Global, regional, and national burden of atrial fibrillation and flutter and associated heart failure from 1990 to 2021 and projections to 2050: insights from the Global Burden of Disease Study 2021

doi:10.21203/rs.3.rs-4975360/v1

Background

Atrial fibrillation (AF) and atrial flutter (AFL) are growing global health concerns. The increasing burden of these conditions highlights the need for comprehensive insights into their global impact and epidemiological trends. This study assesses the global burden and trends of AF/AFL, as well as AF/AFL-associated heart failure over time: 1990 to 2021, with forecasts to 2050.

Methods

We leveraged data from the Global Burden of Disease (GBD) study 2021 to examine the burden and trends of AF/AFL and associated heart failure across 204 countries and territories from 1990 to 2021. The incidence, prevalence, disability-adjusted life years (DALY), years lived with disability (YLD), and average annual percentage changes were computed. A Bayesian Age-Period-Cohort (BAPC) model was applied to forecast the trends of AF/AFL from 2022 to 2050.

Results

The number of incidence, prevalence, DALY, and YLD for AF/AFL, as well as the burden of AF/AFL-related heart failure, significantly increased from 1990 to 2021. However, age-standardized rates for these metrics showed only minor fluctuations. The burden was highest among the elderly and varied by sociodemographic index (SDI), with the greatest increase observed in the middle SDI region. Global increases in AF/AFL burden were primarily driven by population growth and aging. Projections indicate that the AF/AFL burden will continue rising through 2050.

Conclusion

The global burden of AF/AFL and associated heart failure has steadily increased. Public health strategies targeting high-burden regions and the elderly are required to mitigate its impact on global public health.

Atrial Fibrillation

Atrial Flutter

Global Burden

Heart Failure

Epidemiology

Atrial fibrillation (AF) and atrial flutter (AFL) are the most common arrhythmias encountered in clinical practice. They are strongly linked to increased risks of stroke, heart failure, renal disease, and overall mortality and as such, they have a substantial impact on global public health [1]. Multiple systematic reviews have revealed a steady increase in the global burden of AF/AFL in the past few decades [2–7]. According to the data from the Global Burden of Disease (GBD) Study 2019, the worldwide incidence of AF/AFL increased by 111% between 1990 and 2019, and the age-standardized mortality rate of AF/AFL rose by 2% in the same time period [3]. The burden of AF/AFL has been projected to continue to rise in the coming decades, mainly due to the continued ageing of the global population and the increasing incidence of cardiovascular comorbidities [4, 5, 7, 6]. Heart failure is the most common complication of AF/AFL and a major cause of AF/AFL-associated mortality. Heart failure occurs in 40–55% of patients with persistent AF [8]. Among Medicare beneficiaries diagnosed with AF in the United States, the most common outcomes within five years are death (48.8%), heart failure (13.7%), new-onset stroke (7.1%), gastrointestinal bleeding (5.7%), and myocardial infarction (3.9%) [9]. Although AF/AFL and heart failure each have adverse effects on prognosis, their coexistence is known to lead to a worse outcome [10]. As such, AF/AFL and associated heart failure have become a significant public health concern, with their socio-economic impact anticipated to rise further in the future.

Although a number of studies have assessed the global burden of AF/AFL based on the data from the 2019 GBD Study [3, 11], there have been no updates since the 2021 GBD study results were posted to public database. We aimed to estimate the burden of AF/AFL and associated heart failure at the global, regional, and national levels between 1990 and 2021 with projections to 2050 by analyzing the data from the 2021 GBD study. The findings from this study should provide crucial information for developing public health strategies to effectively manage the rising global burden of AF/AFL.

Overview

The 2021 GBD study results encompassed estimates of the incidence, prevalence, mortality, disability-adjusted life years (DALY), and years lived with disability (YLD) for 371 diseases and injuries across 21 GBD regions and 204 countries and territories between 1991 and 2021, along with risk assessment of 87 behavioral, environmental, occupational, and metabolic risks [12]. These estimates are presented in absolute numbers (incidence), numbers per 100,000 population (prevalence), and age-standardized rates (ASRs). We retrieved data on AF/AFL from the 2021 GBD database (http://ghdx.healthdata.org/gbd-results-tool), which included the region-, age-, and gender-specific incidence, prevalence, DALY, and YLD with corresponding 95% uncertainty intervals (UIs). Neither ethical approval nor patient consent is required for downloading and analyzing anonymized, publicly accessible epidemiological data. This research adhered to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) [13].

