Key result
MENA region sees RHD incidence drop ~63% alongside sharp rises in metabolic risks and AF.
Why the study?
The Middle East is undergoing an epidemiological transition in AF, with rheumatic heart disease declining while obesity, diabetes, hypertension, and MASLD are rising to create an alternative atrial substrate in the absence of serious valve disease.
Atrial fibrillation in the Middle East is shifting from a predominantly rheumatic valve-driven etiology to a mixed and increasingly metabolic non-valvular phenotype driven by obesity, diabetes, and MASLD, requiring phenotype-specific anticoagulation and upstream cardiometabolic risk management.
Answers are grounded in this paper and cite their sources.
May warrant metabolic AF screening in MENA; leaves open prospective prevention trials.
Background: There is a significant epidemiological transition in atrial fibrillation (AF) in the Middle East. Historically, rheumatic heart disease (RHD) has provided a significant AF substrate by damaging the mitral valve, overloading atrial pressures, and causing fibrosis. Recent regional statistics reveal a declining trend in RHD, with obesity, diabetes, hypertension, and metabolic dysfunction-related steatotic liver disease (MASLD) on the rise. These disorders produce an alternative atrial substrate which frequently occurs in the absence of a serious valve disease. Methods: The systematic review of the literature was performed with PubMed as the main database and Google Scholar as the auxiliary search and citation management tool. The literature published after 2021 and up to September 2026 was in scope. Search terms: atrial fibrillation, Middle East, MENA, Saudi Arabia, Gulf, rheumatic heart disease, obesity, diabetes, metabolic syndrome, MASLD, fatty liver, and atrial remodeling. The number of publications that were retained was eleven since they covered the regional disease trends, Saudi metabolic risk, AF mechanisms, Gulf non-valvular AF, or management variation between rheumatic and metabolic AF. Findings: RHD incidence across the Middle East and North Africa declined by 63.4% between 1990 and 2019.¹ During the same period, high body mass index exposure increased by 76.0%, while high fasting plasma glucose exposure increased by 92.4%.² AF and atrial flutter incident cases increased from about 49,900 in 1990 to 145,164 in 2021, while prevalent cases rose from about 474,000 to 1.42 million.³ Saudi studies show substantial metabolic syndrome and MASLD in early and middle adulthood.⁵˒⁶ However, direct longitudinal Saudi evidence linking these exposures to AF onset during the fourth and fifth decades remains limited. Conclusions: The Middle East seems to be shifting to a less rheumatic AF model with an increasing role of metabolic non-valvular AF. RHD has clinical implications due to the presence of rheumatic cohorts that need special anticoagulation and valve evaluation. Future Saudi research is needed to compare rheumatic, metabolic, and mixed AF phenotypes with age, status of the valves, metabolic load, atrial morphology, and clinical outcome.
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Anmar Mandourah (2026) conducted a review in Atrial fibrillation. Metabolic risk factors (high BMI, high fasting plasma glucose, metabolic syndrome, MASLD) vs. Rheumatic heart disease substrate was evaluated on Epidemiological trends in rheumatic heart disease, metabolic exposures, and atrial fibrillation/flutter incidence and prevalence in the Middle East and North Africa. Across the Middle East and North Africa, RHD incidence fell by 63.4% while high BMI, high fasting glucose, and AF/flutter incident cases rose sharply.
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