REVIEWS

Global epidemiology of atrial fibrillation

Faisal Rahman, Gene F. Kwan and Emelia J. Benjamin
Abstract | Atrial fibrillation (AF) is a major public health burden worldwide, and its prevalence is set to
increase owing to widespread population ageing, especially in rapidly developing countries such as Brazil,
China, India, and Indonesia. Despite the availability of epidemiological data on the prevalence of AF in North
America and Western Europe, corresponding data are limited in Africa, Asia, and South America. Moreover,
other observations suggest that the prevalence of AF might be underestimated—not only in low-income and
middle-income countries, but also in their high-income counterparts. Future studies are required to provide
precise estimations of the global AF burden, identify important risk factors in various regions worldwide,
and take into consideration regional and ethnic variations in AF. Furthermore, in response to the increasing
prevalence of AF, additional resources will need to be allocated globally for prevention and treatment of AF
and its associated complications. In this Review, we discuss the available data on the global prevalence,
risk factors, management, financial costs, and clinical burden of AF, and highlight the current worldwide
inadequacy of its treatment.
Rahman, F. et al. Nat. Rev. Cardiol. advance online publication 12 August 2014; doi:10.1038/nrcardio.2014.118

Introduction
Atrial fibrillation (AF) was first demonstrated on
electrocardiograms >100 years ago, 1,2 and has since
become increasingly recognized as a major global
health burden. Although accurate worldwide esti-
mates are lacking, calculations suggest that ≥1% of
the adult population is affected in Australia, Europe.
and the USA.3–7 However, the actual prevalence could
be considerably higher, because many patients with
AF remain undiagnosed.8–10 Importantly, AF is asso-
ciated with increased risks of stroke, 11,12 myocardial
infarction,13,14 heart failure (HF),11,15 dementia,16,17 and
chronic kidney disease,18,19 as well as increased mor-
tality.3,11,20,21 The global prevalence and cost of AF are
expected to surge owing to factors such as economic
growth, an ageing population, and increased preva-
lence of risk factors for AF in both Western countries
and rapidly developing countries such as Brazil, China,
India, and Indonesia.22–26
Global trends
Department of
Medicine (F.R.), Prevalence
Department of The worldwide age-adjusted prevalence of AF, as esti-
Cardiovascular
Medicine (G.F.K.),
mated in the 2010 Global Burden of Disease Study,27 is
Boston Medical Center, 596 per 100,000 men and 373 per 100,000 women, equat-
Boston University ing to approximately 33 million people. In Australia,
School of Medicine,
72 East Concord Street, Europe, and the USA the estimated prevalence of AF
Boston, MA 02118, in adults is 1–4%,4,6,28–32 rising to >13% of individuals
USA. The Framingham
Heart Study, 73 Mount
aged >80 years.3–7 Approximately 3–5 million individu-
Wayte Avenue, als in the USA have AF. 28,29 With population ageing,
Suite 2, Framingham, AF is expected to affect >8 million people in the USA
MA 01702‑5827, USA
(E.J.B.). by 2050,28,29 and in Europe, AF is projected to increase
Correspondence to:
E.J.B. Competing interests
emelia@bu.edu The authors declare no competing interests.
from the current estimated prevalence of 8.8 million5,22 to
approximately 18 million in 2060 (Figure 1).5,33
The incidence of AF increases rapidly with advanc-
ing age, and the majority of patients in high-income
countries are aged >65 years.22,29 An estimated 700,000
people in Japan have AF, which is projected to increase
to >1 million by 2050, despite a predicted decrease in the
total population (Figure 1).34,35 In China, AF affects an
estimated 3.9 million (2%) individuals aged ≥60 years,36
but by 2050, China will have 460 million individuals
aged ≥60 years, of whom an estimated 9 million will
have AF.37,38 Estimates from other regions of the world
are less accurate, although populations of elderly adults
in low-income and middle-income countries (LMICs,
as defined by the World Bank39) are similarly expected
to swell. For example, by 2050, the number of individu-
als aged >60 years in India is predicted to rise from the
current 96 million to >330 million, and in Africa from
approximately 53 million to 220 million.37 Consequently,
AF is likely to become a major cause of morbidity in
these regions.
Burden of disease
In the 2010 Global Burden of Disease Study, 40 age-
standardized­disability-adjusted life-years (DALYs, cal-
culated by adding the years lived with disability to the
years of life lost secondary to death from disease), indi-
cate the overall morbidity contributed by a given disease
in the population. For AF, the age-standardized DALYs
in Central Asia, China, Russia, South Asia, Southeast
Asia, and Sub-Saharan Africa were 35–50 per 100,000
people. 40 In comparison, age-standardized DALYs
for patients with AF in Australia, Canada, the USA,
and Western Europe were >60 per 100,000 people.40

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Key points patients from remote or rural areas. Similarly, urban and
rural populations could have different risk factors for
■■ Atrial fibrillation (AF) is a worldwide epidemic affecting approximately 33 million
AF, such as an increased prevalence of rheumatic heart
people, and its rising prevalence is expected to account for increasing clinical
and public health costs
disease (RHD) in rural populations.42
■■ Australia, Europe, and the USA have the highest reported prevalence of AF (1% in Even though large studies from high-income coun-
the adult population), but the prevalence of AF in low-income and middle-income tries are available, our current data might still under-
countries is probably underestimated estimate the true prevalence of AF in these regions.
■■ AF is associated with an increased risk of myocardial infarction, heart failure, Investigators in studies of AF usually identify affected
stroke, dementia, and chronic kidney disease, as well as increased mortality patients from single-occasion screening electrocardio-
■■ Treatment of patients with AF is inadequate: <50% of those at high thromboembolic grams,9 which are likely to reveal only permanent AF
risk receive anticoagulation therapy worldwide
(Table 1). Many patients with AF are asymptomatic
■■ The dearth of data on the prevalence, lifetime risk, prognosis, prevention,
treatment, and economic implications of AF in many regions around the world and some are identified only as a result of other inves-
remains to be addressed tigations or interventions,10 such as after a stroke,43–46
during ambulatory electrocardiography,8 or implanta-
tion of a pacemaker device.47,48 The underestimation of
30.0
Current estimated prevalence of AF AF prevalence is a worldwide problem, as demonstrated
27.5
2050 estimates of AF prevalence
based on population projections
by a study of patients aged >30 years with hypertension
by the USA Census Bureau in Malaysia, among whom the prevalence of asympto-
25.0 matic AF was 0.75%.49 The possible underestimation of
AF might explain some of the variability in prevalence
22.5
reported worldwide. Consequently, upcoming studies
2.5 using ambulatory and mobile electrocardiography
20.0
2.0
might demonstrate an increased prevalence of AF, even
Prevalence of AF (×103)