Sociodemographic index (SDI) and decomposition analysis

The SDI is a composite measure of sociodemographic development that is closely associated with health outcomes. It is calculated as the geometric mean of three common indicators: the lag-distributed income (LDI) per capita, average educational attainment of individuals age 15 and older, and total fertility rate of women under 25. The SDI ranges from 0 to 1, with 0 and 1 representing the theoretical minimum and maximum level of development, respectively. In this study, we employed decomposition methods used in previous research [14] to analyze the impact of population growth, population ageing, and epidemiologic transition on the incidence, prevalence, DALY, and YLD of AF/AFL.

Projection analysis

We employed a Bayesian Age-Period-Cohort (BAPC) model used in a previous study [15] to forecast the incidence, prevalence, DALY, and YLD of AF/AFL from 2022 to 2050. This multiplicative model assumed that the age, period, and cohort effects follow the Poisson distribution with the logarithm as the link function. Projections were made using the data in 2021 as a baseline. A 1% annual increase was considered a pessimistic scenario, while a 1% annual decrease was deemed optimistic.

Statistical analysis

We performed a descriptive analysis to delineate the global burden of AF/AFL and associated heart failure. We disaggregated the incidence, prevalence, DALY, and YLD of AF/AFL by age, gender, region, and country. The variables were computed in the form of numbers, percentages, and rates. To analyze the trends, we utilized the method of joinpoint regression [16] to estimate the average annual percentage changes (AAPC). The trend analysis was further performed with gender, region, and SDI stratification. All statistical analyses were carried out using the R software (version 4.4.0, https://www.r-project.org/), and a p-value of < 0.05 was deemed statistically significant.

1. Global and regional changes in the disease burden of AF/AFL from 1990 to 2021, with projections to 2050

Overall global trends

Globally, the incidence of AF/AFL increased by 120% between 1990 and 2021, rising from 2 million cases to 4.5 million. Despite this substantial increase in the number of cases, the ASR of AF/AFL prevalence remained relatively stable, decreasing marginally by 0.74% from 52.51 per 100,000 population in 1990 to 52.12 per 100,000 population in 2021, with an AAPC of merely − 0.03% (Table 1). Similarly, although both DALY and YLD for AF/AFL showed an upward trend from 1990 to 2021, their ASRs exhibited minimal variations with a negligible AAPC (Table S1).

