Key result
Heart failure leads CV events in AF at ~3 cases per 100 person-years without historical decline.
Meta-Analysis (n=5,498,857)
In patients with atrial fibrillation, heart failure is the most common and persistent adverse cardiovascular outcome, emphasizing the need for targeted heart failure prevention strategies alongside stroke prevention.
Background and aims Absolute risk estimates of long-term cardiovascular complications after atrial fibrillation (AF) diagnosis from contemporary cohorts are needed to guide clinical care. Quantifying these risks can inform outcome selection in future randomised clinical trials and improve health service delivery. We systematically reviewed and synthesised incidence rates (IRs), risks and temporal trends of adverse cardiovascular events in patients with AF. Methods Longitudinal cohort studies published from 2015 onwards, reporting cardiovascular events in AF, were included. IRs were pooled using random-effects meta-analyses. Meta-regressions explored the influence of age, CHA ₂ DS ₂ -VASc Score (a clinical stroke risk assessment tool for patients with AF), geographic region, study period (pre/post-2011) and sex on IRs. Results 80 studies (5 498 857 patients) were identified, of which 73 studies, representing 24 817 465 person-years of follow-up, were included in the primary meta-analyses of IRs. Cardiovascular events in descending frequency were heart failure (IR 2.98 cases per 100 person-years, 95% CI 2.10 to 4.24), ischaemic stroke (IR 1.76 cases per 100 person-years, 95% CI 1.44 to 2.15), cardiovascular death (IR 1.66 cases per 100 person-years, 95% CI 1.24 to 2.23) and myocardial infarction (0.64 cases per 100 person-year, 95% CI 0.41 to 0.98). Except for heart failure (incidence rate ratio (IRR) 0.66, 95% CI 0.33 to 1.34), study outcomes declined over time (ischaemic stroke IRR 0.56, 95% CI 0.40 to 0.80; cardiovascular death IRR 0.52, 95% CI 0.29 to 0.93; myocardial infarction IRR 0.27, 95% CI 0.14 to 0.49). Sex differences appear to have diminished over time and were not found to be statistically significant in more recent studies. Conclusions In patients with AF, heart failure was the most common and persistent adverse outcome. Despite improvement in stroke prevention, heart failure incidence has not declined, highlighting the need for targeted strategies and guideline focus. Further research is needed to address heart failure prevention and refine the understanding of sex-specific cardiovascular risks. PROSPERO registration number CRD42023474268.
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Mu et al. (2025) conducted a meta-analysis in Atrial fibrillation (n=5,498,857). Atrial fibrillation was evaluated on Heart failure incidence (95% CI 2.10 to 4.24). In patients with atrial fibrillation, heart failure was the most frequent cardiovascular event (2.98 cases per 100 person-years; 95% CI 2.10-4.24) and its incidence has not declined over time.
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