1.5
17.5
1.0 in high‑income countries.
0.5
15.0
0 Ethnicity and geography
The exact reasons underlying the ethnic and regional
n

12.5
Th a
nd

lia

il
pa

ny

az
ra
la

variation in AF have not been identified, but are prob-

Ja

Ke

Br
ai

st
Au

10.0 ably attributable to differences in study design (as noted

above), genetics, and environmental factors. Variants
7.5
at several genetic loci are associated with the develop-
5.0 ment of AF and seem to differ in frequency between
populations, and are likely to explain some of the ethnic
2.5 v­ariation observed in the prevalence of AF.50,51
Individuals of non-European ancestry have a lower
0
prevalence of AF. Among members of the Kaiser
Permanente Southern California Health Plan who were
A

pe

nd

lia

il
az
ny
ric

di

in

pa
US

ra
ro

la
In

Ch

Br
Ke
Af

Ja

ai

st
Eu

aged ≥60 years in 2008, the prevalence of AF was sig-

Th

Au

Geographical region nificantly higher in white individuals (8.0%) than in

Figure 1 | Global prevalence of AF. Estimated increase of AF in different regions.
37
Abbreviation: AF, atrial fibrillation.
A comparison of these values with data from the 1990
Global Burden of Disease Study shows that the burden
of AF is steadily rising, and now comprises an increased
percentage of total DALYs for each nation.40,41
Sources of variability in the data
Methodological limitations
The majority of epidemiological studies conducted
outside North America and Western Europe have
limitations, such as a cross-sectional design, the small
number of individuals with AF, and lack of inclusion of
an adequate proportion of the population. For example,
patients admitted to hospital, cardiovascular clinics, or
fitted with pacemaker devices have much higher rates
of major risk factors for AF, such as cardiomyopathies,
than do the general population. The cohorts are also
often over-representative of urban populations, and lack
black (3.8%), Hispanic (3.6%), and Asian (3.9%) ethnic
groups;52 the increased prevalence of AF in white groups
is supported by several other large US studies. 22,53–56
Similarly, data from the UK-based West Birmingham
Atrial Fibrillation Project 57,58 showed a low prevalence of
AF among Indo-Asian participants aged >50 years (0.6%),
whereas the prevalence of AF was 2.4% in the general
study population aged ≥50 years. Global studies lend
support to the findings of ethnic variation in the prev-
alence of AF in the Western world: an analysis of data
from the multinational ASSERT trial59 (in which patients
had an implanted pacemaker or defibrillator) revealed
a higher incidence of AF in individuals of European
ancestry than in individuals of African, Chinese, or
Japanese backgrounds.
Data are lacking on the prevalence of AF in Africa,
South America, and South Asia, owing to a dearth of
longitudinal epidemiological studies. The available data
on the prevalence of AF suggest that values in LMICs
are lower than those in the Western world (Table 1).
In East Asian nations, the estimated prevalence of AF

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Table 1 | Worldwide prevalence of AF

Country Year(s) Sample Study population Prevalence Study
data- size (n) (%) total
obtained Data source Age (men, women)
(% participation, if available) (years)
Australia 2000 14,194 50 consecutive patients at 321 ≥30 4.0 (6.0, 4.0) Sturm et al. (2002)6
general practices*
Brazil 2003–2005 1,524 Systematic door knock in ≥65 2.4 (3.2, 2.0) Kawabata-Yoshihara et al.
São Paulo (70%) (2009)63
China Unknown 29,079 Random sample of 14 cohorts ≥30 0.8 (0.9, 0.7) Zhou et al. (2008)36
2,410 from 13 provinces (96%) ≥70 3.7 (4.1, 3.1)
China Unknown 9,309 Cluster sampling in Taiyuan ≥20 0.9 (1.0, 0.9) Chen et al. (2011)136
India Unknown 984 Tribal Himalayan village‡ ≥15 0.1 (ND, ND) Kaushal et al. (1995)66
Iran 2001 463 Two general practitioners serving 50–79 2.8 (1.3, 4.3) Habibzadeh et al.
the National Iranian Oil Company‡ (2004)245
Japan 2003 630,138 Examinations from company clinics, ≥40 0.9 (1.4, 0.4) Inoue et al. (2009)35
123,425 local governments, health centres ≥70 2.3 (3.6, 1.3)
Kenya 2008–2010 22,144 One hospital’s admissions ≥18 0.7 (ND, ND) Shavadia et al. (2013)65
in Nairobi‡
South 2000 14,540 General health screening data ≥40 0.7 (1.2, 0.4) Jeong et al. (2005)60
Korea 1,639 from five cities in three counties ≥70 2.0 (2.9, 1.2)
South 2001–2003 10,012 Cohort from one urban and one 40–69 0.4 (0.6, 0.2) Lee et al. (2008)74
Korea 2,688 rural location‡ 60–69 1.0 (1.8, 0.5)
Sweden 2010 209,141 All hospitals nationwide ≥20§ 2.9 (3.3, 2.5) Friberg et al. (2013)4
Tanzania 2009–2010 2,232 12 villages in a district (89%) ≥70 0.7 (1.0, 0.3) Dewhurst et al. (2012)64
Thailand 1991 8,791 Random sampling of national ≥30 0.4 (0.4, 0.4) Kiatchoosakun et al.
government database (1999)61
Thailand Unknown 963 Cross-section of a Thai rural area ≥60 2.2 (1.8, 2.3) Assantachai et al. (2002)62
Turkey 2006–2007 3,450 Prospective cohort of Turkish ≥32 1.3 (1.6, 0.9) Uyarel et al. (2008)75
722 adults‡ ≥70 2.5 (3.2, 1.9)
UK 2009–2010 761,965 National primary care practice ND 1.4 (ND, ND) Health & Social Care
database Information Centre (2010)31
UK 2003 12,267 131 primary care practices ≥35 ND (1.3, 1.1) DeWilde et al. (2006)30
nationwide
USA 2004–2005 242,903 National databases of employer- ≥20 1.1 (ND, ND) Naccarelli et al. (2009)29
funded insurance and Medicare
Studies were included based on AF population size and date of data collection. Large studies encompassing multiple regions within a country were included
in preference over small but more recent studies. *321 of 396 general practitioners returned data, 9% of selected patients withdrew or refused participation.
‡
Uncertain participation. §Mean age 71.9 ± 12.3 years. Abbreviations: AF, atrial fibrillation; ND, not determined.

