Atrial Fibrillation: Age at Diagnosis, Incident Cardiovascular Events, and Mortality

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In this population-based cohort study, early-onset (age ≤50 years) atrial fibrillation (AF) was associated with a more than eightfold increased risk of heart failure, more than twofold increased risks of ischemic stroke and mortality, and a mean estimated loss of life of 9.2 years.
These findings emphasize the substantial cumulative health burden associated with the onset of AF at earlier life stages, highlighting the need for intensive efforts targeting risk factors for AF onset and progression throughout the lifespan.


Written by Christian Paludan-Müller MD, PhD
For the last 5 years or so, there has been an increased focus on cardiomyopathy and heart failure among patients with atrial fibrillation (AF), supported by a genetic component particularly among those with early-onset AF (age ≤65 years), which might explain a portion of these well-known associations.1-5 Although AF is well-known as the initial manifestation of later myocardial disease,6 the risks of subsequent cardiomyopathy, heart failure, and mortality among patients with AF in accordance with age have not previously been reported; this nationwide population-based cohort study provides novel information on the topic.

The present study involved 216,579 patients diagnosed with AF and 866,316 matched controls between 2000 and 2020. The authors analyzed the absolute risks and rates of outcomes according to age and estimated the expected differences in residual life years. In summary, comparing the patients with controls, the study observed a stepwise pattern for cardiomyopathy, heart failure, and mortality, with a higher rate increase at earlier diagnosis. Younger age was especially associated with increased rates of myocardial disease and a large reduction in expected average life-years.

The most noteworthy hazard ratios for the investigated outcomes when comparing patients with AF aged ≤50 and >80 years with matched controls were as follows: cardiomyopathy ranged from 8.90 (95% CI, 7.17–11.0) to 2.90 (95% CI, 2.46–3.42), heart failure ranged from 8.64 (95% CI, 7.74–9.64) to 4.11 (95% CI, 3.99–4.24), and mortality ranged from 2.74 (95% CI, 2.53–2.96) to 2.29 (95% CI, 2.26–2.32). The expected average loss of residual life-years between patients and controls varied from 11.3 years (95% CI, 11.0–11.6) among individuals aged ≤30 years to 3.6 years (95% CI, 3.5–3.6) among individuals aged ≤80 years at the time of diagnosis.

At a time when the knowledge of AF among younger patients is steadily improving, it is important that continued research is performed to understand if there is a causal relationship and whether AF could be used as an early indication (eg, a red flag or risk marker) of future ventricular myocardial disease. It should be further investigated to which degree these associations could be caused by the arrythmia per se or by shared underlying risk factors, including a genetic component. Causality should be determined as the mechanisms for disease progression among patients may be different in accordance with age. Since there is an effort to improve risk stratification for AF itself,7,8 this study could stimulate interest among colleagues to improve the prediction of AF complications as well. The development of better prediction models for arrhythmia complications is especially relevant, considering that the newest US guidelines from November provide a weak recommendation for genetic testing among patients with AF onset before 45 years of age.9

The problem with these studies showing AF leads to heart failure is that none I've seen control for antiarrhythmics, rate control, and ablation/Maze. I don't have the time to go look for them now, but there are studies showing that well-managed afib does not reduce life expectancy.

I was sort of thinking what Carey is. When I got Tachy-cardia mediated Cardio-myopathy and Heart Failure, it was because my condition was undiagnosed, and my HR went uncontrolled for a long time. I after I slowed my HR down in the normal NSR range, with rate-control drugs, my Heart strengthened back to normal, and is still normal after 14 years.

It seems to me that if the HR is well controlled while in AFIB, than the risk of AFIB directly causing Heart Failure would not be that high, and I don't understand by what mechanism this would happen. Association yes, direct cause seems much less likely. But this is only my opinion.

What do you consider HR well controlled? I am in A Fib 6% of the time as measured by my pace maker. When in A Fib my kardia device shows rates at 144 average. When I started to have problems and not on any meds my rate would be 260 to 300( flutter?)

Well controlled is a HR under 100. Brief forays into higher rates are okay as long as they're not prolonged.

260-300? My, that's impressive... and dangerous.

"What do you consider HR well controlled?"

I consider it close to what your HR is when your in NSR. For me personally that means 65-80 bpm. Like Carey said the standard figure used for being too high, is anything over 100, for more than 24 hours straight. 144 is too high if you can do anything about it. Short periods of time is ok, when people exercise or run a triathalon for example, their HR is elevated around or over 144, but this is only for hours, not days.

