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  • Review Article
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Epidemiology and modifiable risk factors for atrial fibrillation

Nature Reviews Cardiology volume 20, pages 404–417 (2023)Cite this article

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An Author Correction to this article was published on 17 January 2023

This article has been updated

Abstract

The global prevalence of atrial fibrillation (AF) has increased substantially over the past three decades and is currently approximately 60 million cases. Incident AF and its clinical consequences are largely the result of risk factors that can be modified by lifestyle changes. In this Review, we provide evidence that the lifetime risk of AF is modified not only by sex and race but also through the clinical risk factor and comorbidity burden of individual patients. We begin by summarizing the epidemiology of AF, focusing on non-modifiable and modifiable risk factors, as well as targets and strategies for the primary prevention of AF. Furthermore, we evaluate the role of modifiable risk factors in the secondary prevention of AF as well as the potential effects of risk factor interventions on the frequency and severity of subsequent AF episodes. We end the Review by proposing strategies that require evaluation as well as global policy changes that are needed for the prevention of incident AF and the management of recurrent episodes in patients already affected by AF.

Key points

  • The global prevalence of atrial fibrillation (AF) is approximately 60 million cases and contributes to >8 million disability-adjusted life years.

  • The lifetime risk of AF is approximately 33%, with estimates modified by patient-level factors such as age, sex, race and burden of clinical risk factors.

  • Modifiable risk factors, including hypertension, type 2 diabetes mellitus and physical inactivity, increase the lifetime risk of AF, independent of genetic risk.

  • Novel risk factors for AF include epigenetic markers of biological age and body composition.

  • Evidence is accumulating that risk factor interventions reduce incident AF and have a central role in the secondary prevention of AF episodes.

  • Future research should focus on risk factor management for the primary and secondary prevention of AF and major policy changes to reduce the global burden of AF.

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Fig. 1: Increase in DALYs due to atrial fibrillation and the contribution of modifiable risk factors to atrial fibrillation-related DALYs between 1990 and 2019.
Fig. 2: Risk factors for atrial fibrillation and their associated mechanisms.

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Acknowledgements

A.D.E. is supported by a Future Leader Fellowship from the National Heart Foundation of Australia. M.E.M. is supported by a postdoctoral fellowship from the University of Adelaide. P.S. is supported by a Practitioner Fellowship from the National Health and Medical Research Council of Australia.

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Authors and Affiliations

  1. Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, South Australia, Australia

    Adrian D. Elliott, Melissa E. Middeldorp & Prashanthan Sanders

  2. Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia

    Adrian D. Elliott, Melissa E. Middeldorp & Prashanthan Sanders

  3. Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center (CMA), Los Angeles, CA, USA

    Melissa E. Middeldorp & Christine M. Albert

  4. Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands

    Isabelle C. Van Gelder

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A.D.E., M.E.M. and P.S. researched data for the article, and all the authors discussed its content. A.D.E., M.E.M. and P.S. wrote the manuscript, and I.C.V.G. and C.M.A. reviewed and/or edited it before submission.

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Correspondence to Prashanthan Sanders.

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Competing interests

P.S. reports having served on the advisory board of Abbott Medical, Boston Scientific, CathRx, Medtronic and Pacemate. P.S. reports that the University of Adelaide has received, on his behalf, lecture and/or consulting fees from Abbott Medical, Boston Scientific, CathRx, Medtronic and Pacemate. P.S. reports that the University of Adelaide has received, on his behalf, research funding from Abbott Medical, Boston Scientific, Medtronic, Microport and Pacemate. The other authors declare no competing interests.

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Elliott, A.D., Middeldorp, M.E., Van Gelder, I.C. et al. Epidemiology and modifiable risk factors for atrial fibrillation. Nat Rev Cardiol 20, 404–417 (2023). https://doi.org/10.1038/s41569-022-00820-8

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