is 0.36–0.90%,34–36,60–62 whereas among Brazilians aged
>65 years, its prevalence is 2.40%.63 Similarly, in a small,
cross-sectional study of individuals aged >70 years in
rural Tanzania, the prevalence of AF was surprisingly
low (0.67%),64 and among 22,000 admissions to a Kenyan
hospital, the prevalence of AF was 0.70%.65 The only
study we found from South Asia included residents in
a tribal Himalayan village in India who received a single
electro­cardiogram; the reported prevalence of AF of
0.10% is likely to be an underestimate.66 However, with
the release of data from the PANARM‑HF registry,67
a more accurate estimate of AF prevalence in India should
become available.
Age and sex
In addition to regional and ethnic variation in the preva-
lence of AF, the age distribution of those affected can
differ between regions. In Australia, North America,
and Western Europe, >70% of patients with AF are aged
>65 years.4,5,22,29,30,32 Outside these regions, the average
age of patients with AF seems to be lower: for example,
in a study of six Middle Eastern nations, the mean age of
patients with AF was 57 years,68 and in an Ethiopian study
it was 41 years.69 Similarly, in a general screening study in
South Korea, 43% of patients identified with AF were
aged <65 years,60 and at a hospital in South Africa, 38%
of the patients with AF were aged <50 years.70 Regional
variation was also reported in the RE‑LY AF registry,71
in which investigators enrolled patients from 164 emer-
gency departments worldwide: patients with AF in Africa,
India, and the Middle East were on average 10–12 years
younger than those from other regions of the world. In the
Gulf SAFE registry 72 of Middle Eastern countries, 16% of
patients had RHD, a condition that affects a younger pop-
ulation (aged 5–30 years), is rare in developed countries
and, importantly, is a risk factor for AF.68 Heterogeneity
in the underlying causes of AF might, therefore, partly
explain the lower mean age of patients with AF in LMICs.73

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80
HTN DM CAD HF
VHD RHD Obesity
70

60

Prevalence of risk factor (%) 50

40

30

20

10

0
ia

nd

la

tio dle

UK

A
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di

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US
op

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In

Ch

nt

na id

Ko
Ke

Af

Ja
hi

ai

ez

st x M
ge
Et

Th

h
Ar
ut

Ve

ut
Ea Si
So

So
Countries by gross domestic product per capita (lowest to highest)

Figure 2 | Risk factors for atrial fibrillation. Major risk factors reported in countries worldwide as a function of gross
domestic product per capita (from the World Bank databank).241 Abbreviations: CAD, coronary artery disease; DM, diabetes
mellitus; HF, heart failure; HTN, hypertension; RHD, rheumatic heart disease; VHD, valvular heart disease.

The overall decreased life expectancy observed in Obesity

LMICs compared with their high-income counterparts
also influences the prevalence and demographics of AF.
How­ever, the increase in prevalence of AF with advancing
age,34,36,49,64,74,75 as well as the (usually) higher prevalence of
AF in men than in women, seem to be worldwide phenom-
ena (Table 1).27,34,63,74 In China, by contrast, the p ­ revalence
of AF is similar in women and men.27,90
Lifetime risk
The most accurate estimates of the lifetime risk of AF come
from the Framingham Heart 76 and Rotterdam77 studies,
both of which were restricted to individuals of European
ancestry. In the Framingham cohort, men and women aged
40 years had a lifetime risk of AF of approximately 25%.76
As the incidence of AF increases rapidly with each decade,
the lifetime risk at 80 years of age is still high, at about 22%.
In men and women aged 40 years without HF or myocar-
dial infarction, the lifetime risk is lower (16%).76 The large
Rotterdam Study 77 found a similar lifetime risk in Europe.
However, the lifetime risk of AF in other ethnic groups
and regions of the world are unknown, which highlights
the need for large epidemiological studies from around the
globe to provide accurate estimates of current prevalence
and future projections of diagnosed and asymptomatic AF,
particularly in individuals of non-European ancestry.
Risk factors
Multiple risk factors influence the incidence of AF. Studies
from around the world demonstrate that the major risk
factors for cardiovascular disease (obesity, smoking,
hypertension, and diabetes mellitus) as well as cardiac
pathologies such as myocardial infarction, HF, RHD, and
valvular disorders are all commonly a­ssociated with AF
(Figure 2, Table 2).
Obesity has become a worldwide epidemic and is now
a bigger health crisis than malnutrition,78 with a >20%
prevalence of being overweight or obese in many
LMICs.79 Many studies from around the world have estab-
lished associations between elevated BMI (approximately
≥25 kg/m2) and an increased incidence or prevalence of
AF.80–86 The risk of AF among individuals who are obese
in China, Europe, Japan, and the USA was >1.6 times
that of counterparts with a normal BMI (approximately
<25 kg/m2).81,85,87 Furthermore, in a meta-analysis of six
studies of catheter ablation from China, Europe, and the
USA, patients with AF who were overweight or obese had
a 31% increased risk of recurrence when compared with
patients with a normal BMI.88 In the Atherosclerosis Risk
in Communities Study 89 from the USA, the population-
attributable fraction of the risk of AF contributed by being
overweight or obese was estimated at 17.9%, making it
the second most important risk factor after hyperten-
sion. We speculate that the growing obesity epidemic
will be a major driving force in the global increase in the
p­revalence of AF.
Hypertension and diabetes
Hypertension and diabetes are common diseases that
are widely accepted to predispose individuals to AF. As
a result of its high prevalence, hypertension is the most
common medical condition associated with AF world-
wide, affecting 29–78% of patients with AF.36,73,76,90–95 In
two large epidemiological studies of data from 19 and
26 countries, hypertension and diabetes were present
in >70% and >19% of patients with AF, respectively.91,96
Although the prevalence of each risk factor among indi-
viduals with AF varies globally (Table 2), researchers
have not reported significant variation in the risk of AF

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Table 2 | Risk factors for atrial fibrillation

Population Sample Prevalence of risk factors (%)* Study
size (n)
HTN DM RHD CAD HF VHD
19 countries‡ 10,614 78 22 ND 19 21 ND Kakkar et al. (2013)91
26 countries§ 9,816 72 21 ND 33 47 27 Chiang et al. (2012)96
6 Middle East nations 2,043 52 30 16 28 27 24 Zubaid et al. (2011)68
Argentina¶ 782 72 15 ND ND 42 ND Maurice et al. (2011)219
Cameroon 172 48 10 26 6 58 ND Ntep-Gwet et al. (2010)106
China 224 54 6 13 13 ND ND Zhou et al. (2008)36
China 1,253 51 24 6 15 8 ND Liu et al. (2010)92
China 194 56 9 ND 5 ND 17 Zhang et al. (2009)195
Denmark 217 29 19 ND 46 ND ND Jorgensen et al. (1996)137
Ethiopia 136 10 ND 66 7 ND ND Maru (1997)69
India 137 15 4 61 1.5 ND ND Bhardwaj (2012)108
Japan 2,892 58 18 ND 7|| 20 ND Inoue et al. (2010)246
Kenya 156 68 33 4 19 38 12 Shavadia et al. (2013)65
Pakistan 218 39 8 ND ND 46 ND Rasool et al. (2009)243
Saudi Arabia 400 63 48 29 29 32 ND Hersi et al. (2014)107
South Africa 246 60 4 21 7 56 ND Sliwa et al. (2010)70
South Korea 2,133 43 14 ND ND 13 13 Lee et al. (2013)247
Thailand 513 36 13 ND 14 ND 28 Jedsadayanmata et al. (2013)213
UK 6,292 66 25 ND ND 12 ND Mathur et al. (2013)211
UK (south Asian ancestry) 450 70 47 ND ND 14 ND Mathur et al. (2013)211
USA 562 54 16 ND 19 ||
13 15 Lubitz et al. (2013)183
USA 1,385 54 16 ND 20 7 5 Thacker et al. (2013)90
Venezuela 996 54 12 ND 5 23 ND Bennett et al. (2011)248
*Rounded to nearest integer. Australia, Austria, Brazil, Canada, China, Denmark, Finland, France, Germany, Italy, Japan, Korea, Mexico, the Netherlands, Norway,
‡

