Rising Prevalence of Atrial Fibrillation in the Elderly Population

New Challenges of Geriatric Cardiology

Mariëlle Kloosterman; Harry J.G.M. Crijns; Isabelle C. Van Gelder


Europace. 2019;21(10):1451-1453. 

In This Article

Abstract and Introduction


In the last two decades, a rapid upward course of atrial fibrillation (AF) prevalence and incidence is occurring.[1,2] Current projections are mainly from North America and projections for European populations are limited to data from Iceland,[3] Germany,[4] and the Netherlands.[5] In this issue of Europace, Di Carlo et al.[6] aimed to estimate the prevalence of AF in the elderly Italian population, and generate projections on the number of elderly patients with AF in Italy and the European Union over the next four decades.

In 4528 participants from three Italian primary-care practice cohorts age- and sex-specific AF prevalence estimates for 2016 were obtained. The practices covered urban and rural areas, different socio-economic contexts and were located in Northern, Central, and Southern Italy. Population projections for Europe by sex and 5-year age groups, using a 5-year time interval, were obtained from Eurostat, the European Union statistical office. Prevalence data were achieved through systematic or opportunistic screening if participants did not respond to systematic screening, followed by clinical and 12-lead electrocardiogram confirmation. Older age and female sex were covariates that increased the risk of non-participation.

The Italian AF prevalence was estimated at 7.3% (6.6% from systematic plus 0.7% from opportunistic screening); 8.6% in men and 6.2% in women. Multivariate analyses showed independent associations for advancing age, male sex, heart failure, and previous stroke with presence of AF. The number of Italian patients having AF in 2016 was estimated at ~1 081 000 and is projected to increase to ~1 892 000 in 2060, reaching a total prevalence of 10.0%. The number of European Union patients having AF in 2016 was estimated at ~7 617 000 and is projected to increase to ~14 401 000 in 2060. By that time AF in patients aged >80 years will make up >65% of all AF cases.

The authors are to be congratulated on their contribution to the current literature. Their results are in line with predictions of Krijthe et al.[5] who, using data from the prospective community-based Rotterdam Study, also predict that the number of elderly adults with AF in the European Union will increase tremendously by the year 2060 (Figure 1A). Major strengths of the current study include the methodological approach with systematic and opportunistic screening, as well as diagnostic confirmation of AF. Risk factors may vary between countries and this can influence estimates of European prevalence. This first study focusing on a South European population will improve precision of estimates on the future burden of AF in Europe. Nonetheless, the relatively small sample size of 4528 participants yielding 331 AF cases is a limitation. Additionally, the authors assumed that AF prevalence remains stable, whereas several studies suggest that prevalence may further rise over time.[7] Based on data from the Framingham Heart Study and the Rotterdam Study, the risk of AF starting from 40 years was estimated to be ~1 in 4.[5] However, more recent studies, including the European BiomarCaRE consortium, estimate that the lifetime risk of AF in individuals from European ancestry has increased to ~1 in 3 by age 90 years.[1]

Figure 1.

(A) Expected number (millions) of elderly patients with AF in the European Union in the coming four decades. Estimates are for the age categories >65 years (red), >75 years (green), and >80 years (blue).5,6 (B) Cumulative incidence (%) of events in the 5 years after diagnosis of incident AF in Medicare patients (average age 79.5 ± 7.3 years). Reprinted from Piccini et al.8 AF, atrial fibrillation.

The increasing incidence, prevalence, and shift in distribution across age groups, will impose a huge burden on health care provision and expenditure. Based on data from Medicare patients (average age 79.5 ± 7.3 years), the cumulative incidence of events 5 years after the diagnosis of incident AF is high in these old patients: 13.7% chance of heart failure, 7.1% chance of stroke, a 5.7% chance of gastro-intestinal bleeding, and a 3.9% chance of myocardial infarction (Figure 1B).[8] In addition, data show that the number of primary and secondary AF-related hospitalizations continues to increase, annually people with AF are twice as likely to be hospitalized as age- and sex-matched referents, posing a substantial and growing economic burden on health care systems.[7] Furthermore, AF is associated with an increased risk of cognitive impairment and dementia, and a higher risk of falls.[7] Death rates in older patients with AF are higher than age-matched referents without the arrhythmia (men 75–84 years, respectively with and without AF: 1 year ~45% vs. ~10%, 5 year 75% vs. ~44%; women 75–84 years, respectively with and without AF: 1 year ~37% vs. ~6%, 5 year ~66% vs. ~28%).[9] These rates seem to remain static in older patients. In patients aged >75 years mortality rates remain similar despite improved pharmacological and interventional treatment options, while in patients aged 55–74 years a reduction in mortality is observed.[2]