Epidemiology of atrial fibrillation/atrial flutter and its risk factors from 1990 to 2021: a systematic analysis and Mendelian randomization study based on the China and Global Burden of Disease Study 2021

doi:10.12122/j.issn.1673-4254.2025.10.14

Abstract

Abstract:

Objective To analyze the changes in disease burden and risk factors of atrial fibrillation/atrial flutter (AF/AFL) in China and globally from 1990 to 2021 to provide epidemiological evidence for developing effective preventive measures for AF/AFL in China. Methods Based on data from the Global Burden of Disease Study 2021, we analyzed sex- and age-specific AF/AFL burden metrics across 204 countries or territories. Age-standardized incidence rate (ASIR), prevalence, mortality rate (ASMR), and disability-adjusted life-years (DALYs) rate (ASDR) were calculated. Joinpoint regression was employed to compute average annual percentage changes (AAPC) in trends. The risk factors were systematically evaluated and further validated using Mendelian randomization analysis. Results From 1990 to 2021, China experienced an increase in ASIR of AF/AFL (from 42.63 to 44.93 per 100 000), contrasting with the global decline. While China's ASMR decreased (from 4.93 to 4.33 per 100 000), global ASMR rose slightly (from 4.24 to 4.36 per 100 000). China's ASDR remained stable at 93.29 per 100 000, whereas global ASDR increased marginally (100.81 to 101.40 per 100 000). Significant sex disparities were observed: males showed higher ASIR and ASDR, while females exhibited greater ASMR and ASDR. China had higher incidence and prevalence but lower mortality and DALY rates compared to global averages. In 2021, the key risk factors for AF/AFL included elevated systolic blood pressure, high BMI, smoking, alcohol use, high-sodium diet, and low temperature. Gender-specific patterns emerged: smoking was predominant in males, whereas high BMI disproportionately affected females. Conclusion AF/AFL incidence and prevalence keep increasing in China, and its large population base and demographic aging pose significant public health challenges. Maintaining healthy lifestyle habits, including smoking cessation, alcohol moderation, and a low-sodium diet can help to lower AF/AFL incidence, and regular screenings is crucial for its early detection and treatment.

Key words: atrial fibrillation/atrial flutter, disease burden, epidemiology, risk factors, Mendelian randomization

Huihua MA, Kuipo YAN, Gang LIU, Yazhou XU, Lei ZHANG, Yizhuo LI. Epidemiology of atrial fibrillation/atrial flutter and its risk factors from 1990 to 2021: a systematic analysis and Mendelian randomization study based on the China and Global Burden of Disease Study 2021[J]. Journal of Southern Medical University, 2025, 45(10): 2182-2190.

Figures/Tables 8

References 35

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Variable	Case	Data source	ID	Population
Exposure				European
Hypertension	463 010	MRC-IEU	ukb-b-12493	European
BMI	681 275	GIANT	ieu-b-40	European
Smoking	607 291	GSCAN	ieu-b-4877	European
High alcohol	112 117	UK Biobank	ieu-a-1283	European
Outcome
AF/AFL	463 010	MRC-IEU	ukb-b-964	European

Variable	Case	Data source	ID	Population
Exposure				European
Hypertension	463 010	MRC-IEU	ukb-b-12493	European
BMI	681 275	GIANT	ieu-b-40	European
Smoking	607 291	GSCAN	ieu-b-4877	European
High alcohol	112 117	UK Biobank	ieu-a-1283	European
Outcome
AF/AFL	463 010	MRC-IEU	ukb-b-964	European