Poland, Spain, Sweden, and the UK. §Algeria, Azerbaijan, Belgium, Bulgaria, Czech Republic, Egypt, Germany, Hungary, Ireland, India, Italy, Lebanon, Lithuania,
Mexico, Morocco, Portugal, Russia, Slovakia, Spain, Sweden, Switzerland, Taiwan, Tunisia, Turkey, Ukraine, and Venezuela. ||Only reported myocardial infarction
history. ¶Atrial fibrillation and flutter combined. Abbreviations: CAD, coronary artery disease; HF, heart failure; HTN, hypertension; ND, not determined; RHD,
rheumatic heart disease; VHD, valvular heart disease.

associated with hypertension or diabetes according to
ethnic group.54,97
Coronary heart disease and cardiac failure
Coronary heart disease is associated with an increased risk
of AF across different ethnicities and countries.55,92,97–101
The risk of AF is high within 30 days of a myocardial
infarction,102 and remains considerable (19%) over the
subsequent 5‑year period.102,103 Similarly, the risk of
developing AF is increased by over threefold in both
men and women with HF.100 In a Japanese study, patients
with AF had a close to fivefold increase in the prevalence
of coronary artery disease or HF compared with par-
ticipants without AF, further highlighting the associa-
tions between AF and these two conditions.104 With the
epidemio­logical transition towards increased longevity
and unhealthy lifestyles, we speculate that myocardial
infarction and HF will contribute to further growth of the
global prevalence of AF.
Rheumatic and valvular heart disease
Patients with valvular heart disease have an increased risk
of developing AF. In a large study involving data from
26 countries,96 valvular heart disease was observed in 27%
of participants with AF. RHD and associated mitral valve
disease were a major cause of AF in the Western world
in the past,105 but the availability of early treatments for
streptococcal infection has made these diseases rare in
developed countries, and the latest studies do not often
report it as a separate risk factor. However, studies from
Africa, Asia, and the Middle East report a substantial
prevalence of RHD in patients with AF,36,68,70,71,106,107 reach-
ing >60% in particular regions;69,108 even in high-income
Middle Eastern countries, 15–29% of patients with AF
also have RHD.68,71,107
Other risk factors
Reports on AF prevalence in the Western world reveal a
wide variety of other risk factors, but supportive data from
international studies are lacking. Hyper­thyroidism92,109,110
and heavy or binge alcohol drinking 111 are well-established­
risk factors for AF, and ongoing research continues to
define other risk factors, such as inflammation112–114 and
serum levels of natriuretic peptides.114 The relationship
between physical activity levels and AF seems to be non-
linear: sedentary lifestyle and vigorous exercise are both

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Box 1 | Stroke risk prediction in patients with AF 12,126
CHADS2
C: congestive heart failure (1 point)
H: hypertension* (1 point)
A: age ≥75 years (1 point)
D: diabetes mellitus (1 point)
S2: previous stroke, transient ischaemic attack, or 18–26% have pre-existing AF and approximately 5%
thromboembolism (2 points)
CHA2DS2–VASc
C: congestive heart failure or left ventricular systolic higher in patients of European descent than in ethnic
dysfunction (1 point)
H: hypertension* (1 point)
A2: age ≥75 years (2 points)
D: diabetes mellitus (1 point)
S2: previous stroke, transient ischaemic attack, or similar among European, Japanese, and North American
thromboembolism (2 points)
V: vascular disease, such as peripheral artery disease, beneficiaries with AF, the risk of ischaemic stroke was
myocardial infarction, aortic plaque (1 point)
A: age 65–74 years (1 point)
Sc: female sex (1 point)‡
*Blood pressure consistently >140/90 mmHg, or receiving
treatment for hypertension. ‡Female sex only scores 1 point if the
patient has at least one other risk factor; it does not score any
points in isolation. Abbreviation: AF, atrial fibrillation.
associated with increased risk,115,116 whereas m ­ oderate
activity levels seem to be protective.117
In individuals of European descent, a family history
of AF is associated with an increased risk of developing
the disease.118–121 Additionally, familial AF has also been
described in individuals of Chinese ancestry.122,123 Genetic
variants have an important part in explaining the ethnic
differences in AF prevalence,124 as reviewed elsewhere.125
Nevertheless, future studies are needed to help to define
geographical and ethnic variability in the p­opulation-
attributable fractions of various well‑accepted classic and
novel risk factors for AF.
Prognosis
The most feared complication of AF is embolic stroke,
the average annual risk of which in patients with AF is
4.4%.126 AF is also associated with an increased risk of
HF,25,127–129 myocardial infarction,13,14 dementia,17,130–132
and chronic kidney disease,18,19 as well as with increased
mortality.20,133,134
Stroke and thromboembolism
The presence of AF increases the relative risk of stroke by
about fivefold, but the size of the attributable risk, which
indicates the number of strokes that would be elimi-
nated if AF were prevented, is strongly age-dependent,
increasing from 4.6% in individuals aged 50–59 years to
>20% in those aged 80–89 years.133 Major risk factors
that are associated with AF have been used to develop
risk prediction models for embolic stroke, such as the
CHADS2 and CHA2DS2–VASc scores (Box 1).12,126 In risk
stratification schemes developed in patients of European
ancestry, patients with the highest risk have an estimated
annual risk of ischaemic stroke of 12%.12,126 Studies from
Middle Eastern and Eastern Asian nations broadly
support the validity of these risk stratification scores in
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other populations, although the frequency of stroke in
patients with the highest risk was lower than in European
individuals with the same score.134–136
The risk of stroke in patients with AF varies between
ethnic groups. Among patients admitted to hospi-
tal with acute stroke in Europe and North America,
are newly diagnosed as having AF.137–139 Notably, the
prevalence of AF among patients with acute stroke is
minorities in the USA140,141 or in LMICs (Table 3),142–144
which might reflect the higher prevalence of AF in indi-
viduals of European ancestry. The prevalence of AF is
patients with stroke.145,146 However, among Medicare
more than twice as high among individuals of Hispanic
ancestry (10.6 per 100 patient-years) and black patients
(12.2 per 100 patient-years) compared with white
patients.147 Therefore, although the prevalence of AF is
higher among white individuals, the risk of stroke if one
has AF seems to be higher among black and Hispanic
individuals compared with white individuals.147 Ethnic
differences in the risk of stroke might reflect variation
in the influence of comorbidities, environmental expo-
sures, genetic factors, and adherence to treatment leading
to stroke, as well as the availability of medical services.
Many LMICs might not have early stroke recognition
and management algorithms for use in pre-hospital
emergency medical services, or might lack specialized
stroke services at medical centres.148
The risk of stroke in different populations is complex.
In the RE‑LY study 149 (to evaluate the efficacy of dabi-
gatran versus warfarin) the stroke rate was higher in
Asian than in non-Asian patients with AF, despite the
former being younger. However, Asian patients were
also more likely than non-Asian patients to be subthera-
peutic when taking warfarin,149,150 probably owing to
different prescribing practices and genetics. In patients
treated with warfarin, vitamin K antagonists vary in
efficacy according to genetic variants of genes such as
CYP2C9 and VKORC1. 151,152 For example, a study of
Omani patients showed that warfarin dosing varied
between ethnicities and was associated with genotypic
variation.153 Similarly, genetic variations by race or eth-
nicity affecting warfarin treatment were previously dem-
onstrated in other studies.154–157 In comparison, studies
of the pharmacokinetics, safety, and efficacy of novel
oral anticoagulants in different ethnicities are scarce.
The available data have shown no or nonsignificant
differences between groups; therefore, new, appropri-
ately powered, h­ypothesis-driven, prospective studies
are required.149,158–161
Stroke has a worse prognosis in patients with AF than
in those in sinus rhythm. Worse outcomes were ini-
tially demonstrated in epidemiological studies in North
American162 and European137,163 populations—in which
mortality in patients with AF was at least 1.7‑fold higher
than in those without AF—and these findings have
since been replicated worldwide. For example, 28‑day
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Table 3 | Prevalence of AF in patients with acute ischaemic stroke

