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Original Research: Cardiovascular Disease |

Prevalence, Incidence, and Lifetime Risk of Atrial Fibrillation in ChinaAtrial Fibrillation in China: New Insights Into the Global Burden of Atrial Fibrillation FREE TO VIEW

Yutao Guo, MD, PhD; Yingchun Tian, MD; Hao Wang, MD; Quanjin Si, MD, PhD; Yutang Wang, MD, PhD; Gregory Y. H. Lip, MD
Author and Funding Information

From the Department of Geriatric Cardiology (Drs Guo, H. Wang, Si, and Y. Wang), Chinese PLA General Hospital, Beijing, China; the Department of Gerontology (Dr Tian), Second People’s Hospital, Yunnan Province, China; and University of Birmingham Centre for Cardiovascular Sciences (Dr Lip), City Hospital, Birmingham, England.

CORRESPONDENCE TO: Gregory Y. H. Lip, MD, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, B18 7QH, England; e-mail: g.y.h.lip@bham.ac.uk


Drs Y Wang and Lip are the joint senior authors of this manuscript.

FOR EDITORIAL COMMENT SEE PAGE 9

FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(1):109-119. doi:10.1378/chest.14-0321
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BACKGROUND:  Much of the epidemiology of atrial fibrillation (AF) is based on data from Western populations. Despite the huge population of Asia, data on the clinical epidemiology of AF in Asian countries are limited. The current study aimed to investigate the prevalence and incidence of newly diagnosed (ie, incident) AF, as well as lifetime risk, in China and to determine the clinical risk factors contributing to its development.

METHODS:  Using a medical insurance database involving > 10 million individuals for the years 2001 to 2012 in the southwest of China, trends in incident AF were calculated using Kaplan-Meier analysis and Cox regression. The usefulness of the CHADS2 (congestive heart failure, hypertension, age, diabetes, stroke [doubled]) and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 [doubled], diabetes, stroke [doubled], vascular disease, age 65-74, and sex category [female]) scores was tested in predicting the occurrence of incident AF.

RESULTS:  A total of 471,446 individuals (aged ≥ 20 years) were studied, with 1,924,975 person-years of experience. We identified 921 patients with incident AF (62% male; mean age, 62 years). The prevalence of incident AF in subjects aged ≥ 20 years was 0.2 per 100 people, with an incidence of AF of 0.05 per 100 person-years overall. Over an 11-year period, the prevalence of AF increased 20-fold, whereas AF-related stroke increased 13-fold. The lifetime risk of AF was approximately one in five among Chinese adults, and it increased with advancing age. The CHA2DS2-VASc score was superior to the CHADS2 score in predicting the risk of incident AF in our Chinese population (DeLong test, Z = 6.621, P < .001).

CONCLUSIONS:  The AF burden, as well as the risk of AF-related stroke, has increased significantly over the past 11 years in the southwest of China. The public health burden of AF and its complications are greatest in the very elderly, with major implications for health-care systems given the global burden of this common arrhythmia.

Figures in this Article

Atrial fibrillation (AF) is the most common cardiac rhythm disorder, and its prevalence will at least double in the next 50 years because of an aging population.1 Most of the clinical epidemiology of AF has been based on predominantly white populations in North America or Europe.2 The burden of AF and its related stroke has been well documented, and the management of AF has evolved greatly in North America or Europe. Nonetheless, data on AF in the nonwhite population are scare, especially data on incidence and the antecedent risk factors for arrhythmia development. Also, time trends in the clinical epidemiology of AF among the Chinese are uncertain, in contrast to extensive data in the white population.3

In a cross-sectional survey of 19,363 Chinese, 199 AF cases were reported, suggesting a low prevalence.4 Even if the prevalence of AF was truly low, the number of patients with AF at the risk of stroke could be very high, given the huge population of China. Furthermore, there is a great unmet need in AF management, particularly with suboptimal thromboprophylaxis in the Chinese population leading to missed opportunities in stroke prevention.5

In this study, we have used, we believe for the first time, a large medical insurance database to investigate the trends in age-adjusted AF prevalence, incidence, and adjusted age-specific lifetime risk of AF during an 11-year period (2001-2012) in the southwest of China. Second, we evaluated the risk factors contributing to AF in our population. With 1,924,975 person-years of experience, this represents the largest dataset to our knowledge investigating the clinical epidemiology of AF in Asian subjects, specifically the Chinese.

Database Description

A medical insurance database in Yunnan Province, China, with data from January 1, 2001, through December 30, 2012, was used. This database includes > 10 million individuals who enrolled in a large, governmental medical insurance plan. This medical insurance scheme covers urban residents in Yunnan Province, located in the far southwest of China, spanning approximately 394,000 km2 and with a population of 46.3 million (2011 population statistics), representing 3% of the total Chinese population. All participants had a permanent and personal registration number through which information on medical history, drugs, and mortality data recorded in their lifetime could be collected. The recorded medical information was obtained from local 2A-grade hospitals and 3A-grade hospitals, which provide the highest quality of medical services and corresponding diagnoses.

