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  • Review Article
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The bidirectional association between atrial fibrillation and myocardial infarction

Nature Reviews Cardiology volume 20, pages 631–644 (2023)Cite this article

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Abstract

Atrial fibrillation (AF) is associated with an increased risk of myocardial infarction (MI) and vice versa. This bidirectional association relies on shared risk factors as well as on several direct and indirect mechanisms, including inflammation, atrial ischaemia, left ventricular remodelling, myocardial oxygen supply–demand mismatch and coronary artery embolism, through which one condition can predispose to the other. Patients with both AF and MI are at greater risk of stroke, heart failure and death than patients with only one of the conditions. In this Review, we describe the bidirectional association between AF and MI. We discuss the pathogenic basis of this bidirectional relationship, describe the risk of adverse outcomes when the two conditions coexist, and review current data and guidelines on the prevention and management of both conditions. We also identify important gaps in the literature and propose directions for future research on the bidirectional association between AF and MI. The Review also features a summary of methodological approaches for the study of bidirectional associations in population-based studies.

Key points

  • Atrial fibrillation (AF) is a risk factor for myocardial infarction (MI); the rate of MI is approximately 50% higher in patients with AF than in those without AF.

  • MI is associated with subsequent AF, and the rate of AF is particularly high in the first days after MI.

  • The bidirectional association between AF and MI might be partly explained by indirect mechanisms related to shared risk factors such as age, sex, modifiable risk factors, comorbidities and social determinants of health.

  • There are several mechanisms through which one condition can lead directly to the other, including coronary embolism, oxygen supply–demand mismatch, atrial ischaemia, cardiac remodelling and inflammation.

  • Patients with coexisting AF and MI have an increased risk of stroke, heart failure and death compared with those with either condition alone, emphasizing the importance of prevention and management.

  • Medical treatment in patients with both AF and MI is challenging owing to the need to balance the risks of thromboembolic complications, bleeding and stent thrombosis.

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Fig. 1: Timeline of selected literature on the bidirectional relationship between AF and MI.
Fig. 2: Inflammatory cells and mediators of inflammation modulate cardiac electrophysiology and structural properties leading to atrial fibrillation.
Fig. 3: Pathophysiology of MI leading to AF and AF leading to MI.

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Acknowledgements

T.C.F. is supported by Aarhus University, Region Midtjyllands Sundhedsvidenskabelig Forskningsfond (A3116), Helsefonden (20-B-0206) and the Danish Agency for Higher Education and Science (EliteForsk 2025-00072B). S.R.P. is supported by NIH grant 5R01HL128914-04. H.L. is supported by the European Commission Grant (Agreement No 847770) and NIH U01AG068221. L.T. is supported by the American Heart Association (18SFRN34150007). E.J.B. is supported by the NIH (2R01 HL092577, 1R01 HL141434 01A1, 2U54HL120163, 1R01AG066010 and 1R01AG066914) and the American Heart Association (18SFRN34110082). J.K. received funding from the Marie Sklodowska-Curie Actions under the European Union’s Horizon 2020 research and innovation programme (agreement No. 838259).

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Authors and Affiliations

  1. Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark

    Tanja Charlotte Frederiksen

  2. Department of Clinical Medicine, Aarhus University, Aarhus, Denmark

    Tanja Charlotte Frederiksen

  3. Department of Public Health, Aarhus University, Aarhus, Denmark

    Christina Catherine Dahm

  4. Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA

    Sarah R. Preis

  5. Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA

    Honghuang Lin

  6. Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA

    Ludovic Trinquart

  7. Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA

    Ludovic Trinquart

  8. Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA

    Emelia J. Benjamin

  9. Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA

    Emelia J. Benjamin & Jelena Kornej

  10. Framingham Heart Study, Framingham, MA, USA

    Emelia J. Benjamin & Jelena Kornej

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T.C.F., E.J.B. and J.K. researched data for the article. T.C.F., S.R.P., H.L., E.J.B. and J.K. discussed the content of the article. T.C.F. and S.R.P. wrote the manuscript. C.C.D., H.L., L.T., E.J.B. and J.K. reviewed and edited the manuscript before submission.

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Correspondence to Jelena Kornej.

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Frederiksen, T.C., Dahm, C.C., Preis, S.R. et al. The bidirectional association between atrial fibrillation and myocardial infarction. Nat Rev Cardiol 20, 631–644 (2023). https://doi.org/10.1038/s41569-023-00857-3

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