Location	Year	Incidence (10 000)	ASIR (/100 000)	Prevalence (10 000)	ASPR (/100 000)	Deaths (10 000)	ASMR (100 000)	DALYs (10 000)	ASDR (/100 000)
Total
China	1990	306 585	42.63	3 195 309	457.72	16 449	4.93	508 610	93.29
	2021	916 180	44.92	10 775 721	524	64 728	4.33	1 653 117	89.76
	AAPC (%, 95% CI)		0.16 (0.05-0.26)		0.43 (0.32-0.54)		-0.45 (-0.78--0.1)		-0.12 (-0.32-0.07)
Global	1990	2 006 571	52.51	22 214 495	616.58	114 540	4.24	3 358 708	100.82
	2021	4 484 926	52.12	52 552 045	620.51	338 947	4.36	8 358 894	101.40
	AAPC (%, 95% CI)		-0.02 (-0.05-0.00)		0.02 (-0.02-0.06)		0.11 (0.03-0.18)		0.01 (-0.03-0.06)
Male
China	1990	152 972	42	1 627 899	487.47	5207	3.56	221 887	81.96
	2021	451 977	45.23	5 626 767	574.50	21 789	3.81	753 106	89.62
	AAPC (%, 95% CI)		0.25 (0.10-0.4)		0.52 (0.41-0.64)		0.18 (-0.11-0.47)		0.28 (0.09-0.46)
Female
China	1990	153 613	41.74	1 567 410	429.293	11 242	5.54	286 723	97.72
	2021	464 203	43.28	5 148 954	473.40	42 939	4.58	900 010	87.69
	AAPC (%, 95% CI)		0.24 (0.10-0.2)		0.27 (0.10-0.44)		-0.64 (-1.04--0.2)		-0.37 (-0.62--0.12)
Male
Global	1990	1 015 287	57.99	11 492 470	727.79	42 677	4.20	1 569 927	109.93
	2021	2 295 811	57.11	27 899 046	728.87	134 700	4.44	4 032 121	112.05
	AAPC (%, 95% CI)		-0.05 (-0.01--0.02)		-0.00 (-0.05-0.04)		0.19 (0.09-0.30)		0.06 (0.00-0.11)
Female
Global	1990	991 284	47.43	10 722 025	529.53	71 862	4.25	1 788 781	93.29
	2021	2 189 116	47.27	24 652 999	529.11	204 247	4.295	4 326 773	92.24
	AAPC (%, 95% CI)		-0.03 (-0.09-0.03)		-0.02 (-0.07-0.03)		0.05 (-0.05-0.15)		-0.04 (-0.12- 0.04)

Location	Year	Incidence (10 000)	ASIR (/100 000)	Prevalence (10 000)	ASPR (/100 000)	Deaths (10 000)	ASMR (100 000)	DALYs (10 000)	ASDR (/100 000)
Total
China	1990	306 585	42.63	3 195 309	457.72	16 449	4.93	508 610	93.29
	2021	916 180	44.92	10 775 721	524	64 728	4.33	1 653 117	89.76
	AAPC (%, 95% CI)		0.16 (0.05-0.26)		0.43 (0.32-0.54)		-0.45 (-0.78--0.1)		-0.12 (-0.32-0.07)
Global	1990	2 006 571	52.51	22 214 495	616.58	114 540	4.24	3 358 708	100.82
	2021	4 484 926	52.12	52 552 045	620.51	338 947	4.36	8 358 894	101.40
	AAPC (%, 95% CI)		-0.02 (-0.05-0.00)		0.02 (-0.02-0.06)		0.11 (0.03-0.18)		0.01 (-0.03-0.06)
Male
China	1990	152 972	42	1 627 899	487.47	5207	3.56	221 887	81.96
	2021	451 977	45.23	5 626 767	574.50	21 789	3.81	753 106	89.62
	AAPC (%, 95% CI)		0.25 (0.10-0.4)		0.52 (0.41-0.64)		0.18 (-0.11-0.47)		0.28 (0.09-0.46)
Female
China	1990	153 613	41.74	1 567 410	429.293	11 242	5.54	286 723	97.72
	2021	464 203	43.28	5 148 954	473.40	42 939	4.58	900 010	87.69
	AAPC (%, 95% CI)		0.24 (0.10-0.2)		0.27 (0.10-0.44)		-0.64 (-1.04--0.2)		-0.37 (-0.62--0.12)
Male
Global	1990	1 015 287	57.99	11 492 470	727.79	42 677	4.20	1 569 927	109.93
	2021	2 295 811	57.11	27 899 046	728.87	134 700	4.44	4 032 121	112.05
	AAPC (%, 95% CI)		-0.05 (-0.01--0.02)		-0.00 (-0.05-0.04)		0.19 (0.09-0.30)		0.06 (0.00-0.11)
Female
Global	1990	991 284	47.43	10 722 025	529.53	71 862	4.25	1 788 781	93.29
	2021	2 189 116	47.27	24 652 999	529.11	204 247	4.295	4 326 773	92.24
	AAPC (%, 95% CI)		-0.03 (-0.09-0.03)		-0.02 (-0.07-0.03)		0.05 (-0.05-0.15)		-0.04 (-0.12- 0.04)

Location	Year	High systolic blood pressure	Smoking	High alcohol	High BMI	High sodium diet	Low temperature
China	1990	24.4%	8.7%	3.3%	0.4%	7.5%	3.4%
	2021	29.8%	6.9%	3.7%	4.5%	6.6%	3.4%
Global	1990	31.2%	6.5%	4.6%	5.2%	3.4%	2.4%
	2021	30%	4.7%	4.3%	8.7%	3.4%	2.7%