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Socioeconomic Factors and Outcome of Atrial Fibrillation in Europe
Quick Takes
- Atrial fibrillation (AF) is the most common arrhythmia worldwide with significant morbidity and mortality; however, there are limited data on its impact across Europe.
- This study sought to evaluate trends in AF incidence and mortality across Europe between 1990-2017.
Study Questions:
Do socioeconomic factors and sex differences play a role in changing trends in atrial fibrillation (AF) incidence and mortality?
Methods:
AF and atrial flutter incidence and mortality data from 1990-2017 for 20 countries across Europe were obtained from the Global Burden of Disease (GBD) Database. Gross domestic product (GDP) per capita for 2017 was calculated and grouped relative to the 2017 European Union (EU) mean GDP. Age-adjusted incidence, mortality, and mortality-to-incidence ratios (MIRs) were calculated.
Results:
Incidence trends were heterogenous but consistently higher in men than women in all countries. Mortality trends were also heterogenous but similar between men and women, suggesting a higher per-case mortality in women. Mortality rates were higher and had more marked increases in wealthier countries: Sweden had the highest mortality rates for both men and women (8.83 and 8.88 per 100,000, respectively) in 2017. Sweden also had the highest incidence rate for men (80.4 per 100,000) with Austria the highest for women (52.36 per 100,000). MIRs showed some heterogeneity in trends but were consistently higher in women for all countries studied. The disparity between men and women varied greatly, increasing the most in Germany (43.6% in 1990 to 74.5% in 2017).
Conclusions:
Higher mortality rates due to AF were observed in wealthier countries. Women with AF had worse outcomes then men. In general, there were stable trends in AF incidence and mortality across the 20 countries over the study period.
Perspective:
AF has been projected to reach prevalences of epidemic proportions worldwide. This interesting observational study reported a relatively flat trend of incidence across 20 EU countries over a 28-year study period. Mortality was also relatively flat but higher in the higher GDP nations and despite improvements in AF and stroke prevention therapies over time.
The authors postulate that improved survival to older age increases risk of developing AF and its associated consequences. While this could be a major reason, the observations in this study could also be reflecting an epidemiologic transition: a shift over time in populations (especially higher income) to noninfectious or lifestyle-related chronic diseases as the primary source of mortality. By this concept, mortality is increasingly attributed to conditions such as diabetes, obesity, and hypertension, even in middle-income and low-income countries.
Women with AF had worse outcomes, consistent with previous studies, and whether this is due to biology or health care disparity (e.g., delay in AF diagnosis) warrants further study.
Limitations of the study include the reliability of AF diagnosis, especially in countries with less access to electrocardiographic technologies; accuracy of cause of death attribution in the GBD database; grouping together of AF and atrial flutter; and inability to account for confounders (e.g., alcohol use) and comorbidities (e.g., hypertension) on individual and population levels.
Treatment of AF is complex and requires a multidisciplinary and multifaceted approach. As the authors note, further understanding is needed of the interplay in AF between culture, modifiable risk factors, comorbidities, and social determinants of health.
Clinical Topics: Arrhythmias and Clinical EP, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Atrial Flutter, Gross Domestic Product, Healthcare Disparities, Secondary Prevention, Sex Characteristics, Social Determinants of Health, Socioeconomic Factors
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