Table 1

The incidence and prevalence of atrial fibrillation and flutter in 1990 and 2021, and their temporal trends from 1990 to 2021
Location	Incidence					Prevalence
	Number, in thousands (95% UI)		ASR, per 100,000 (95% UI)		AAPC (95% CI), 1990–2021	Number, in thousands (95% UI)		ASR, per 100,000 (95% UI)		AAPC (95% CI), 1990–2021
	1990	2021	1990	2021	AAPC (95% CI), 1990–2021	1990	2021	1990	2021	AAPC (95% CI), 1990–2021
Global	2006.57(1554.97 to 2640.38)	4484.93(3610.62 to 5706.02)	52.51(40.39 to 69.01)	52.12(41.85 to 66.23)	-0.03(-0.06 to 0.01)	22214.49(17526.21 to 28522.55)	52552.04(43137.88 to 64963.85)	616.58(485.22 to 795.26)	620.51(511.36 to 768.88)	0.03(-0.02 to 0.07)
Sex
Female	991.28 (754.26 to 1318.50)	2189.12 (1723.11 to 2821.65)	47.43 (35.96 to 62.83)	47.26 (37.38 to 60.87)	-0.04(-0.13 to 0.04)	10722.02 (8387.11 to 13889.79)	24653.00 (20031.48 to 30931.40)	529.53 (413.11 to 690.99)	529.12 (430.79 to 663.14)	-0.03(-0.1 to 0.03)
Male	1015.29 (786.88 to 1319.47)	2295.81 (1853.68 to 2899.44)	58.00 (44.89 to 75.80)	57.11 (46.19 to 72.14)	-0.05(-0.08 to -0.02)*	11492.47 (9169.28 to 14778.46)	27899.05 (23026.33 to 34646.02)	727.79 (578.43 to 929.67)	728.88 (601.91 to 895.81)	0(-0.02 to 0.03)
Socio-demographic index
High SDI	722.98(553.82 to 943.98)	1334.73(1139.38 to 1572.64)	64.54(50.18 to 83.44)	65.10(56.11 to 76.05)	0.02(-0.02 to 0.06)	8631.67(6800.99 to 11018.13)	17401.07(15107.03 to 20202.16)	766.60(608.09 to 974.16)	788.35(690.97 to 910.90)	0.09(0.04 to 0.14)*
High-middle SDI	476.34(365.29 to 628.54)	934.17(740.42 to 1198.98)	48.86(37.88 to 63.69)	47.16(37.67 to 60.25)	-0.12(-0.16 to -0.08)*	5443.47(4254.25 to 7001.41)	11539.35(9330.86 to 14532.46)	587.77(464.15 to 754.80)	581.39(473.47 to 731.22)	-0.04(-0.1 to 0.02)
Middle SDI	454.02(351.99 to 596.80)	1330.38(1031.64 to 1752.21)	48.88(37.12 to 64.96)	51.11(39.20 to 67.85)	0.14(0.09 to 0.19)*	4673.67(3692.43 to 6104.44)	14670.50(11595.53 to 19210.98)	537.07(422.34 to 692.70)	579.06(457.58 to 748.76)	0.24(0.21 to 0.27)*
Low-middle SDI	268.08(206.73 to 354.73)	682.89(523.05 to 912.04)	49.52(37.34 to 65.82)	50.99(38.44 to 67.86)	0.09(0.09 to 0.1)*	2632.14(2062.58 to 3472.86)	6929.83(5413.49 to 9033.56)	524.91(409.36 to 683.63)	546.49(425.68 to 711.16)	0.13(0.12 to 0.14)*
Low SDI	82.74(63.35 to 109.67)	198.49(153.24 to 261.94)	41.74(31.59 to 55.83)	43.25(32.70 to 57.75)	0.12(0.1 to 0.14)*	806.01(629.01 to 1060.71)	1959.34(1535.18 to 2587.65)	442.34(345.89 to 576.61)	463.23(362.02 to 602.71)	0.15(0.13 to 0.17)*
Region
Andean Latin America	10.66(8.33 to 13.96)	33.00(25.56 to 43.75)	54.40(41.63 to 72.43)	56.44(43.34 to 75.08)	0.12(0.11 to 0.14)*	112.47(88.86 to 146.49)	371.26(290.31 to 478.82)	599.92(471.70 to 773.74)	647.36(505.19 to 835.55)	0.25(0.23 to 0.27)*
Australasia	17.29(15.42 to 19.40)	38.35(29.26 to 50.11)	73.00(65.35 to 81.38)	73.34(57.30 to 94.35)	-0.01(-0.12 to 0.11)	208.04(190.58 to 225.39)	508.53(400.84 to 650.59)	885.17(810.92 to 960.40)	913.63(725.73 to 1163.47)	0.07(-0.07 to 0.2)
Caribbean	15.32(11.70 to 20.44)	31.92(24.66 to 42.13)	60.10(46.18 to 79.67)	59.14(45.45 to 78.13)	-0.05(-0.07 to -0.04)*	168.73(130.82 to 218.39)	367.64(289.06 to 476.68)	677.46(527.46 to 877.57)	678.59(533.41 to 881.12)	0.01(-0.01 to 0.03)
Central Asia	20.05(15.18 to 26.39)	36.23(27.49 to 47.29)	44.05(33.40 to 58.03)	44.53(33.54 to 57.85)	0.04(0.03 to 0.05)*	222.46(171.71 to 290.36)	392.83(305.78 to 509.90)	513.48(395.59 to 666.95)	536.72(410.76 to 698.74)	0.15(0.14 to 0.16)*
Central Europe	76.66(57.34 to 101.38)	122.63(94.47 to 154.04)	50.47(38.22 to 65.71)	55.16(44.12 to 68.47)	0.26(0.22 to 0.3)*	901.37(699.71 to 1154.31)	1585.13(1281.86 to 1949.45)	616.69(478.07 to 790.30)	679.00(554.31 to 827.23)	0.27(0.23 to 0.32)*
Central Latin America	49.66(38.65 to 65.62)	154.32(119.07 to 205.02)	62.71(48.02 to 83.50)	62.38(47.92 to 83.05)	-0.02(-0.03 to -0.01)*	524.83(413.23 to 681.70)	1711.30(1340.76 to 2226.16)	702.85(548.24 to 910.96)	707.02(552.56 to 921.13)	0.02(0.01 to 0.03)*