Country Sample Study population Prevalence Study
size (n) of AF (%)*
Argentina 545 Admission to hospitals with acute stroke 11 Weir et al. (2001)249
Argentina 275 One hospital 31 Gonzalez Toledo et al. (2013)250
Australia 26,960 New South Wales 25 Gattellari et al. (2011)166
Brazil 133 One emergency department 14 Mallman et al. (2012)251
Canada 10,528 12 regional stroke centres in Ontario 26 McGrath et al. (2013)138
China 4,782 62 hospitals registry 10 Gao et al. (2012)218
Denmark 1,185 One hospital in Copenhagen 18 Jorgensen et al. (1996)137
Europe 13,974 Seven European countries 18 Weir et al. (2001)249
India 100 One hospital in Himalayan town 6 Mahajan et al. (2004)142
Iran 302 One hospital 9 Ghandehari et al. (2006)252
Japan 15,831 156 hospitals 21 Kimura et al. (2005)146
Japan 315 One hospital 32 Tagawa et al. (2007)145
Jordan 200 One hospital 8 Bahou et al. (2004)253
Nepal 49 One hospital 10 Devkota et al. (2006)254
Nigeria 272 One hospital 9 Alkali et al. (2013)255
Pakistan 596 One hospital in Karachi <6 Syed et al. (2003)143
Pakistan 270 One hospital 12 Shafqat et al. (2004)256
Qatar 455 Only stroke facility in Qatar 13 Deleu et al. (2006)257
Qatar 217 Only stroke facility in Qatar 14 Khan et al. (2008)258
Tanzania 132 Patients with a history of stroke in Dar es Salaam and 52 villages 5 Walker et al. (2013)144
USA 147,780 Eight states 23 Hanchate et al. (2013)141
*Rounded to nearest integer. Abbreviation: AF, atrial fibrillation.

mortality among patients presenting with acute stroke in Heart failure

the Japan Multicenter Stroke Investigators’ study 146 was
11.3% in patients with AF and 3.4% in other patients.
Similarly, a large, multinational, prospective study
showed higher in-hospital mortality in Asian patients
who had AF than in their counterparts without AF
(OR 2.4).164 Furthermore, the presence of AF in patients
with a newly diagnosed stroke is associated with pro-
longed hospitalization,165,166 increased persistent dis-
ability,167–169 and elevated health-care costs.170 Therefore,
more data from large-scale studies are required to clarify
the worldwide variation in stroke risk in the setting of AF.
Cognitive decline
AF is a risk factor for dementia, even in patients without
a history of stroke. Several studies, including a meta-
analysis of 21 observational studies, have reported
that decreased cognitive scores (OR 1.5–3.5) are asso-
ciated with the presence of AF in different popula-
tions.17,130–132,171 In the ONTARGET and TRANSCEND
studies,172 patients with AF showed faster worsening
of Modified Mini-Mental State Examination and Digit
Symbol Substitution Test scores over the subsequent
5 years than did patients without AF.90 Similarly, in a
study from Brazil, individuals with AF had an odds ratio
of 2.8 for dementia compared with individuals without
AF.130 The increased risk of dementia in patients with AF
was also associated with increased mortality (HR 2.9).173
AF and HF are common conditions that often coexist,
share risk factors, and each predispose to the develop-
ment of the other. For example, in a study of patients in
Minnesota, USA, 7.8% of patients with newly diagnosed
AF developed HF within the subsequent year, and 20%
developed HF within 5 years.15 Similar observations
were made in patients admitted with acute HF to hos-
pitals across Africa, 18% of whom had AF,174 and in a
smaller study in Nigeria, where 10% of patients with HF
had AF.175
Several studies have reproducibly demonstrated that
patients with either HF or AF who then develop the
other condition have significantly increased mortal-
ity compared with individuals having either condition
alone.80,176–178 The strongest evidence comes from two
major meta-analyses including >30,000 patients with HF.
Patients with HF and AF demonstrated odds ratios for
mortality of 1.14–1.57 compared with patients with HF
only.179,180 In a study from Sub-Saharan Africa, patients
admitted with acute HF and found also to have AF had
higher 180‑day mortality than those without AF. 181
Therefore, the concomitant presence of AF and HF
i­dentifies patients at a high risk of mortality.
Mortality
Worldwide age-adjusted mortality in individuals with
AF aged ≥35 years in the 2010 Global Burden of Disease

