Long-term cardiovascular risks after atrial fibrillation diagnosis: a systematic review and meta-analysis
Heart failure was the most frequent long-term cardiovascular complication after atrial fibrillation diagnosis.
*Systematic review and meta-analysis of cohort studies; Level 2a.
Citation
Mu L, Larvin H, Nadarajah R, Gale CP, Wu J. Heart. 2026;112:820-827. doi:10.1136/heartjnl-2025-326376
Background
Atrial fibrillation care has traditionally emphasized stroke prevention. Contemporary absolute risks for other cardiovascular complications are important for guidelines, trial design, and service planning.
Patients
Adults with atrial fibrillation in 80 multicentre cohort studies, totaling 5,498,857 patients. Included studies had at least 1000 patients, at least 3 years of follow-up, and were published from 2015 onward; smaller or unsuitable studies were excluded.
Intervention
Diagnosis of atrial fibrillation.
Control
No primary active control; some studies compared patients with and without atrial fibrillation.
Outcome
Incidence of stroke, heart failure, cardiovascular death, and heart attack.
Follow-up Period
Weighted average median follow-up: 4.6 years.
Results
| Outcome | Incidence per 100 person-years |
|---|---|
| Heart failure | 2.98 (95% CI, 2.10 to 4.24) |
| Ischemic stroke | 1.76 (95% CI, 1.44 to 2.15) |
| Cardiovascular death | 1.66 (95% CI, 1.24 to 2.23) |
| Heart attack | 0.64 (95% CI, 0.41 to 0.98) |
Compared with studies enrolling patients before 2011, later studies showed lower incidence of ischemic stroke, cardiovascular death, and heart attack. Heart failure did not show a statistically significant decline. Sex differences in cardiovascular outcomes appeared to narrow over time.
CI = confidence interval.
Limitations
All included studies were observational, so causation cannot be proven. Results varied substantially across studies. Most studies had some or high risk of bias, anticoagulant use over time was poorly captured, publication bias was possible, and data came mainly from Europe and Eastern Asia.
Funding
Barts Charity; some author industry ties reported.
Clinical Application
Continue stroke prevention, but routinely assess and manage heart failure risk after atrial fibrillation diagnosis; guidelines may need greater heart failure emphasis.
Discussion
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In this systematic review/meta-analysis of longitudinal cohorts, AF diagnosis was associated with heart failure as the most frequent outcome (IR 2.98/100 person-years), while stroke declined over time. Given heterogeneity and observational data, how valid and practice-changing is adding routine HF prevention to AF care? In this meta-analysis, the pooled incidence rate of heart failure after AF diagnosis was 2.98 cases per 100 person-years. Which interpretation is most accurate?