Central Sub-Saharan Africa	7.72(5.86 to 10.15)	19.10(14.93 to 25.12)	40.17(30.36 to 53.20)	39.56(29.91 to 52.82)	-0.05(-0.05 to -0.05)*	73.69(57.05 to 95.88)	182.59(142.53 to 241.99)	427.06(330.92 to 558.11)	424.57(331.96 to 559.66)	-0.02(-0.03 to -0.01)*
East Asia	321.77(246.73 to 424.27)	953.90(737.31 to 1249.81)	42.98(32.71 to 56.93)	45.11(35.12 to 59.61)	0.17(0.06 to 0.29)*	3359.58(2649.14 to 4376.80)	11215.16(8885.91 to 14572.50)	462.71(363.30 to 601.04)	526.44(420.60 to 683.56)	0.41(0.31 to 0.52)*
Eastern Europe	130.20(98.55 to 170.81)	176.79(133.42 to 231.76)	46.52(35.77 to 60.37)	50.47(38.83 to 65.64)	0.26(0.24 to 0.28)*	1601.35(1245.87 to 2080.67)	2327.31(1805.31 to 3029.89)	584.41(454.97 to 753.25)	648.92(507.00 to 836.25)	0.34(0.32 to 0.36)*
Eastern Sub-Saharan Africa	24.73(19.15 to 32.33)	62.82(49.40 to 81.80)	36.74(28.10 to 49.06)	39.66(30.44 to 52.91)	0.25(0.22 to 0.29)*	253.30(198.23 to 333.96)	645.69(507.53 to 839.25)	407.55(320.71 to 534.37)	448.76(354.06 to 589.55)	0.32(0.27 to 0.37)*
High-income Asia Pacific	86.52(66.80 to 113.26)	152.47(116.38 to 199.32)	43.22(33.54 to 56.82)	36.27(29.16 to 46.41)	-0.53(-0.6 to -0.46)*	1052.10(825.88 to 1364.55)	2165.45(1737.90 to 2727.23)	533.61(423.32 to 688.79)	465.22(383.84 to 577.04)	-0.4(-0.49 to -0.31)*
High-income North America	278.73(205.98 to 367.02)	586.32(534.19 to 649.28)	77.60(59.70 to 101.77)	88.24(80.92 to 97.25)	0.44(0.41 to 0.46)*	3293.63(2543.34 to 4240.13)	7106.42(6544.30 to 7755.03)	900.45(701.18 to 1153.05)	1031.17(952.30 to 1117.88)	0.47(0.43 to 0.51)*
North Africa and Middle East	49.89(38.44 to 65.91)	145.16(114.58 to 186.09)	33.93(25.04 to 45.30)	35.04(26.72 to 45.54)	0.1(0.06 to 0.14)*	474.27(369.34 to 613.69)	1417.37(1140.56 to 1788.91)	345.93(267.05 to 451.62)	366.92(291.62 to 468.40)	0.19(0.15 to 0.22)*
Oceania	1.30(1.01 to 1.70)	3.48(2.74 to 4.55)	51.68(39.37 to 68.62)	52.33(39.94 to 69.52)	0.04(0.03 to 0.06)*	12.77(10.04 to 16.71)	34.99(27.52 to 45.18)	558.23(439.17 to 726.94)	578.44(455.22 to 750.19)	0.12(0.11 to 0.13)*
South Asia	249.15(190.69 to 331.29)	698.92(527.87 to 934.82)	50.08(37.35 to 66.50)	51.01(38.09 to 67.89)	0.06(0.03 to 0.08)*	2357.50(1827.47 to 3099.82)	6882.58(5295.96 to 9026.14)	519.49(401.88 to 683.87)	530.90(410.19 to 696.69)	0.07(0.04 to 0.1)*
Southeast Asia	135.28(105.02 to 176.23)	369.52(285.92 to 483.60)	58.77(44.77 to 78.09)	59.66(45.60 to 79.28)	0.05(0.04 to 0.06)*	1377.75(1089.21 to 1799.89)	3898.61(3091.00 to 5118.88)	637.21(502.03 to 823.86)	662.33(519.61 to 854.36)	0.13(0.12 to 0.13)*
Southern Latin America	19.57(14.79 to 26.22)	28.85(23.28 to 35.80)	42.83(32.53 to 57.25)	33.00(26.86 to 40.72)	-0.86(-0.94 to -0.78)*	212.02(165.91 to 278.67)	348.81(291.74 to 425.44)	475.26(372.44 to 622.31)	391.08(328.22 to 476.31)	-0.63(-0.68 to -0.57)*
Southern Sub-Saharan Africa	11.86(9.13 to 15.60)	25.56(19.61 to 33.83)	47.32(35.92 to 63.20)	47.60(36.27 to 63.27)	0.02(0.01 to 0.03)*	121.14(94.91 to 158.84)	258.59(201.94 to 342.44)	510.12(398.24 to 662.20)	512.78(398.19 to 671.03)	0.02(0.01 to 0.02)*
Tropical Latin America	60.44(46.59 to 78.72)	172.83(133.61 to 224.37)	68.71(52.98 to 90.29)	67.55(52.09 to 88.35)	-0.09(-0.11 to -0.07)*	661.73(521.05 to 861.79)	2004.72(1580.58 to 2599.90)	802.54(631.12 to 1040.53)	794.78(625.65 to 1025.18)	-0.04(-0.04 to -0.03)*
Western Europe	410.48(310.30 to 539.19)	600.74(491.66 to 740.67)	69.97(54.22 to 90.22)	68.19(56.60 to 82.27)	-0.08(-0.14 to -0.02)*	4930.28(3885.22 to 6301.41)	8410.14(7063.58 to 10013.00)	817.69(649.57 to 1042.91)	844.93(717.15 to 992.46)	0.11(0.06 to 0.17)*
Western Sub-Saharan Africa	29.31(22.48 to 38.78)	72.01(56.37 to 94.02)	36.54(27.78 to 49.07)	39.82(30.36 to 53.28)	0.28(0.26 to 0.29)*	295.51(230.75 to 390.71)	716.91(561.81 to 945.36)	393.31(305.99 to 515.67)	434.84(339.54 to 567.05)	0.32(0.31 to 0.34)*
Abbreviations: *P < 0.05; SDI, socio-demographic index; ASR, age-standardized rates; AAPC, average annual percentage change; UI, uncertainty interval; CI, confidence interval.