I agree Carey. I speculate it is overall tachycardia burden that isn’t controlled for > week at a time that reoccurs frequently that may cause wear and tear and perhaps weaken one’s heart.

I think it’s a combination of perhaps yearly tachycardia burden overall and genetically inclined for HF.

One can attempt to be rate controlled but flutter isn’t easy to control.

Maybe that’s where, untreated, the study got their 9.2 life expectancy rate risk.

There is a recent article on ICliniq that AFIB is now being detected in much younger people, and no longer just in "old people", For the most part I have had good care for my AFIB over the past 40+ years. (diagnosed at 30) I agree that management of the condition likely makes a difference in mortality rates. My cardiologist once told me that I will likely die with it, not from it.

When you read the study - which is quite long and lots of stats, there are limitations to the study and the following excerpt:

"Third, the analyses did not adjust for ablation and medication, including antiarrhythmic and anticoagulation drugs nor were time-dependent variables and clinical information (e.g. body weight and tobacco use) included; thus, there will be residual confounding."

[academic.oup.com]

Full study paper link

Well shit….i was diagnosed at 28. 33 now. Guess I should revise my lifespan expectations thought for some reason I’d live a normal life if I kept myself medicated and in NSR

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Zb3
Well shit….i was diagnosed at 28. 33 now. Guess I should revise my lifespan expectations thought for some reason I’d live a normal life if I kept myself medicated and in NSR

See my comment on the study. Studies show you will live a normal lifespan if your afib is well controlled. Although medications may be sufficient for you, you're going to depend on those meds for an awfully long time. At your age I would definitely consider ablation to be done with the drugs.

I could name 20+ physical issue that left unmanaged or untreated, would lead to a shortened life span. However, most of us choose to either manage our afib with drugs as well as some possible lifestyle changes or have an ablation. I have had two successful ablations within my 26-year history of afib. I see no reason I will not live well past 90 as I make a great effort to stay fit and healthy. I am 79. My father made it to 97.

Quote
Carey

Well shit….i was diagnosed at 28. 33 now. Guess I should revise my lifespan expectations thought for some reason I’d live a normal life if I kept myself medicated and in NSR

See my comment on the study. Studies show you will live a normal lifespan if your afib is well controlled. Although medications may be sufficient for you, you're going to depend on those meds for an awfully long time. At your age I would definitely consider ablation to be done with the drugs.

Are we sure about that? The study notes:

“ The study included 216 579 AF patients from year 2000 to 2020 and 866 316 controls.” I cannot imagine that almost 216,000 patients were not being treated at all. Also a 2000 to 2020 time period is a relatively recent one, so they would have access to modern medicine and it also demonstrates the study was only just published. Sounds quite worrying to me

I was diagnosed at 30 with AFIB, now 74. I have had this for over 40 years. I have had a full life. Back then there were so few options, today so many more. You will likely at your age have the advantage of even better treatment options and research. There are many folks in the forum that have lived with this for years and still here.

I've had afib for 2 months shy of 20 years. During that time, I've known a huge number of people with afib. I can think of very few that I knew of who died from afib (stroke or heart failure). One that I know of is moderator Shannon's father who died of an afib related stroke, and another is his sister who was living in a nursing home for a number of years subsequent to an afib ablation incident and then she passed. Shannon was living in Europe and had advised his sister to go to Dr. Natale in the late 2000's. She did not take his advice and her local doc botched the ablation. Shannon learned of this after it happened. A couple of the folks here that I know passed died in their 90's, with, but not from, afib. This includes Hans Larsen who founded the site. His late life issue was prostate cancer. Jackie and LIz are two that I've known here since the beginning. LIz is in her 90's and Jackie is 87 or 88. Both still lead active lives.

There was a paper I read in 2007. It followed afib patients living in Olmsted County, MN (where the Mayo Clinic headquarters are located) for up to 30 years. My recollection is the folks with afib lived longer than those without it. Another takeaway is they started out healthier, but their health (like metabolic conditions) converged to be like those without afib. I vowed at that point that I would not let that happen.

