Highlights
- •
Atrial fibrillation / Atrial fibrillation flutter incidence and mortality rate has increased in the United States.
- •
The greatest incidence rates for men in 2017 were clustered in the New England region.
- •
An inflection point in year 2001 is notable for increased incidence and mortality rates for both genders across most states.
Atrial fibrillation (AF) and flutter (AFL) are the most common clinically significant arrhythmias in older adults with an increasing disease burden due to an aging population. However, up-to-date trends in disease burden and regional variation remain unknown. In an observational study utilizing the Global Burden of Disease (GBD) database, age-standardized mortality and incidence rates for AF overall and for each state in the United States (US) from 1990 to 2017 were determined. All analyses were stratified by gender. The relative change in age-standardized incidence rate (ASIR) and age-standardized death rate (ASDR) over the observation period were determined. Trends were analyzed using Joinpoint regression analysis. The mean ASIR per 100,000 population for men was 92 (+/-8) and for women was 62 (+/-5) in the US in 2017. The mean ASDR per 100,000 population for men was 5.8 (+/-0.3) and for women was 4.4 (+/-0.4). There were progressive increases in ASIR and ASDR in all but 1 state. The states with the greatest percentage change in incidence were New Hampshire (+13.5%) and Idaho (+16.0%) for men and women, respectively. The greatest change regarding mortality was seen in Mississippi (+26.3%) for men and Oregon (+53.8%) for women. In conclusion these findings provide updated evidence of increasing AF and/or AFL incidence and mortality on a national and regional level in the US, with women experiencing greater increases in incidence and mortality rates. This study demonstrates that the public health burden related to AF in the United States is progressively worsening but disproportionately across states and among women.
Atrial fibrillation (AF) is a heart rhythm disorder characterized by rapid disorganized electrical activity originating in the atrium which is associated with increased morbidity and mortality. , The likelihood of developing AF is complex and influenced by biological factors, environmental factors, genetics, epigenetics, and social determinants. Studies have shown that the prevalence and incidence of AF have been increasing in North America and Europe from the 1970s to the beginning of the 21 st century. It is estimated that the prevalence of AF ranges from 2.7 to 6.1 million people in the United States (US) and this number is expected to increase to 12.1 million in 2030. The upsurge in AF is straining the US healthcare system. The net incremental cost of AF was shown to be $8705 per patient and the national incremental cost was estimated to range between $6 and $26 billion based on prevalence data from 2004 to 2006. , Despite the growing public health challenge posed by AF, detailed up-to-date trends on the epidemiology of AF on a national and state level in the US remain limited. An accurate understanding of the current epidemiology of AF is crucial to the appropriate allocation of resources and therapies aimed at reducing the clinical and socioeconomic impact of the disease.
The objectives of this study were to determine current mortality and incidence rates for atrial fibrillation (AF) and/or flutter (AFL) overall and for each state in the US across a defined time period using the Global Burden of Disease database.
Methods
For this observational analysis of AF incidence and mortality, data collected for the Global Burden of Disease (GBD) study was utilized. The GBD methodology has been published previously and reports global results for health loss related to specific diseases: deaths and death rates, years of life lost due to premature mortality, prevalence and incidence. The study data are estimated annually and each round of results are internally consistent (i.e., cause-specific mortality estimates match all-cause mortality estimates). The data are made available publicly ( http://ghdx.healthdata.org/gbd-results-tool ).
In the GBD methodology, AF was defined as a diagnosis of AF or atrial flutter by ECG finding. GBD study attributes each death to a single underlying cause that began the series of events leading to death, in accordance with International Classification of Diseases (ICD)-10 principles. To estimate incidence and mortality of AF and/or flutter, GBD used a systematic review strategy to identify claims data for both in-patient and out-patient visits in the US. To address changes in coding practices of AF, GBD uses an approach which combines disease model (i.e., ‘DisMod-MR’) tool and cause of death ensemble model (i.e., ‘CODEm’) to estimate deaths from AF and AFL. These tools are used to pool disparate information on incidence, prevalence, and mortality for varying age groupings and from varying age groupings from data sources that use varying methods. This combined approach allows for more accurate estimate of the number of deaths attributable to AF and/or flutter. We extracted, incidence and mortality estimates for AF between 1990 and 2017 across 51 US states were extracted from the online data repository.