Global trends by gender and projections to 2050

Between 1990 and 2021, the incidence, prevalence, and YLD for both males and females showed a steady upward trend, with males experiencing a slightly higher disease burden than females in 2021. The DALY for both genders also increased overtime during this period, although females had a somewhat higher DALY than males in 2021 (Fig. 1).

The incidence, prevalence, DALY, and YLD for AF/AFL were anticipated to keep rising from 2022 to 2050 for both genders. The ASRs of these metrics were expected to remain stable in males, while in females, the ASRs of incidence, prevalence, and YLD were projected to increase, but the ASR of DALY was expected to decrease slightly (Fig. 2).

Global trends by age

From 1990 to 2021, the AAPCs in global incidence, prevalence, and YLD for AF/AFL trended downward in older age groups of 80–84, 85–89, and 90–95 + years, while the DALY trended upward in these age groups (Fig. 3). In both 1990 and 2021, the highest AF/AFL incidence was found in the 65–69 and 70–74 age groups, the highest prevalence and YLD in the 70–74 and 75–79 age groups, and the greatest DALY in the 75–79 and 80–84 age groups. In both 1990 and 2021, the ASR of prevalence increased rapidly with age and peaked at 85–89 and 90–94 years. The ASRs of incidence and YLD increased with age at a slower and somewhat variable speed, while the ASR of DALY increased with age at a steady speed (Fig. S1).

Global trends by SDI

The incidence, prevalence, DALY, and YLD for AF/AFL trended upward in all five SDI regions from 1990 to 2021, with the greatest increases observed in the middle SDI region. The ASRs of incidence and prevalence increased in all SDI regions except the high-middle region, in which they declined. The middle SDI region saw the greatest growth in the ASR of prevalence (Table 1). The high and high-middle SDI regions saw a decline in the ASR of DALY from 1990 to 2021. The other SDI regions saw an increase, with the low-middle SDI region saw the greatest growth. The ASR of YLD declined in the high-middle SDI region but increased in the low, low-middle, and middle SDI regions, with the greatest growth observed in the middle SDI region (Table S1).