Random sampling was performed among the enrolled individuals biennially, based on the periods of 2001-2002, 2003-2004, 2005-2006, 2007-2008, 2009-2010, and 2011-2012. Thus, a total of 1,228,639 people were selected. After excluding people with incomplete data (n = 2,611 cases) and readmission (n = 754,582), 471,446 cases were entered into the final analysis (Fig 1). For individuals with rehospitalization, only the first admission was indexed. All subjects were ≥ 20 years old. The medical ethics committee of PLA General Hospital approved the study (Approval No. 13BJZ40).

Figure Jump LinkFigure 1 –  Flowchart of patient data. AF = atrial fibrillation.Grahic Jump Location
Evaluation of AF and Comorbidities

All individuals enrolled had a diagnosis of AF (International Classification of Diseases, Ninth Revision/International Classification of Diseases, 10th Revision codes 427.31/I48). Information on comorbidities and events were also based on these codes. AF was defined based on an ECG or Holter recording. The inclusion criteria for an AF case were limited to inpatients, with AF diagnosis confirmed on admission and discharge. AF diagnoses at outpatient visits were excluded, as was atrial flutter.

Statistical Analysis

Continuous variables were tested for distribution by the Kolmogorov-Smirnov test. Those with a normal distribution are presented as means with SDs and were analyzed by t test. Data with a nonnormal distribution are presented as medians with interquartile ranges and were analyzed by the Mann-Whitney U test. The comparison of discrete variables was done via the χ2 test.

To understand the epidemiology of AF between 2001 and 2012 in Yunnan Province, first, the prevalence, incidence, and lifetime risk of AF were calculated. The annual prevalence of AF was calculated as the cumulative rate of AF among cumulative people free of death. Prevalence estimates were calculated for the total study population, for women and men separately, and for different age categories. Annual prevalence of stroke related to AF was defined as the cumulative rate of stroke in AF cases divided by cumulative people free of death.

Annual incidence was defined as the number of patients with new-onset AF divided by the number of person-years free of AF within a 1-year time period. The index date was the first date of diagnosis of AF. Incidence rates were calculated for those aged ≥ 20 years, aged ≥ 50 years, and aged ≥ 75 years. Incident AF cases occurring 30 days after enrollment were excluded from the calculation of the annual incidence.

For the calculation of lifetime risk, the incidence of AF among the subjects with death free of the end point for each age attained during the 11-year period was calculated. Lifetime risk estimates reflect the sum of adjusted, age-specific incidences from study entry to age at last observation. Age-specific hazards, incidence rates, cumulative incidence, and survival probabilities were calculated using a Kaplan-Meier analysis. To assess the risk factors contributing to AF in the elderly, an adjustment was made for competing risk (death, and so forth) to yield a true remaining lifetime risk of AF, and the sex-specific lifetime effect of the clinical risk factors (hypertension, coronary artery disease [CAD], heart failure [HF], and so forth) at 50 years of age were observed.

A multivariate analysis (Cox hazard model regression) was used to analyze the association of clinical risk factors and the occurrence of AF. Given the relation of common comorbidities to incident AF, we examined the possibility of risk factor clustering as an antecedent to incident AF. Taking into account the assessed clinical risk factors that are included in the CHADS2 (congestive heart failure, hypertension, age, diabetes, stroke [doubled]) and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 y[doubled], diabetes, stroke [doubled], vascular disease, age 65-74 y, and sex category [female]) scores, the predictive ability for AF using both these scores was tested with receiver operating characteristic (ROC) curves. To compare the diagnostic accuracy of risk scores, the respective areas under the curve were calculated, and differences were tested for significance by the DeLong equality test.

Given the underlying influence on AF of rheumatic heart disease (RHD) and hyperthyroidism, sensitivity analyses with Cox hazard model regression, and ROC curves were conducted in the individuals without RHD and hyperthyroidism. To test the accuracy of the diagnoses, we also did a sensitivity analysis of ROC curves for typical rate-control drugs (β-blocker, digoxin) and antithrombotic drugs (aspirin, warfarin) used for AF treatment (although not exclusively). A P value < .05 was accepted as statistically significant. The 95% CIs were calculated and statistical analysis was performed using IBM SPSS Statistics, version 21.0 (IBM) and MedCalc 12.6.1.0 (MedCalc Software).

We studied a dataset of 471,446 individuals (aged ≥ 20 years), with 1,924,975 person-years of experience. We identified 1,237 patients with AF, with 921 newly diagnosed (62% male; mean age, 62 years) and 316 who had been rehospitalized for AF. As expected, when compared with individuals without AF, patients with AF had more comorbidities (Table 1). The median CHA2DS2-VASc score of patients with AF was 2 (interquartile range, 1-3) and the CHADS2 median score was 1 (0-1). Thirty-two percent were taking aspirin, and only 4% were taking warfarin.

