50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: a cohort study
Open accessAbstract
Background Comprehensive long-term data on atrial fibrillation trends in men and women are scant. We aimed to provide such data through analysis of the Framingham cohort over 50 years.Methods We investigated trends in incidence, prevalence, and risk factors for atrial fibrillation and its association with stroke and mortality after onset in 9511 participants enrolled in the Framingham Heart Study between 1958 and 2007. We analysed trends within 10 year groups (1958-67, 1968-77, 1978-87, 1988-97, and 1998-2007), stratified by sex.Findings During 50 years of observation (202,417 person-years), 1544 cases of new-onset atrial fibrillation occurred (of whom 723 [47%] were women). Between 1958-67 and 1998-2007, age-adjusted prevalence of atrial fibrillation quadrupled from 20·4 to 96·2 cases per 1000 person-years in men and from 13·7 to 49·4 cases per 1000 person-years in women; age-adjusted incidence increased from 3·7 to 13·4 new cases per 1000 person-years in men and from 2·5 to 8·6 new cases per 1000 person-years in women (ptrend<0·0001 for all comparisons). For atrial fibrillation diagnosed by electrocardiograph (ECG) during routine Framingham examinations, age-adjusted prevalence per 1000 person-years increased (12·6 in 1958-67 to 25·7 in 1998-2007 in men, ptrend=0·0007; 8·1 to 11·8 in women, ptrend=0·009). However, age-adjusted incidence of atrial fibrillation by Framingham Heart Study ECGs did not change significantly with time. Although the prevalence of most risk factors changed over time, their associated hazards for atrial fibrillation changed little. Multivariable-adjusted proportional hazards models revealed a 74% (95% CI 50-86%) decrease in stroke (hazards ratio [HR] 3·77, 95% CI 1·98-7·20 in 1958-1967 compared with 1998-2007; ptrend=0·0001) and a 25% (95% CI -3-46%) decrease in mortality (HR 1·34, 95% CI 0·97-1·86 in 1958-1967 compared with 1998-2007; ptrend=0·003) in 20 years following atrial fibrillation onset.Interpretation Trends of increased incidence and prevalence of atrial fibrillation in the community were probably partly due to enhanced surveillance. Measures are needed to enhance early detection of atrial fibrillation, through increased awareness coupled with targeted screening programmes and risk factor-specific prevention.Funding NIH, NHLBI, NINDS, Deutsche Forschungsgemeinschaft.
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Treated hypertension versus none is independently associated with AF (HR 1.32, 95% CI 1.08-1.60).
“Hypertension (treated) vs. none 19 HR 1.32 (95% CI 1.08-1.60)”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [19]
Heart failure versus none is independently associated with AF (HR 1.43, 95% CI 0.85-2.40).
“Heart failure vs. none 19 HR 1.43 (95% CI 0.85-2.40)”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [19]
Older age is independently associated with AF; compared with 50-59 years, HRs are 4.98 for 60-69 years, 7.35 for 70-79 years, and 9.33 for 80-89 years.
“Older age 19 50-59 years 60-69 years 70-79 years 80-89 years HR: 1.00 (reference) 4.98 (95% CI 3.49-7.10) 7.35 (95% CI 5.28-10.2) 9.33 (95% CI 6.68-13.0)”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [19]
Obesity is independently associated with AF, with overweight HR 1.13 and obese HR 1.37 compared with BMI <25 kg/m2.
“Obesity 19, 208 none (BMI < 25 kg/m²) overweight (BMI 25-30 kg/m²) obese (BMI ≥ 31 kg/m²) HR: 1.00 (reference) 1.13 (95% CI 0.87-1.46)1.37 (95% CI 1.05-1.78)”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [19]
Myocardial infarction versus none is independently associated with AF (HR 1.46, 95% CI 1.07-1.98).
“Myocardial infarction vs. none 19 HR 1.46 (95% CI 1.07-1.98)”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [19]
Diabetes mellitus versus none is independently associated with AF (HR 1.25, 95% CI 0.98-1.60).
“Diabetes mellitus vs. none 19 HR 1.25 (95% CI 0.98-1.60)”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [19]
In North American and European populations, the age-adjusted incidence of AF is 1.5 to 2 times higher in men than in women.