Regional trends

From 1990 to 2021, all 21 GBD regions saw either stable or rising incidence of AF/AFL. The ASR of incidence showed variable trends in different GBD regions, with the most rapid increases recorded in high-income North America (AAPC 0.47%), Western Sub-Saharan Africa (AAPC 0.28%), and Eastern and Central Europe (AAPC 0.26%), and the most significant decrease reported in high-income Asia Pacific region (AAPC − 0.53%). In 2021, the highest ASRs of incidence were reported in high-income North America (88.24 per 100 000 population), Australasia (73.34 per 100 000 population), and Western Europe (68.19 per 100 000 population). All 21 GBD regions saw an increase in AF/AFL prevalence, with East Asia and Andean Latin America experiencing the greatest growths (Table 1).

From 1990 to 2021, the DALY for AF/AFL trended upward in 12 GBD regions and downward in 9, with the most significant rise observed in South Asia (AAPC 0.7%) and the most substantial decrease reported in high-income Asia Pacific (AAPC − 0.58%). In 2021, the highest DALYs were found in Australasia (148 per 100,000 population), high-income North America (144 per 100,000 population), and Western Europe (131 per 100,000 population) while the lowest DALYs were observed in high-income Asia Pacific (69 per 100,000 population), Southern Latin America (74 per 100,000 population), and Central Asia (75 per 100,000 population). The YLD trended up in all 21 GBD regions, with East Asia seeing the greatest increase followed closely by Andean Latin America and Central Latin America. The ASR of YLD trended upward in 14 GBD regions and downward in 7, with East Asia seeing the greatest AAPC at 0.4% (Table S1).

2. National changes in the disease burden of AF/AFL from 1990 to 2021

At the national level, Austria saw the greatest increase in the ASR of AF/AFL incidence from 1990 to 2021 (AAPC 1.98%) followed by Czechia (AAPC 1.3%) and Sweden (AAPC 1.29%). Austria also had the highest ASRs of prevalence and YLD for AF/AFL during this time period. In terms of the ASR of DALY, Sweden saw the most significant increase (AAPC 1.57%) while Cyprus saw the most substantial reduction (AAPC − 1.60%) followed by Guam (AAPC − 1.53%) (Fig. 4).

In 2021, the ASRs of incidence and prevalence showed significant variations among the 204 countries. Sweden reported the highest ASR of incidence while Turkey reported the lowest. The lowest ASR of prevalence was found in Portugal. The ASRs of DALY and YLD also varied considerably among the 204 countries in 2021, with the greatest ASR of DALY found in Montenegro and the highest ASR of YLD recorded in Sweden (Fig. S2).

3. Primary factors driving the changes in the AF/AFL disease burden from 1990 to 2021

Using decomposition analysis, we evaluated the effects of population growth, population aging, and epidemiologic transition on the disease burden of AF/AFL across 5 SDI and 21 GBD regions between 1990 and 2021. Population growth followed by aging and epidemiologic transition were identified as the primary drivers of the upward trends of the incidence, prevalence, DALY, and YLD of AF/AFL across all 21 GBD regions, including regions with a high-middle SDI (e.g. high-income Asia Pacific) which experienced a slowing down in demographically adjusted epidemiologic transition. East Asia saw the greatest increases in the incidence and prevalence of AF/AFL, driven by rapid population growth and ageing (Fig. 5A and B).

In the past 30 years, decelerated epidemiologic transition in high and high-middle SDI regions such as East Asia and high-income Asia Pacific has helped to curb the upward trend of the DALY burden of AF/AFL. Nevertheless, every SDI region still saw an increase in DALY between 1990 and 2021, primarily driven by population growth and ageing. Every SDI region also saw an increase in YLD from 1990 to 2021 for the same reasons. East Asia saw the greatest YLD increase largely due to rapid population growth, ageing, and epidemiologic transition. In contrast, high-income Asia Pacific and Southern Latin America experienced a slower rise in YLD attributed to decelerated epidemiologic transition (Fig. 5C and D).

4. Global, regional, and national changes in the disease burden of AF/AFL-associated heart failure from 1990 to 2021

Global trends

Globally, both the prevalence and YLD, as well as the ASRs of prevalence and YLD of AF/AFL-associated heart failure trended upward from 1990 to 2021. In 2021, the worldwide incidence of AF/AFL-associated heart failure reached 0.71 million (95% UI 0.52 to 0.94), with an ASR of 8.85 per 100,000 population (95% UI 6.38 to 11.63). The males and females exhibited similar trends in this time period (Table S2).