Table Graphic Jump Location
TABLE 1 ]  Baseline Characteristics of 471,446 Chinese in 2001-2012, in Relation to Presence or Absence of AF

ACE = angiotensin-converting enzyme; AF = atrial fibrillation; ARB = angiotensin receptor blocker; CCB = calcium antagonist; CHADS2 = congestive heart failure, hypertension, age, diabetes, stroke (doubled); CHA2DS2-VASc = congestive heart failure, hypertension, age ≥ 75 y (doubled), diabetes, stroke (doubled), vascular disease, age 65-74 y, and sex category (female); IQR = interquartile range.

a 

Antiacid drugs include antacids, H2-receptor antagonists, and proton pump inhibitors.

Prevalence of AF and Associated Stroke

The prevalence of AF in subjects aged 20 years was 0.20 per 100 subjects, which increased with age to 0.77 per 100 subjects in those aged > 80 years (P < .001) (Table 2). Subjects aged 71 to 80 years had a fivefold increase (0.60/0.13) in AF compared with those aged 51 to 60 years, whereas subjects aged > 80 years had a nearly sixfold increase (0.77/0.13) in AF compared with those aged 51 to 60 years (Table 2). A higher prevalence was seen among women in more elderly individuals aged > 70 years (Fig 2).

Table Graphic Jump Location
TABLE 2 ]  Prevalence of AF Classified by Age and Sex

See Table 1 legend for expansion of abbreviation.

Figure Jump LinkFigure 2 –  Prevalence of AF classified by age and sex. The prevalence of AF increased with aging, which was significant in very elderly people. A higher prevalence was seen among women, especially in more elderly individuals aged > 70 y. *P for trend < .001. See Figure 1 legend for expansion of abbreviation.Grahic Jump Location

A total of 13,304 strokes occurred between 2001 and 2012, of which 59 strokes occurred in patients with AF. Stroke rates in patients with AF (59 of 921) increased significantly compared with non-AF cases (13,245 of 470,525) (AF vs non-AF: 6.4% vs 2.8%; OR, 2.28; 95% CI, 1.81-3.08; P < .001). In the overall population, the prevalence of AF increased 20-fold (0.20/0.01) and AF-related stroke increased > 13-fold (0.13/0.01) between 2001 and 2012 (Fig 3, Table 3).

Figure Jump LinkFigure 3 –  Prevalence of AF and AF-related stroke in 471,446 Chinese. See Figure 1 legend for expansion of abbreviation.Grahic Jump Location
Table Graphic Jump Location
TABLE 3 ]  Prevalence of AF and Its Related Stroke in 2001-2012

Cumulative people were the living cases every year. AF and stroke prevalence were calculated as cumulative AF by cumulative people, and cumulative stroke by cumulative people, respectively. See Table 1 legend for expansion of abbreviation.

Incidence of AF and Lifetime Risk of AF

The overall incidence of AF was 0.05 per 100 person-years, with a stepwise increase with aging (Table 4). AF incidence was two times higher (0.14/0.07) in the very elderly (aged ≥ 75 years) than in people aged > 50 years.

Table Graphic Jump Location
TABLE 4 ]  Incidence of AF in 471,446 Chinese Between 2001 and 2012

See Table 1 legend for expansion of abbreviation.

a 

The total incidence of AF in subjects aged > 20 y, 50 y, and 75 y during the 11-y period, respectively.

The lifetime risks of AF in female and male Chinese at different ages compared with the Western population are shown in Table 5. For adults aged > 55 years, the lifetime risk of AF was approximately 1 in 5.3 in China, compared with 1 in 4.3 in the Rotterdam study6 and about one in 4.1 in the Framingham study.7 At the age of 55 years, the lifetime risk of AF was 21.1% for women in China, compared with 22.2% for women in The Netherlands6 and about 23% for women in the United States. The lifetime risk of AF increased with advancing age in this Chinese population; however, the lifetime risk of AF was lower in the male Chinese than in the female Chinese (Table 5).

Table Graphic Jump Location
TABLE 5 ]  Lifetime Risk of AF in the Chinese Compared With Western Populations at Different Ages by Sex

Data are presented as % (95% CI). See Table 1 legend for expansion of abbreviation.

Hypertension, CAD, HF, and dilated cardiomyopathy were associated with an increased lifetime risk of AF in both women and men aged > 50 years (Fig 4). The presence of HF and dilated cardiomyopathy conferred a high lifetime risk of AF, at 70% to 72% for women and 58% to 65% for men.