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100 Rate versus rhythm control

90
The practice of rate or rhythm control changed after
publication of results from the AFFIRM190 and RACE
trials,191 which did not demonstrate substantial differ-
Patients recieving each treatment (%)

80
ences in the prognosis of patients with AF, irrespec-
70
tive of which strategy was employed. In the Euro Heart
60 Survey,192 40% of patients with AF received antiarrhyth-
mic agents, 65% received rate-control medication, and
50
12% received neither. In the Central Registry of the
40 German Competence Network on Atrial Fibrillation
(AFNET),193 antiarrhythmic drugs were used in 21.3%
30
of patients, the majority of whom had paroxysmal or
20 persistent AF. Among symptomatic patients with per-
sistent AF, 53.4% received electrical or pharmaco­logical
10
cardioversion, and 5% received ablation therapy. 193
0 During 2000–2002 in China, rate-control strategies were
used in 44% of patients with paroxysmal AF and 83% of
st D

pe

es

nd

il

a
az

ny
pa

in

ta

in

oo
US

patients with chronic AF.36,194–196 These differences might

gi L
ry

at
ro

la
re FIE

Ch

nt
is

Br

Ke
Ja

er
ai
st
Eu

ge
R

m
Th

Pa

result from the treatment setting: major and tertiary

lf
GA

Ar

Ca
Gu

Oral anticoagulation Antiplatelet No antithrombotic
No therapy or antiplatelet agents with unknown breakdown
Figure 3 | Global use of antithrombotic therapy. This Figure is based on data from the
GARFIELD registry,91 the USA,242 Europe (Euro Heart Survey of Atrial Fibrillation192),
Japan (J‑TRACE101), China,194 Middle Eastern states (Gulf SAFE registry207),
Thailand,213 Pakistan,243 Brazil,208 Argentina,244 Cameroon,106 and Kenya.65
Study was 3.8 per 100,000 men and 4.2 per 100,000
women. 27 As discussed above, patients with AF and
either HF177–179 or a previous stroke162,163 have higher
mortality than similar patients without AF. Additionally,
in the international, prospective REACH study,182 indi-
viduals with both atherosclerotic vascular disease and
AF had higher 4‑year cardiovascular mortality than their
counterparts without AF (10.6% versus 3.5%). A similar
increase in mortality can be observed in patients with AF
and several other coexistent conditions in studies from
North America,20,183,184 Europe,185 and East Asia.186,187
Importantly, mortality was even higher if patients were
not on anticoagulation therapy.187
Fundamental questions still remain about the spec-
trum of complications associated with AF in many
regions around the world. Future studies are needed
to define the sources of this variability after taking
into account the underlying prevalence of AF, the
demographics of the population, and heterogeneity in
t­reatment approaches.
Treatment
The management of AF involves two major decisions:
selection of either rate or rhythm control, and whether
or not to start anticoagulation therapy. Rate control can
involve the use of β‑blockers, calcium-channel block-
ers, digoxin, or, in rare cases, atrioventricular node
ablation with ventricular pacing. Rhythm-control strat-
egies include pharmacological cardioversion, electrical
cardio­version, and ablation therapy. Current guidelines
for the management of AF recommend the use of the
risk-prediction model CHA2DS2-VASc to guide decisions
about anticoagulation treatment.188,189
hospitals, where techniques such as catheter ablation are
increasingly available, might be more likely to employ
rhythm-control strategies.197
β‑Blockers and calcium-channel blockers have become
the most commonly used rate-control agents in Europe
and North America, which constitutes a shift from the
use of digoxin in the past.198,199 Nevertheless, digoxin use
remains common outside Australia, Europe, and North
America, mainly in Africa and Asia.70,73,106,200 In a study
from Cameroon, 83% of participants were receiving
rate-control therapy, among whom >60% were taking
digoxin.64 Similarly, at a Kenyan hospital, >50% of patients
receiving a rate-control strategy were taking digoxin.65 In
this study, <15% of patients underwent rhythm control
by electrical or chemical cardioversion,65 and amiodarone
was the most frequently used antiarrhythmic drug used
for cardioversion.65
The exact frequency with which AF-ablation proce-
dures are performed worldwide (as well as their com-
plication rates) is uncertain, in part owing to the lack
of an inclusive global registry.201,202 However, the avail-
able data show that AF-ablation procedures are increas-
ing, particularly in high-income countries. Surveys
from electrophysiological centres around the world
reported more ablation procedures in 2003–2006 than
in 1995–2002.201,203
Anticoagulation
Despite ACC/AHA and ESC guidelines, a substantial
percentage of patients who merit anticoagulation do
not receive it, owing to perceived risks and concerns
(Figure 3).71,192,204–206 In the multinational GARFIELD
study 91 of patients with AF from Australia, Brazil, Canada,
East Asia, Mexico, and Western Europe, 40.7% of patients
with a CHA2DS2–VASc score ≥2 were not receiving anti-
coagulation. Similarly, in the RE‑LY AF registry 71 of
patients in emergency departments worldwide, only 34%
of patients with AF and a CHADS2 score ≥2 were receiving
oral anticoagulation. The proportion of patients receiving
anticoagulation varies, with some smaller studies report-
ing that >60% of patients might not be receiving oral