“In North American and European populations, the age-adjusted incidence of AF has been estimated to be 1.5 to 2 times higher in men than in women (Supplementary Tables S1 and S2).”
From Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis (2016) · cites this paper as [5]
Age-adjusted prevalence of AF is lower in women than in men in North America and Europe.
“Similarly to incidence, age-adjusted prevalence of AF has been reported to be lower in women than in men in North America and Europe (Figure 2) (Supplementary Tables S3 and S4).”
From Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis (2016) · cites this paper as [5]
Elevated body mass index, hypertension, diabetes mellitus, coronary heart disease, valvular heart disease, and heart failure are major risk factors for AF, but their prevalence varies between women and men.
“Elevated body mass index, hypertension, diabetes mellitus, coronary heart disease, valvular heart disease, and heart failure (HF) constitute major risk factors for AF, but the prevalence of these risk factors vary between women and men.3–5”
From Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis (2016) · cites this paper as [5]
Women with AF have higher prevalence of hypertension and valvular heart disease and lower prevalence of coronary heart disease than men with AF.
“Women with AF have higher prevalence of hypertension and valvular heart disease and lower prevalence of coronary heart disease than men with AF.5,11,34”
From Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis (2016) · cites this paper as [5]
In studies from North America, Europe, and Australia, women with AF are, on average, older than men.
“However, in studies from North America,5 Europe,34,35 and Australia,11 women with AF are, on average, older than men.”
From Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis (2016) · cites this paper as [5]
Body mass index has increased significantly in both women and men with AF.
“In particular, body mass index has increased significantly (Figure 3).5”
From Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis (2016) · cites this paper as [5]
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- Authors
- Schnabel, R. B., Yin, X., Gona, P., Larson, M. G., Beiser, A. S., McManus, D. D., Newton-Cheh, C., Lubitz, S. A., Magnani, J. W., Ellinor, P. T., Seshadri, S., Wolf, P. A., Vasan, R. S., Benjamin, E. J., & Levy, D.
- Affiliations
- Framingham Heart Study (US)
- Boston University (US)
- University of Massachusetts Chan Medical School (US)
- Harvard University (US)
- Broad Institute (US)
- Corresponding author
- Schnabel, Renate B
- ORCID
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2015-07
- Volume
- 386
- Issue
- 9989
- Pages
- 154-162
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC4553037
- OpenAlex
- W1924098982
- Cited by
- 1,746
- References
- 32
- Citations by year
- 2026: 126 · 2025: 209 · 2024: 253 · 2023: 192 · 2022: 198 · 2021: 155 · 2020: 145 · 2019: 141 · 2018: 120 · 2017: 110 · 2016: 76 · 2015: 20
- FWCI
- 79.02
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- The Lancet (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- The Journal of the American Medical Association (JAMA) Network (American Medical Association) (submittedVersion)
- Funders
- NIH/NHLBI (contract N01-HC-25195, grant 1K23HL114724)
- NIH (grants 1RC1HL101056, HL102214, and AG028321, grant 2R01HL092577, grants 1U01HL105268-01 and KL2RR031981)
- Fondation Leducq (14CVD01) and NIH grants (1R01HL092577, 1RC1HL101056, 1R01HL102214, 1R01AG028321, R01HL104156, and 1K24HL105780)
- American Heart Association Established Investigator Award (13EIA14220013)
- Deutsche Forschungsgemeinschaft (German Research Foundation) Emmy Noether Program (SCHN 1149/3-2)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Epidemiology › Acute Ischemic Stroke Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Keywords
- atrial fibrillation, prevalence trends, incidence trends, sex differences, risk factors, stroke, mortality, Framingham Heart Study, electrocardiogram screening, atrial fibrillation screening, atrial fibrillation prevention, cardiovascular disease prevention, long-term cohort follow-up
- MeSH terms
- Aged, Aged, 80 and over, Atrial Fibrillation, Electrocardiography, Female, Humans, Male, Middle Aged, Mortality, Risk Factors, United States, Cohort Studies, Incidence, Prevalence, Age Distribution, Sex Distribution, Stroke
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