Figure Jump LinkFigure 4 –  Cumulative incidence of AF adjusted for the competing risk of death for women and men, according to individual clinical risk factor strata at 50 y of age. A, Hypertension. B, Coronary artery disease. C, Heart failure. D, Dilated cardiomyopathy. The numbers at the right of each graph represent the adjusted cumulative incidence to 95 y of age or the lifetime risk of AF.Grahic Jump LocationGrahic Jump Location
Clinical Risk Factors for the Occurrence of AF

On multivariate analysis, RHD, dilated cardiomyopathy, HF, hyperthyroidism, CAD, COPD, diabetes, hypertension, and being elderly were significant risk factors for AF (all P < .001) (Table 6). Given the relation of common comorbidities to incident AF, risk factor clustering with the CHADS2 and CHA2DS2-VASc scores were significantly predictive of incident AF, with ROC curves (C statistics, 95% CI) of 0.68 (0.68-0.69) and 0.72 (0.72-0.73), respectively (both P < .001). The CHA2DS2-VASc score was superior to the CHADS2 score in predicting the risk of AF (Delong test, Z = 6.621; P < .001).

Table Graphic Jump Location
TABLE 6 ]  Risk Factors for the Occurrence of AF in 471,446 Chinese During the 11-y Follow-up Period

See Table 1 legend for expansion of abbreviation.

A sensitivity analysis using Cox hazard model regression and ROC curves performed in individuals without RHD and hyperthyroidism showed similar results (data not shown). The sensitivity analysis of rate-control drugs (β-blocker, digoxin) and antithrombotic drugs (aspirin, warfarin) for the diagnosis of AF showed modest consistency between the drugs and AF diagnosis (C statistics for aspirin, 0.64; for warfarin, 0.562; for digoxin, 0.58; and for β-blocker, 0.65).

To our knowledge, this is the largest study to examine the clinical epidemiology of incident AF with a long-term follow-up period in a Chinese population. The main findings are as follows: (1) AF burden, as well as the risk of AF-related stroke, has increased significantly over past 11 years in the southwest of China; (2) over an 11-year period, the prevalence of AF increased 20-fold, whereas AF-related stroke increased 13-fold, and the lifetime risk of AF nearly doubled in the very elderly (aged ≥ 75 years) compared with those aged > 50 years; and (3) the CHA2DS2-VASc score was superior to the CHADS2 score in predicting the risk of AF in this Chinese population.

In the current study, the prevalence of incident AF was 0.2 per 100 people in adults aged > 20 years, which increased to 0.6 per 100 people in the elderly (aged > 70 years). Various community-based studies on the prevalence of AF in China between 2003 and 2009 have reported a prevalence of 0.8% to 2.8% but have included both incident and known AF.811 In community studies, AF prevalence varied from 0.1% to 2.8% in the Far East (0.6% to 1.6% in Japan,1221 0.4% to 2.2% in Thailand,22,23 1.4% in Singapore,24 and 0.1% in India).25 In hospital-based studies, the prevalence of AF was higher (2.8% in Malaysia,26 7.9% in China,27 and 12% to 14% in Japan).2830 In contrast, the reported prevalence of AF fluctuated from 0.5% to 7.5% in North America and Europe, depending on the different age categories, sex, and study design.6,3138

The prevalence of incident AF has increased 20-fold and AF-related stroke has increased more than 13-fold over the past 10 years in this Chinese population. These figures are much higher than the reported trends in North America and Europe.3,39 For example, there was an annual percentage change of 2.0% in AF prevalence in Iceland from 1998 to 2008,39 and the annual percentage change of AF prevalence was about 1.0% in elderly Germans between 2004 and 2007.40 Given that the population of China is substantially larger than that of Europe or North America, this would translate to more individuals with AF in China (or Asia) compared with Europe or North America, with the resultant consequences of a major public health burden and health-care costs.41

The burden of AF may be related to the increasingly elderly population in China. Compared with those aged 51 to 60 years, AF prevalence is increased five- to sixfold in the very elderly, which confirms the findings of a cross-sectional survey of 19,363 Chinese.4 The significant rise in prevalence with age also confers a higher risk of stroke/thromboembolism. The latter may also reflect suboptimal thromboprophylaxis in China.5 As with previous observations, we found that aspirin was commonly used for stroke prevention in China, despite its limited efficacy and safety compared with warfarin, especially in the elderly.5,42 Warfarin use was low (used by only 4% in the current study).43 The underuse of warfarin was also common in white AF populations at high risk of stroke and in elderly patients, who are usually at the highest risk of stroke.44,45

The overall incidence of AF in the current study was 0.05 per 100 person-years, which increased with age. In one Taiwanese study, the incidence of AF was reported as 0.76 to 1.37 per 1,000 person-years.46,47 Reported AF incidences were slightly higher in Europe and North America, ranging from 1.70 to 3.68 per 1,000 person-years.31,34,4850 The lifetime risk of AF was also slightly higher in Western populations (one in four in the United States and Europe) compared with Chinese adults (one in five in China).6,7 The increasing trend in the incidence of AF is consistent with the rise in AF prevalence, which is greatest in the very elderly. Accordingly, the lifetime risk of AF increases with advancing age.