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anticoagulation, and that up to 12% of patients are receiv-
ing neither anticoagulation nor antiplatelet agents.204,205
In the Euro Heart Survey,192 which included data from 35
nations, 67% of eligible patients received anticoagulation
therapy, 7% received no antithrombotic therapy, and the
remaining patients were given antiplatelet agents.
The use of anticoagulation seems to be higher in Europe
and North America than in other regions (Figure 3).
A retrospective study in China of data collected during
2000–2002 showed that only 2.7% of patients were
receiving oral anticoagulation, and 64.5% were taking
antithrombotic therapy,194 and a subsequent Chinese study
showed that anticoagulation was continued for a median
of 7 months.195 The use of anticoagulation is similarly low
in the Gulf states (49% of patients),207 Brazil (58%),208 and
Cameroon (30%).106 Moreover, the RealiseAF study 95
showed that only 21.5% of patients with AF and a CHADS2
score ≥2 who were of Asian ancestry (originally from
Azerbaijan, India, Taiwan, or Turkey) were receiving
anticoagulation. Even in Japan, the J‑TRACE registry 101
reported warfarin use in only 75% of those with a CHADS2
score >1 in 2005. Reassuringly, some evidence indicates a
global improvement in warfarin prescription in the past
2 decades, including among Medicare patients in the
USA,209 the UK,210,211 Australia,212 Thailand,213 and Japan.214
By contrast, patients who have a CHA2DS2–VASc or
CHADS2 score of 0, for whom the bleeding risk associ-
ated with warfarin therapy outweighs the risk of throm-
boembolic events, sometimes inappropriately receive
anticoagulation. In the multinational GARFIELD regis-
try 91 and RealiseAF study,95 39% and 46% of patients with
a CHA2DS2-VASc or CHADS2 score of 0 were receiving
anticoagulation, respectively.91 Similar observations were
made among 172 study participants in Cameroon, where
21% of low-risk patients received oral anticoagulation,106
and in a Saudi Arabian study, the frequency of inappro-
priate anticoagulation therapy was 57%.107 Furthermore,
in a major hospital in Kenya, 4.4% of patients with a
CHADS2 score of 0 were receiving anticoagulation.65
Even patients who do receive warfarin anticoagulation
might not consistently achieve serum levels in the thera-
peutic range. The time spent in the therapeutic range is
significantly lower in countries outside North America
and Western Europe.149,215 Among closely monitored
patients in the warfarin arm of the ROCKET-AF trial216
(in which investigators compared rivaroxaban and war-
farin), a substantial proportion of participants from all
geographical regions had subtherapeutic anticoagula-
tion, defined as an international normalized ratio (INR)
<2 for >25% of the time: 27% in Latin America, 44% in
India, 37% in East Asia, and 35% in Eastern Europe.
Although elderly patients with AF have the highest
risk of thromboembolic complications, data suggest
that such individuals are often undertreated. Results
from the National Nursing Home Survey in the USA,217
the China QUEST registry study,218 and other studies
worldwide219 confirm that elderly patients are less likely
to receive anticoagulation therapy than other age groups,
even in the absence of contraindications. Despite evi-
dence to the contrary,220–223 the widespread perception is
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that elderly patients have too high a risk of haemorrhage
and falls to consider using anticoagulation therapy. In an
Argentinian study, for example, advanced age and falls
were cited as contraindications to anticoagulation in 21%
of the study population.219
In LMICs, patients living outside areas with major hos-
pitals are less likely to receive and maintain guideline-
recommended treatment. Access to medical therapy is
limited in many regions of the world, and regular evalua-
tions of INR might be an unmanageable burden in many
LMICs. The increasing use of direct thrombin inhibitors
and factor Xa inhibitors might in time reduce the barrier
to anticoagulation, but currently their high cost limits
their availability.
Complications of treatment
Patients with AF at high risk of thromboembolic compli-
cations should receive anticoagulation treatment, which
unfortunately also increases their risk of haemorrhage.
In the ATRIA study cohort,224 patients receiving warfarin
had an annual rate of major haemorrhage of 1.1%, an
annual rate of intracranial haemorrhage of 0.47%, and
30‑day mortality of 50%.
Asian patients with AF have a higher risk of haem-
orrhage than do non-Asian individuals with AF. In
a study of 503 Japanese patients, the rates of intracra-
nial and major haemorrhage were 0.6% and 2.4% per
patient-year, respectively.225 In the RE‑LY trial,149 despite
the inclusion of a young population who were consist-
ently subtherapeutic when receiving warfarin, patients
of Asian ancestry had a higher rate of major bleeding
than did non-Asian patients. Similarly, a study of patients
included in the Kaiser Permanente Southern California
Health Plan found that the risk of intracranial haemor-
rhage was highest in Asian patients (HR 4.06), followed
by Hispanic patients (HR 2.06), and black patients
(HR 2.04) compared with white patients.226 The reasons
for the ethnic variability observed in haemorrhage fre-
quencies are yet to be precisely defined, but probably
include genetic variation and demographic factors.
Important questions remain about the use of different
modalities of treatment for AF in LMICs, including the
use of ablation therapies. All countries need to improve
the uptake of guideline-driven anticoagulation: vitamin K
antagonists or novel oral anticoagulants. Given the lack of
access to INR testing in many regions of LMICs, penetra-
tion of treatment could be increased if pharmaceutical
companies work with governments and intergovern-
mental organizations to improve access to novel oral
anticoagulants. Furthermore, the inclusion of a broader
representation of ethnicities in the evaluation of novel
oral anticoagulants will help to identify the variability in
safety and efficacy of such treatment between countries.
Public health-care costs
The high prevalence of AF results in a major public
health-care burden in high-income countries. In the
USA, the annual incremental cost of AF was an estimated
US$26 billion, and AF accounted for 3.2 million h­ospital-
days.26 In the Euro Heart Survey,227 in which patients
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Table 4 | Future directions in AF

Region Gaps in knowledge Next step
Global epidemiology
Rural and urban areas Incidence and prevalence in Develop inexpensive electrocardiographic recording on mobile devices
worldwide, LMICs Africa, Asia, and South America to be used by patients and health-care workers
High-income Prevalence of unrecognized AF Conduct population screening using ambulatory rhythm monitoring,
countries, LMICs outpatient screening electrocardiograms, and/or novel devices
Developing countries, Lifetime risk of AF Conduct longitudinal epidemiological studies using routine
LMICs electrocardiography
Risk factors
Global Attributable risk Develop country-specific understanding of the attributable risk
contributed by specific risk factors for AF
Global Understanding risk Integrate epidemiological, clinical, genomic, transcriptomic, proteomic,
factor interactions in metabolomic, molecular, and cellular studies to clearly define the risk
different ethnicities of AF in different populations
Prognosis
Various Predisposition to stroke, Improve understanding of how AF predisposes to stroke, myocardial
myocardial infarction, infarction, heart failure, dementia, and chronic kidney disease through
heart failure, and chronic examination of the variation in nations with differing risk factor profiles;
kidney disease develop improved preventive therapies for complications of AF
Worldwide Dementia Identify the burden of AF‑associated cognitive decline and dementia
Africa, South America, Disability Gather AF‑associated disability data to provide precise estimates
and South Asia of disease burden
Global Mortality Identify factors that contribute to AF‑related mortality in different nations
Treatment
LMICs Primary prevention Refine existing risk-prediction models with additional biomarkers and
‘‑omic’ markers; efficiently target high-risk individuals for increased
surveillance (to facilitate early AF detection); test and implement
therapies to prevent AF development; validate current risk prediction
models in LMICs and additional ethnic groups
Global Secondary prevention Increase access to generic oral anticoagulation for patients with a
(traditional anticoagulants) CHA2DS2–VASc score >1; monitor to achieve and maintain therapeutic
anticoagulation; obtain data from primary care on use of, and concerns
about, anticoagulation
Within and beyond Secondary prevention Include participants of non-European ancestry in trials of novel
North America and (novel oral anticoagulants) anticoagulants
Western Europe
Rural populations in Access to treatment Improve availability of point-of-care measurements of international
LMICs normalized ratio
Various Pathophysiology of ethnic Identify genetic loci that modify bleeding risk
differences in bleeding risk
Worldwide Associated conditions Implement evidence-based treatment for comorbidities of AF, such as
coronary artery disease and heart failure
Worldwide Catheter ablation Collect data on use and complications of ablation therapy in individual
countries; clarify decision-making processes for use of ablation therapy
Developed countries Individualized treatment Implement shared decision-making, using clinical and genomic data to
tailor safety, efficacy, and treatment dosing to reduce complications and
improve outcomes
Public health costs
LMICs, worldwide Direct and indirect Include indirect costs in evaluations of the public-health burden of AF;
estimate AF costs in LMICs
Abbreviations: AF, atrial fibrillation; LMIC, low-income and middle-income country.