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Hans Larsen, The Afib Report
Long-term progression of lone AF
ROCHESTER, MINNESOTA. More than 50 years ago cardiologists at the Mayo Clinic began following a group of lone afibbers in order to determine their long-term prognosis and survival. The group consisted of 34 participants with the paroxysmal variety, 37 with persistent afib, and 5 with permanent afib at entry to the study. Lone AF was defined as atrial fibrillation without underlying structural heart disease or hypertension (no age limitation). Atrial fibrillation was defined as paroxysmal if it terminated on its own, as persistent if cardioversion (electrical or drug-assisted) was required to terminate episodes, and as permanent if sinus rhythm could not be restored or maintained despite intervention. The average age at diagnosis was 44 years and 78% of the group was male. Thirty-four percent of study participants were prescribed digoxin within 30 days of their first episode. The number of "digoxin users" had increased to 75% at the latest follow-up.After an average follow-up of 30 years, 29% of paroxysmal and persistent afibbers had progressed to permanent AF. It is interesting to note that 68% of persistent afibbers became paroxysmal and 22% became permanent during follow-up. Only 6% of paroxysmal afibbers became persistent, while 41% became permanent. In most cases the progression to permanent AF occurred within the first 15 years after diagnosis. Survival in the study group at 92% at 15 years and 68% at 30 years was similar to or even slightly better than expected for an age- and sex-matched group of Minnesotans (86% and 57% at 15 and 30 years respectively). Twelve of the reported deaths were due to cardiovascular causes, while the remaining 15 deaths were due to other causes. The development of congestive heart failure (19% of group at 30 years follow-up) was not significantly higher than expected (15%). During the follow-up, 5 strokes (0.2%/person-year) and 12 transient ischemic attacks (0.5%/person-year) occurred in the group – mostly among permanent afibbers. All strokes and TIAs occurred in participants who had developed one or more risk factors for stroke during follow-up (hypertension in 12 patients, heart failure in 4, and diabetes in 3). Not a single stroke or TIA occurred among lone afibbers with no risk factors for stroke. This prompted the following remark from the researchers:Our long-term data suggest that the increased risk of stroke in atrial fibrillation is due to "the company it keeps".In other words, lone atrial fibrillation as such is not a risk factor for ischemic stroke. The overall conclusion of the study is highly reassuring to lone afibbers,After >30 years of follow-up of our rigorously defined cohort, findings confirm that overall survival is not affected adversely by lone atrial fibrillation.In an accompanying editorial, Dr. Lars Frost of the Aarhus University Hospital in Denmark makes the following interesting comment, Cardiologists with strong political influence have suggested that a diagnosis of lone atrial fibrillation should be restricted to patients <60 years of age, although there is not evidence of any threshold values by age regarding the risk of stroke in patients with atrial fibrillation – or in any other medical condition for that matter.
Jahangir, A, et al. Long-term progression and outcomes with aging in patients with lone atrial fibrillation. Circulation, Vol. 115, June 19, 2007, pp. 3050-56

Edited 1 time(s). Last edit at 05/10/2024 04:46PM by GeorgeN.

Treat this as you would the research saying all-cause mortality/relative risk between those taking statins and those who don't favours those taking statins. Of course they would! But it doesn't mean any one person you can point to WILL develop those later and predicted conditions. They may well, but there's a good chance they won't.

Thanks all for your comments, and thanks for posting that study George. Do you know if that study extended further than 30 years? If the average age at diagnosis was in the 40s then the study stopped following them in mid 70s. When I contrast that with the study OP posted, which claims life expectancy was in the mid 70s for afibber diagnosed below 50 - you’d expect at that point people to start dying so it’s a shame the study you linked didn’t extend past that. That gives some hope of course but it does worry me that the other study which claims a 11.2 year loss of life for those diagnosed under 30 does so with a 95% confidence interval. I note that those with lower chadvasc score and no comorbidities seemed to fair slightly better but even the low comorbidity group seemed to have significant loss of life. It was also interesting to note that a lot of them were medicated - I also think 26% of the afib participants had been ablated at some point.

All of that said, I don’t really know what to think of scientists given studies reach contradicting views.

I also found reference 39 in the study to be interesting where it states:

“ The non-arrhythmic substrate is supported by a recent study, which reported increased risk of diastolic dysfunction among AF patients over time, not mitigated by rhythm control.”

I don’t even know what diastolic heart failure is really, is that a common ailment among the older sufferers here?

This is a study referenced in the study from the OP. It is based on Framingham data & a) most of the afib folks had significant comorbidities at diagnosis and b) when they excluded the people who died in the first 30 days from diagnosis, the relative risk for men dropped to 1.1. In the study I posted, the people they included at the beginning were "Lone Afibbers," which could simply be defined as they didn't have comorbidities. That term is no longer used. That was me, I was under 50 when first diagnosed and chronic fitness was my path, not comorbidities. I've been able to maintain the no morbidities for 20 years.