In our population, typical comorbidities, such as RHD, dilated cardiomyopathy, HF, hyperthyroidism, CAD, COPD, diabetes, hypertension, and being elderly were independently associated with AF. Given the relation of common comorbidities to incident AF, we also examined the possibility of risk factor clustering as a predictor of incident AF. Indeed, one risk model derived from 18,556 people (19% black, 81% white) that included age, antihypertension medication, diabetes, myocardial infarction, and HF has been published, with good predictive value (C statistic, 0.76; 95% CI, 0.74-0.78).51 In the current study, the CHA2DS2-VASc score (which is used as a predictor of stroke) also had a good predictive value for incident AF (C statistic, 0.72; 95% CI, 0.72-0.73) that was more accurate than the CHADS2 score. The CHA2DS2-VASc score has also been shown to be superior to the CHADS2 score for predicting stroke in a Chinese population.52

Limitations

This study population consisted of inhabitants of Yunnan Provence in southwest China, and the subjects included in this medical insurance database represented only one-fourth of the total population in this area. Second, asymptomatic AF may be underrepresented, given that there was no opportunistic screening for AF in this study, and this could have contributed to the relatively low prevalence and incidence of AF. Nonetheless, our analysis could still underestimate the lifetime risk because of symptomless AF. Third, the top two grades of local hospitals (2A-grade hospitals and 3A-grade hospitals) provided the medical service for the participants in this medial insurance dataset, and, thus, inaccuracies of diagnosis were avoided as much as possible. However, to enhance the specificity of the definition of AF, the inclusion criteria for our AF cases was limited to hospitalized inpatients who had received an AF diagnosis on admission and/or discharge. AF diagnoses in outpatients were not included, nor was atrial flutter.

AF burden, as well as the risk of AF-related stroke, has increased significantly over the past 11 years in the southwest of China. The public health burden of AF and its complications are greatest in the very elderly, with major implications for health-care systems, given the global burden of this common arrhythmia.

Author contributions: Y. G. and G. Y. H. L. are guarantors of the manuscript. Y. G. and G. Y. H. L. contributed to the original idea, data analyses, and manuscript drafting and revisions; Y. T., H. W., Q. S., and Y. W. contributed to the manuscript drafting and revisions.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Lip has served as a consultant for Bayer; Astellas Pharma; Merck; Sanofi SA; Bristol-Myers Squibb/Pfizer Inc; Daiichi-Sankyo, Inc; BIOTRONIK; Portola Pharmaceuticals, Inc; Medtronic, Inc; and Boehringer-Ingelheim and has been a member of the speakers bureau for Bayer; Bristol-Myers Squibb/Pfizer Inc; Boehringer-Ingelheim; Daiichi-Sankyo, Inc; Medtronic, Inc; and Sanofi SA. Drs Guo, Tian, H. Wang, Si, and Y. Wang have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: We gratefully thank Zhang Wei, BD, Center for Medical Insurance, Human Resources and Social Security, Yunnan Province, for data collection and processing.

AF

atrial fibrillation

CAD

coronary artery disease

CHADS2

congestive heart failure, hypertension, age, diabetes, stroke (doubled)

CHA2DS2-VASc

congestive heart failure, hypertension, age ≥ 75 (doubled), diabetes, stroke (doubled), vascular disease, age 65-74, and sex category (female)

HF

heart failure

RHD

rheumatic heart disease

ROC

receiver operating characteristic

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Suzuki S, Yamashita T, Ohtsuka T, et al. Prevalence and prognosis of patients with atrial fibrillation in Japan: a prospective cohort of Shinken Database 2004. Circ J. 2008;72(6):914-920. [CrossRef] [PubMed]
 
Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22(8):983-988. [CrossRef] [PubMed]
 
Friberg J, Scharling H, Gadsbøll N, Truelsen T, Jensen GB; Copenhagen City Heart Study. Comparison of the impact of atrial fibrillation on the risk of stroke and cardiovascular death in women versus men (The Copenhagen City Heart Study). Am J Cardiol. 2004;94(7):889-894. [CrossRef] [PubMed]
 
Stewart S, Hart CL, Hole DJ, McMurray JJ. A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/Paisley study. Am J Med. 2002;113(5):359-364. [CrossRef] [PubMed]
 
Stewart S, Hart CL, Hole DJ, McMurray JJ. Population prevalence, incidence, and predictors of atrial fibrillation in the Renfrew/Paisley study. Heart. 2001;86(5):516-521. [CrossRef] [PubMed]
 