were enrolled at hospital admission for AF and evaluated
12 months later, the average annual cost per person in
each country was €1,507 (Greece), €3,225 (Italy), €2,328
(the Netherlands), €1,010 (Poland), and €2,315 (Spain),
and the estimated combined annual cost in all five coun-
tries was €6.2 billion. Owing to the ageing of populations,
the global burden of AF has been increasing over the past
few decades185,228,229 and we speculate that health-care
costs related to AF will also continue to rise worldwide.
Worryingly, in LMICs with rapidly ageing populations,
such as China and India, the costs of AF are especially
likely to balloon.

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The above estimates26,227 still might not fully account
for costs indirectly associated with AF, namely thrombo-
embolic events (such as mesenteric infarction and acute
limb ischaemia); increased costs of care owing to demen-
tia and cardiac failure; haemorrhagic complications of
anticoagulation; the economic effect of lost productivity;
prolonged hospital stays; and loss of function requiring
support after hospital discharge (such as care givers,
visit­ing nurse assistants, or nursing home placements).
For example, the presence of AF in a patient admitted
to hospital with an ischaemic stroke was estimated to
increase costs by >$4,700 in the USA.170
Future directions
In summary, comprehensive data on the prevalence,
lifetime risk, prognosis, prevention, treatment, and eco-
nomic implications of AF are lacking in many regions
around the world. This dearth of data remains to be
addressed in the future (Table 4). Half of the world
population is concentrated in a few rapidly developing
countries: Bangladesh, Brazil, China, India, Indonesia,
Nigeria, and Pakistan. In these countries, populations
of individuals aged >60 years are predicted to at least
double by 2050.37 Given that AF is common in elderly
individuals, we hypothesize that the prevalence of AF
in these countries will at least double in the coming
2–3 decades. In addition, the use of pacemaker devices
and ambulatory monitoring of heart rhythm has dem-
onstrated that, even in high-income countries, AF
remains both underdiagnosed and undertreated. To
address these problems, resources need to be allo-
cated to identify and treat AF, as well as to prevent its
various complications.
In contrast to the advances in understanding of coro-
nary heart disease, a major deficit in knowledge about
AF persists, owing to the lack of robust primary preven-
tion strategies in all countries.230 The ongoing develop-
ment of risk-prediction models, in combination with
new ‘‑omic’ (genomic, transcriptomic, proteomic, and
metabolomic) approaches, might be used in the future to
identify target populations for early intervention. Initial
strategies could focus on treatment of known major risk
factors and the establishment of guidelines for regular
screening, for both early detection of AF and preven-
tion of secondary complications. If AF prevention is
to be feasible in LMICs, the development of low-cost
point-of-care ‑omic testing tools is required in addi-
tion to standard AF screening tools. However, whether
screening should be systematic, opportunistic, or spo-
radic remains uncertain; the choice is likely to depend
on the quality of risk-prediction tools, and will require
studies to demonstrate that screening for AF improves
health-care outcomes.
Similarly, although improvement of secondary preven-
tion of stroke in AF has been the focus of intense efforts,
secondary prevention of other outcomes in AF has not
been adequately studied globally. On average, patients
with AF who are aged >65 years have five comorbidi-
ties.231 Furthermore, among elderly US adults diagnosed
with AF, the most frequent complications were HF
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REVIEWS
and death, rather than stroke.232 Inadequate treatment
is another important issue. The results of a 2013 study
from the ORBIT-AF registry 233 suggest that although
93.5% of individuals with AF were eligible for at least
one guideline-based therapy, <50% were receiving all
guideline-indicated therapies. Studies in high-income
countries indicate that nurse management,234 risk factor
treatment, and lifestyle interventions235 improve g­ uideline
a­dherence and outcomes in individuals with AF.
The financial and medical challenges involved in
addressing the lack of data and inadequate treatment
of AF are substantial. Novel techniques for identifying
AF, including the use of smartphone applications236–238
and new small ambulatory recording devices such as the
Zio®Patch (San Francisco, CA, USA)239 and Zenicor®
(Stockholm, Sweden),240 might help to improve rates
of AF diagnosis in developed countries. Similarly, the
increasing availability of smartphones and innovations
such as the <US$150 laptop from the One Laptop per
Child initiative and the US$35 AakashTM tablet have the
potential to improve the detection and monitoring of AF
in LMICs. Additionally, the use of mobile health consul-
tations could help to improve the access of patients in
rural regions to treatment and follow-up. In the future,
similarly innovative approaches will be required to
develop inexpensive electrocardiography devices that can
be used by nonphysician health-care workers to ­diagnose
AF in communities with poor access to health care.
Conclusions
AF is a worldwide epidemic that constitutes an increas-
ing clinical and public health burden. Large studies from
Europe and North America have helped to define impor-
tant epidemiological features of AF in these regions, but
also highlight the underuse of anticoagulation therapy.
Several studies in LMICs, where AF is increasingly
prevalent, have demonstrated that undertreatment and
poor monitoring of treatment efficacy might be an even
larger problem than previously appreciated. Health-care
professionals, national organizations, international socie-
ties, and health insurance companies around the world
should, therefore, recognize the importance of treat-
ing AF to prevent complications, and focus on efficient
resource allocation both to address this major epidemic
and to improve patients’ outcomes.
Review criteria
The authors searched the PubMed database for relevant
studies published until March 2014, including electronic
publications ahead of print. The search terms used were:
“atrial fibrillation” alone or together with “epidemiology”,
“prevalence”, “lifetime risk”, “risk factors”, “treatment”,
“anticoagulation”, “warfarin”, “ablation”, “prognosis”,
“heart failure”, “dementia”, “cognitive”, “stroke”,
“haemorrhage”, “mortality”, and “costs”. A separate
search for “auricular fibrillation” was also conducted.
All search terms were additionally combined with names
of individual countries, regions, and ethnic groups,
including “Africa”, “Asia”, “South America”, “South Asia”,
“India”, “China”, “Turkey”, “Brazil”, and “Asian”.
REVIEWS
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Author contributions
All the authors contributed substantially to
researching data for the article, discussion of
content, writing, reviewing, and editing of the
manuscript before submission.
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