Regional trends

Both the prevalence and YLD, as well as the ASRs of prevalence and YLD of AF/AFL-associated heart failure showed an upward trend from 1990 to 2021 across all 5 SDI regions (Table S2). Additionally, in any given year between 1990 and 2021, regions with a higher SDI saw a greater burden of AF/AFL-associated heart failure.

The prevalence of AF/AFL-related heart failure rose from 1990 to 2021 across all 21 GBD regions, with Tropical Latin America experiencing the most significant increase followed by high-income Asia Pacific. Australasia saw the greatest AAPC in the ASR of prevalence. The YLD for AF/AFL-related heart failure followed similar upward trends across all GBD regions, with the largest growths seen in East Asia and Andean Latin America. Australasia had the highest AAPC in the ASR of YLD (Table S2).

National trends

Among all 204 countries and territories, South Korea had the highest increase in the ASR of prevalence for AF/AFL-associated heart failure from 1090 to 2021 (AAPC 4.38%), which was followed by Denmark (AAPC 3.85%). During the same time period, South Korea also saw the greatest increase in the ASR of YLD for AF/AFL-related heart failure (AAPC 4.37%) (Table S3 and Fig. 6). In 2021, although the prevalence and YLD for AF/AFL-related heart failure varied considerably across the 204 countries and territories, they appeared to continue to tick upward in all countries. In 2021, Sweden recorded the highest ASR of prevalence while Tajikistan and Uzbekistan had the lowest ASRs of YLD (Table S3 and Fig. S3).

Our systematic review of the GBD study 2021 data on AF/AFL confirms that AF/AFL remains a significant health burden worldwide. Between 1990 and 2021, the common disease metrics including the incidence, prevalence, DALY, and YLD for global AF/AFL all trended upward. Our decomposition analysis identified population growth, population aging, and epidemiologic transition as the primary factors driving these upward trends. Meanwhile, the ASRs of incidence, prevalence, DALY, and YLD remained relatively stable between 1990 and 2021, thanks to increased early detection and medical or surgical intervention. The disease burden of AF/AFL was projected to continue to rise from 2022 to 2050, particularly in females. Effective public health policies and intervention strategies are critical for managing this growing public health concern.

We found that males had marginally higher AF/AFL incidence and prevalence than females, but females had slightly higher DALY than males. The higher incidence and prevalence in men could be attributed to the lifestyle and behaviors associated with the male gender. Middeldorp and colleagues [17] found that the male gender, body weight, current or past smoking, and consuming ≥ 2 drinks/day were significantly associated with persistent AF in a prospective study. Meanwhile, the higher DALY and thus greater overall disease burden in women could be associated with the poorer disease management in females. It has been shown that women with AF/AFL are less inclined to adopt rhythm control strategies such as antiarrhythmic medications, cardioversion, and catheter ablation [18], leading to higher rates of complications and mortality in females than males [19]. Hence, preventive measures such as controlling weight, quitting smoking, abstaining from alcohol, and undergoing regular check-ups can effectively reduce the risk for AF/AFL in men [20]. Meanwhile, women should focus more on improving disease management and quality of life. By using a BAPC model, we projected that the incidence, prevalence, DALY, and YLD of AF/AFL would continue to increase from 2022 to 2050 for both men and women. In addition, the ASRs of incidence, prevalence, DALY, and YLD would be stable in males, but these metrics would be on the rise in females. These forecasts underscore the importance of personalized management strategies for effective AF/AFL prevention and management [21].

We found that the incidence of AF/AFL increased with age and peaked in the elderly. This was in line with the known association between AF/AFL and ageing [22], underscoring the substantial impact of AF/AFL on public health in a world with an ageing population. As the global aging accelerates, the disease burden of AF/AFL would become increasingly pronounced. Thus, prevention and management of AF/AFL in the elderly should be a high priority for public health policy development. Strategies for managing the disease in the elderly should encompass early detection, continuous monitoring, and targeted treatments [23].

Across all five SDI regions worldwide, the incidence, prevalence, DALY, and YLD of AF/AFL trended upward from 1990 to 2021, with the greatest growths observed in the middle SDI region. The high-middle SDI region was the only SDI region where the ASRs of incidence and prevalence trended downward, while all other SDI regions saw upward trends. These findings were in agreement with the GBD study 2019 data on AF/AFL [24, 3]. The disparities among different SDI regions may be attributed to variations in socioeconomic conditions, healthcare resource allocation, lifestyle, and demographic ageing. Therefore, improving disease prevention and treatment in low and middle SDI regions would be critical for controlling the global burden of this disease.