Rietbrock S, Heeley E, Plumb J, van Staa T. Chronic atrial fibrillation: Incidence, prevalence, and prediction of stroke using the Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack (CHADS2) risk stratification scheme. Am Heart J. 2008;156(1):57-64. [CrossRef] [PubMed]
 
Hobbs FD, Fitzmaurice DA, Mant J, et al. A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Health Technol Assess. 2005;9(40):1-74. [CrossRef]
 
Schmutz M, Beer-Borst S, Meiltz A, et al. Low prevalence of atrial fibrillation in asymptomatic adults in Geneva, Switzerland. Europace. 2010;12(4):475-481. [CrossRef] [PubMed]
 
Andersson P, Löndahl M, Abdon NJ, Terent A. The prevalence of atrial fibrillation in a geographically well-defined population in northern Sweden: implications for anticoagulation prophylaxis. J Intern Med. 2012;272(2):170-176. [CrossRef] [PubMed]
 
Stefansdottir H, Aspelund T, Gudnason V, Arnar DO. Trends in the incidence and prevalence of atrial fibrillation in Iceland and future projections. Europace. 2011;13(8):1110-1117. [CrossRef] [PubMed]
 
Ohlmeier C, Mikolajczyk R, Haverkamp W, Garbe E. Incidence, prevalence, and antithrombotic management of atrial fibrillation in elderly Germans. Europace. 2013;15(10):1436-1444. [CrossRef] [PubMed]
 
Tse HF, Wang YJ, Ahmed Ai-Abdullah M, et al. Stroke prevention in atrial fibrillation—an Asian stroke perspective. Heart Rhythm. 2013;10(7):1082-1088. [CrossRef] [PubMed]
 
Guo Y, Lip GY, Apostolakis S. The challenge of antiplatelet therapy in patients with atrial fibrillation and heart failure. J Cardiovasc Transl Res. 2013;6(3):388-397. [CrossRef] [PubMed]
 
Kakkar AK, Mueller I, Bassand JP, et al; GARFIELD Registry Investigators. Risk profiles and antithrombotic treatment of patients newly diagnosed with atrial fibrillation at risk of stroke: perspectives from the international, observational, prospective GARFIELD registry. PLoS ONE. 2013;8(5):e63479. [CrossRef] [PubMed]
 
Go AS, Hylek EM, Borowsky LH, Phillips KA, Selby JV, Singer DE. Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Ann Intern Med. 1999;131(12):927-934. [CrossRef] [PubMed]
 
Gladstone DJ, Bui E, Fang J, et al. Potentially preventable strokes in high-risk patients with atrial fibrillation who are not adequately anticoagulated. Stroke. 2009;40(1):235-240. [CrossRef] [PubMed]
 
Chien KL, Su TC, Hsu HC, et al. Atrial fibrillation prevalence, incidence and risk of stroke and all-cause death among Chinese. Int J Cardiol. 2010;139(2):173-180. [CrossRef] [PubMed]
 
Lee CH, Liu PY, Tsai LM, et al. Characteristics of hospitalized patients with atrial fibrillation in Taiwan: a nationwide observation. Am J Med. 2007;120(9):819.e1-7. [CrossRef]
 
Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation. 2006;114(2):119-125. [CrossRef] [PubMed]
 
Krahn AD, Manfreda J, Tate RB, Mathewson FA, Cuddy TE. The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba Follow-Up Study. Am J Med. 1995;98(5):476-484. [CrossRef] [PubMed]
 
Ruigómez A, Johansson S, Wallander MA, Rodríguez LA. Incidence of chronic atrial fibrillation in general practice and its treatment pattern. J Clin Epidemiol. 2002;55(4):358-363. [CrossRef] [PubMed]
 
Alonso A, Krijthe BP, Aspelund T, et al. Simple risk model predicts incidence of atrial fibrillation in a racially and geographically diverse population: the CHARGE-AF consortium. J Am Heart Assoc. 2013;2(2):e000102. [CrossRef] [PubMed]
 
Guo Y, Apostolakis S, Blann AD, et al. Validation of contemporary stroke and bleeding risk stratification scores in non-anticoagulated Chinese patients with atrial fibrillation. Int J Cardiol. 2013;168(2):904-909. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Flowchart of patient data. AF = atrial fibrillation.Grahic Jump Location
Figure Jump LinkFigure 2 –  Prevalence of AF classified by age and sex. The prevalence of AF increased with aging, which was significant in very elderly people. A higher prevalence was seen among women, especially in more elderly individuals aged > 70 y. *P for trend < .001. See Figure 1 legend for expansion of abbreviation.Grahic Jump Location
Figure Jump LinkFigure 3 –  Prevalence of AF and AF-related stroke in 471,446 Chinese. See Figure 1 legend for expansion of abbreviation.Grahic Jump Location
Figure Jump LinkFigure 4 –  Cumulative incidence of AF adjusted for the competing risk of death for women and men, according to individual clinical risk factor strata at 50 y of age. A, Hypertension. B, Coronary artery disease. C, Heart failure. D, Dilated cardiomyopathy. The numbers at the right of each graph represent the adjusted cumulative incidence to 95 y of age or the lifetime risk of AF.Grahic Jump LocationGrahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Baseline Characteristics of 471,446 Chinese in 2001-2012, in Relation to Presence or Absence of AF

