Sex-Specific Temporal Trends in the Incidence of Heart Failure Among Patients With Atrial Fibrillation

BACKGROUND Although there is evidence linking women to a higher risk of ischemic stroke in AF, it remains uncertain whether there are sex differences in the hazards of HF. OBJECTIVES This study sought to evaluate sex differences in the temporal trend of incident heart failure (HF) among patients with atrial fibrillation (AF). METHODS Using a territory-wide clinical registry in Hong Kong, patients newly diagnosed with AF between 1997 and 2021 were studied. Annual incidence rate (IR) and incidence rate ratio were estimated by Poisson regression analysis. Multivariate adjusted Fine-Gray regression models were performed to examine the subdistribution hazard ratio between women and HF, accounting for all-cause mortality as a competing event. RESULTS We included 130,132 individuals with newly diagnosed AF (median age: 76.6 years; IQR: 60.4-92.8; 48.6% female). Between 1997 and 2021, the annual IR (per 1000 person-years) of HF declined from 69.6 to 16.7 in women and from 44.5 to 13.7 in men over the years. Women maintained a higher IR than men for the entire follow-up period (IR: 25.3 vs 19.3 per 1000 person-years) and were associated with a higher risk of HF than men (incidence rate ratio [95% CI]: 1.34 [1.31-1.37]). When compared with men, women were older at the time of diagnosis of AF, had higher baseline CHA2DS2-VASc scores, and were more likely to be prescribed reduced doses of direct oral anticoagulants. CONCLUSIONS Despite an overall decrease in the risk of HF among AF patients over two decades of follow-up, women retained elevated residual adjusted HF risk after full adjustment for time-varying comorbidities.