Our decomposition analysis results indicate that population growth and population ageing remain the primary drivers of the rising global burden of AF/AFL. Future public health policies on AF/AFL should continue to focus on population dynamics, particularly in areas experiencing rapid population growth and aging. Epidemiological transition can also influence the health burden of AF/AFL and thus, it also should be taken into consideration.

Heart failure remains a global leading cause of death, morbidity, and poor quality of life [25]. AF contributes to the development and progression of heart failure through multiple mechanisms [26]. Our analysis showed that the global prevalence and YLD of AF/AFL-related heart failure trended upward between 1990 and 2021, with 0.71 million cases reported in 2021. Similar upward trends were observed across all five SDI and 21 GBD regions. Regions with a higher SDI saw greater prevalence and YLD, likely due to higher rates of diagnosis and reporting. At the national level, South Korea experienced the greatest growths in the prevalence and YLD of AF/AFL-related heart failure from 1990 to 2021. The prevalence and YLD varied considerably across countries, with Sweden having the highest and Tajikistan and Uzbekistan the lowest in 2021. The upward trend of AF/AFL-related heart failure was likely associated with population ageing and the rise in sedentary lifestyles and metabolic risk factors. These critical factors should be taken into account when developing public health policies and intervention strategies. Raising public awareness, implementing early detection and preventive measures, and improving the accessibility and quality of healthcare services are key strategies to reduce the burden of AF/AFL and associated heart failure.

This study had several limitations. Firstly, disparities in health information systems and reporting mechanisms across different countries and regions, especially in low- and middle-income countries and areas of conflicts, may have impacted the completeness and reliability of the data. Secondly, underdiagnosis of asymptomatic or paroxysmal AF/AFL may have led to the underestimation of the actual case number and inaccurate assessment of the disease burden. Thirdly, the specific models and parameter settings used in this research may have influenced the outcomes. Additional high-quality studies may be needed to confirm the findings from this research.

Driven primarily by population growth and population aging, the global burden of AF/AFL trended upward from 1990 to 2021, and it was projected to continue to rise from 2020 to 2050. The global burden of AF/AFL-associated heart failure also showed an upward trend from 1990 to 2021. In 2021, the disease burden of AF/AFL and AF/AFL-associated heart failure showed considerable variations at the regional and national levels, highlighting the impact of region-specific population dynamics and epidemiological transition. Implementing targeted public health policies and intervention strategies is vital for tackling this growing burden on public health, particularly in high-burden areas and in the elderly population.

AF, atrial fibrillation; AFL, atrial flutte; GBD, Global Burden of Disease; DALY, disability-adjusted life year; YLD, years lived with disability; BAPC, Bayesian Age-Period-Cohort; SDI, sociodemographic index; ASR, age-standardized rate; UI, uncertainty interval; LDI, lag-distributed income; AAPC, average annual percentage change; CI, confidence interval.

Ethics approval and consent to participate

The GBD 2021 study is an open database, and all data is anonymous.

Consent for publication

Not applicable.

Data availability

The datasets analyzed during the current study are publicly available from the Global Health Data Exchange query tool (https://ghdx.healthdata.org/gbd-results-tool). The datasets supporting the conclusions of this article are available from the corresponding author upon reasonable request.

Competing interests

The authors declare no competing interests.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors’ contributions

XX, BX conceived of and designed the project. XH, WL and YL performed the research. WL, YL analyzed and interpreted the data. XX and BX drafted the manuscript. All authors read and approved the final manuscript.

Acknowledgment

We thank Medjaden Inc. for assistance in the preparation of this manuscript.

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No competing interests reported.

SUPPLEMENTALMATERIAL.docx

Global, regional, and national burden of atrial fibrillation and flutter and associated heart failure from 1990 to 2021 and projections to 2050: insights from the Global Burden of Disease Study 2021

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Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Methods

Overview

Sociodemographic index (SDI) and decomposition analysis

Projection analysis

Statistical analysis

Results

Overall global trends

Global trends by gender and projections to 2050

Global trends by age

Global trends by SDI

Regional trends

2. National changes in the disease burden of AF/AFL from 1990 to 2021

3. Primary factors driving the changes in the AF/AFL disease burden from 1990 to 2021

Global trends

Regional trends

National trends

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1