ACE = angiotensin-converting enzyme; AF = atrial fibrillation; ARB = angiotensin receptor blocker; CCB = calcium antagonist; CHADS2 = congestive heart failure, hypertension, age, diabetes, stroke (doubled); CHA2DS2-VASc = congestive heart failure, hypertension, age ≥ 75 y (doubled), diabetes, stroke (doubled), vascular disease, age 65-74 y, and sex category (female); IQR = interquartile range.

a 

Antiacid drugs include antacids, H2-receptor antagonists, and proton pump inhibitors.

Table Graphic Jump Location
TABLE 2 ]  Prevalence of AF Classified by Age and Sex

See Table 1 legend for expansion of abbreviation.

Table Graphic Jump Location
TABLE 3 ]  Prevalence of AF and Its Related Stroke in 2001-2012

Cumulative people were the living cases every year. AF and stroke prevalence were calculated as cumulative AF by cumulative people, and cumulative stroke by cumulative people, respectively. See Table 1 legend for expansion of abbreviation.

Table Graphic Jump Location
TABLE 4 ]  Incidence of AF in 471,446 Chinese Between 2001 and 2012

See Table 1 legend for expansion of abbreviation.

a 

The total incidence of AF in subjects aged > 20 y, 50 y, and 75 y during the 11-y period, respectively.

Table Graphic Jump Location
TABLE 5 ]  Lifetime Risk of AF in the Chinese Compared With Western Populations at Different Ages by Sex

Data are presented as % (95% CI). See Table 1 legend for expansion of abbreviation.

Table Graphic Jump Location
TABLE 6 ]  Risk Factors for the Occurrence of AF in 471,446 Chinese During the 11-y Follow-up Period

See Table 1 legend for expansion of abbreviation.

References

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Iguchi Y, Kimura K, Kobayashi K, et al. Relation of atrial fibrillation to glomerular filtration rate. Am J Cardiol. 2008;102(8):1056-1059. [CrossRef] [PubMed]
 
Kiatchoosakun S, Pachirat O, Chirawatkul A, Choprapawan C, Tatsanavivat P. Prevalence of cardiac arrhythmias in Thai community. J Med Assoc Thai. 1999;82(7):727-733. [PubMed]
 
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Yap KB, Ng TP, Ong HY. Low prevalence of atrial fibrillation in community-dwelling Chinese aged 55 years or older in Singapore: a population-based study. J Electrocardiol. 2008;41(2):94-98. [CrossRef] [PubMed]
 
Kaushal SS, DasGupta DJ, Prashar BS, Bhardwaj AK. Electrocardiographic manifestations of healthy residents of a tribal Himalayan village. J Assoc Physicians India. 1995;43(1):15-16. [PubMed]
 
Freestone B, Rajaratnam R, Hussain N, Lip GY. Admissions with atrial fibrillation in a multiracial population in Kuala Lumpur, Malaysia. Int J Cardiol. 2003;91(2-3):233-238. [CrossRef] [PubMed]
 
Society of Cardiology, Chinese Medical Association. Retrospective investigation of hospitalized patients with atrial fibrillation in mainland China. Chin Med J (Engl). 2004;117(12):1763-1767. [PubMed]
 
Tomita F, Kohya T, Sakurai M, et al; Hokkaido Atrial Fibrillation Study Group. Prevalence and clinical characteristics of patients with atrial fibrillation: analysis of 20,000 cases in Japan. Jpn Circ J. 2000;64(9):653-658. [CrossRef] [PubMed]
 
Suzuki S, Yamashita T, Ohtsuka T, et al. Body size and atrial fibrillation in Japanese outpatients. Circ J. 2010;74(1):66-70. [CrossRef] [PubMed]
 
Suzuki S, Yamashita T, Ohtsuka T, et al. Prevalence and prognosis of patients with atrial fibrillation in Japan: a prospective cohort of Shinken Database 2004. Circ J. 2008;72(6):914-920. [CrossRef] [PubMed]
 
Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22(8):983-988. [CrossRef] [PubMed]
 
Friberg J, Scharling H, Gadsbøll N, Truelsen T, Jensen GB; Copenhagen City Heart Study. Comparison of the impact of atrial fibrillation on the risk of stroke and cardiovascular death in women versus men (The Copenhagen City Heart Study). Am J Cardiol. 2004;94(7):889-894. [CrossRef] [PubMed]
 
