attributable to AF, even when controlled for the presence of other cardiovascular comorbidities. (3) However, conditions commonly associated with increased risk of AF, such as most of those identified by Staerk et al. have also been implicated in excess mortality, particularly cardiovascular mortality. However, to this date, controversy remains regarding the mechanism of excess mortality attributed to AF itself. (4) Is simply having AF sufficient to increase an individual’s risk of death? Or is he interplay between AF and these comorbidities/risk factors more important? Considering that AF is the most common arrhythmia worldwide, many questions remains unanswered, the inexplicable paucity of data regarding ethnic and racial variations in AF compounds patient management.
Staerk et al. data though in accordance with other well-described reports regarding adverse outcomes known to occur in AF, (5) it is once again only applicable to a predominantly white patient cohort. Aside from recent data from the prospective ARIC Study demonstrated that AF outcomes rates of stroke, heart failure, coronary heart disease, and mortality were considerably larger in black than white individuals; (6) a significant void still exists regarding racial differences in terms of traditional and novel risk factors, genetic studies that include coagulation metrics, utility of new anticoagulants, AF detection and symptom recognition, AF-related outcomes as well as barriers to recruitment among different AF populations.
In our particular case, as healthcare providers for a predominately Hispanic population, an ethnic group not only exquisitely heterogeneous but also known to be significantly burdened with the Metabolic syndrome, (7) a cluster of abnormalities known to be associated with future risk of diabetes as well as cardiovascular disease and likely might be the case for AF. We see an urgent need to include Hispanics as well as Asians in this type of analyses that ultimately will prove critically important in promoting public health efforts toward surveillance and prevention of high-risk individuals as well as improve medical care and lower health costs.
1. Staerk L, Wang B, Preis SR, Larson MG, Lubitz SA, Ellinor PT, McManus DD, Ko D, Weng LC, Lunetta KL, Frost L, Benjamin EJ, Trinquart L. Lifetime risk of atrial fibrillation according to optimal, borderline, or elevated levels of risk factors: cohort study based on longitudinal data from the Framingham Heart Study. BMJ. 2018 Apr 26;361:k1453. doi: 10.1136/bmj.k1453.
2. Pokorney SD, Piccini JP, Stevens SR, et al. Cause of Death and Predictors of All-Cause Mortality in Anticoagulated Patients with Nonvalvular Atrial Fibrillation: Data From ROCKET AF. J Am Heart Assoc. 2016;5(3): e002197 doi:10.1161/JAHA/115/002197
3. Bejamin EJ, Wolf PA, D’Argostino RB, et al. Impact of Atrial Fibrillation on the Risk of Death: the Framignham Heart Study. Circulation. 1998;98(10:946-52.
4. Sankaranarayanan R, Kirkwood G, Visweswariah R, Fox DJ. How Does Chronic Atrial Fibrillation Influence Mortality in the Modern Treatment Era? Curr Cardiol Rev. 2015;11(3):190-8.
5. Ball J, Carrington MJ, McMurray JJ, et al. Atrial fibrillation: Profile and burden of an evolving epidemic in the 21st century. Int J Cardiol. 2013 167(5):1807-24.
6. Magnani JW, Norby FL, Agarwal SK, Soliman EZ, Chen LY, Loehr LR, Alonso A. Racial Differences in Atrial Fibrillation-Related Cardiovascular Disease and Mortality: The Atherosclerosis Risk in Communities (ARIC) Study. JAMA Cardiol. 2016 Jul 1;1(4):433-41.
7. Gurka MJ, Filipp SL, DeBoer MD. Geographical variation in the prevalence of obesity, metabolic syndrome, and diabetes among US adults. Nutrition & Diabetes. 2018; 8:14.
Competing interests: No competing interests