Stewart S, Hart CL, Hole DJ, McMurray JJ. A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/Paisley study. Am J Med. 2002;113(5):359-364. [CrossRef] [PubMed]
 
Stewart S, Hart CL, Hole DJ, McMurray JJ. Population prevalence, incidence, and predictors of atrial fibrillation in the Renfrew/Paisley study. Heart. 2001;86(5):516-521. [CrossRef] [PubMed]
 
Rietbrock S, Heeley E, Plumb J, van Staa T. Chronic atrial fibrillation: Incidence, prevalence, and prediction of stroke using the Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack (CHADS2) risk stratification scheme. Am Heart J. 2008;156(1):57-64. [CrossRef] [PubMed]
 
Hobbs FD, Fitzmaurice DA, Mant J, et al. A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Health Technol Assess. 2005;9(40):1-74. [CrossRef]
 
Schmutz M, Beer-Borst S, Meiltz A, et al. Low prevalence of atrial fibrillation in asymptomatic adults in Geneva, Switzerland. Europace. 2010;12(4):475-481. [CrossRef] [PubMed]
 
Andersson P, Löndahl M, Abdon NJ, Terent A. The prevalence of atrial fibrillation in a geographically well-defined population in northern Sweden: implications for anticoagulation prophylaxis. J Intern Med. 2012;272(2):170-176. [CrossRef] [PubMed]
 
Stefansdottir H, Aspelund T, Gudnason V, Arnar DO. Trends in the incidence and prevalence of atrial fibrillation in Iceland and future projections. Europace. 2011;13(8):1110-1117. [CrossRef] [PubMed]
 
Ohlmeier C, Mikolajczyk R, Haverkamp W, Garbe E. Incidence, prevalence, and antithrombotic management of atrial fibrillation in elderly Germans. Europace. 2013;15(10):1436-1444. [CrossRef] [PubMed]
 
Tse HF, Wang YJ, Ahmed Ai-Abdullah M, et al. Stroke prevention in atrial fibrillation—an Asian stroke perspective. Heart Rhythm. 2013;10(7):1082-1088. [CrossRef] [PubMed]
 
Guo Y, Lip GY, Apostolakis S. The challenge of antiplatelet therapy in patients with atrial fibrillation and heart failure. J Cardiovasc Transl Res. 2013;6(3):388-397. [CrossRef] [PubMed]
 
Kakkar AK, Mueller I, Bassand JP, et al; GARFIELD Registry Investigators. Risk profiles and antithrombotic treatment of patients newly diagnosed with atrial fibrillation at risk of stroke: perspectives from the international, observational, prospective GARFIELD registry. PLoS ONE. 2013;8(5):e63479. [CrossRef] [PubMed]
 
Go AS, Hylek EM, Borowsky LH, Phillips KA, Selby JV, Singer DE. Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Ann Intern Med. 1999;131(12):927-934. [CrossRef] [PubMed]
 
Gladstone DJ, Bui E, Fang J, et al. Potentially preventable strokes in high-risk patients with atrial fibrillation who are not adequately anticoagulated. Stroke. 2009;40(1):235-240. [CrossRef] [PubMed]
 
Chien KL, Su TC, Hsu HC, et al. Atrial fibrillation prevalence, incidence and risk of stroke and all-cause death among Chinese. Int J Cardiol. 2010;139(2):173-180. [CrossRef] [PubMed]
 
Lee CH, Liu PY, Tsai LM, et al. Characteristics of hospitalized patients with atrial fibrillation in Taiwan: a nationwide observation. Am J Med. 2007;120(9):819.e1-7. [CrossRef]
 
Miyasaka Y, Barnes ME, Gersh BJ, et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation. 2006;114(2):119-125. [CrossRef] [PubMed]
 
Krahn AD, Manfreda J, Tate RB, Mathewson FA, Cuddy TE. The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba Follow-Up Study. Am J Med. 1995;98(5):476-484. [CrossRef] [PubMed]
 
Ruigómez A, Johansson S, Wallander MA, Rodríguez LA. Incidence of chronic atrial fibrillation in general practice and its treatment pattern. J Clin Epidemiol. 2002;55(4):358-363. [CrossRef] [PubMed]
 
Alonso A, Krijthe BP, Aspelund T, et al. Simple risk model predicts incidence of atrial fibrillation in a racially and geographically diverse population: the CHARGE-AF consortium. J Am Heart Assoc. 2013;2(2):e000102. [CrossRef] [PubMed]
 
Guo Y, Apostolakis S, Blann AD, et al. Validation of contemporary stroke and bleeding risk stratification scores in non-anticoagulated Chinese patients with atrial fibrillation. Int J Cardiol. 2013;168(2):904-909. [CrossRef] [PubMed]
 
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