Age-standardized incidence and mortality data per 100,000 population categorized by state, gender, and year were extracted from the GBD Results Tool web-based system. For all age-standardized rates, GBD uses a standard population calculated as the non-weighted average across all countries of the percentage of the population in each 5-year age group for the years 2010 to 2035 from the United Nations Population Division’s World Population Prospects (2012 revision) (GBD 2012, United Nations Department of Economics and Social Affairs Population Division). We computed relative change over the observation period by computing the difference between the start and end age-standardized incidence rates (ASIRs) and age-standardized death rates (ASDRs) for each gender in each country.
Trends were assessed using Joinpoint software (Version 4.5.0.1) provided by the United States National Cancer Institute Surveillance Research Program (28). Joinpoint regression analysis assesses changes in linear slope for mortality trends over time, as described previously (28). Briefly, it assesses the overall trends in mortality, initially with no Joinpoints, and tests for significant changes in the model with sequential addition of points where there is significant change in the slope of the line. The model also computes an estimated annual percentage change (EAPC) for each trend by fitting a regression line to the natural logarithm of the rates. The log-linear transformation allows us to approximation of normal distributions and by estimating the annual percentage change, it was possible to assess change in mortality trend at a constant percent per year. EAPCs are reported with 95% Confidence Intervals (CIs). This method of statistical analysis has been previously utilized by Hartley et.al
Results
There were a total of 51 states or territories in the US each with 28 years of available data for analysis. Gender-specific, age-standardized incidence, and death per 100,000 population from Atrial fibrillation and/or Atrial flutter across 51 US states between 1990 and 2017 are shown in Supplementary Figures 1 and 2 . There were no missing data elements. The mean 2017 incidence rate per 100,000 population for AF for men was 92 (+/-8) and the mean 2017 ASIR for women was 62 (+/-5). For men, the greatest incidence rates in 2017 were observed in Massachusetts (105 per 100,000 population), New Hampshire (105 per 100,000 population), Maine (104 per 100,000 population) and Connecticut (104 per 100,000 population). For women, the greatest incidence rates were observed in Ohio (69 per 100,000 population), West Virginia (69 per 100,000 population), Louisiana (68 per 100,000 population), and Delaware (68 per 100,000 population). The 2017 incidence rates for each state are represented graphically in Table 1A .
| Age standardized incidence rates 1990 and 2017 | ||||
|---|---|---|---|---|
| Male | Female | |||
| State | 1990 | 2017 | 1990 | 2017 |
| Alabama | 82.26 | 88.91 | 55.34 | 59.61 |
| Alaska | 82.5 | 89.49 | 54.48 | 58.46 |
| Arizona | 85.81 | 94.75 | 57.15 | 64.6 |
| Arkansas | 79.94 | 84.9 | 54.33 | 57.26 |
| California | 79.04 | 89.35 | 52.2 | 60.1 |
| Colorado | 80.25 | 88.16 | 52.27 | 57.43 |
| Connecticut | 92.56 | 103.62 | 59.02 | 66.78 |
| Delaware | 91.32 | 102.24 | 59.71 | 67.79 |
| District of Columbia | 69.91 | 68.42 | 49.21 | 47.7 |
| Florida | 89.36 | 100.25 | 59.71 | 67.27 |
| Georgia | 83.46 | 90.55 | 55.44 | 60.56 |
| Hawaii | 81.06 | 87.76 | 50.53 | 52.34 |
| Idaho | 82.79 | 92.44 | 56.36 | 65.24 |
| Illinois | 83.34 | 90.78 | 55.89 | 61.54 |
| Indiana | 86.8 | 95.51 | 58.06 | 64.73 |
| Iowa | 80.52 | 85.37 | 52.9 | 54.66 |
| Kansas | 83.39 | 91.2 | 54.89 | 60.16 |
| Kentucky | 87.72 | 96.39 | 59.99 | 67.44 |
| Louisiana | 86.24 | 95.62 | 59.7 | 68.1 |
| Maine | 92.79 | 104.24 | 58.6 | 66.39 |
| Maryland | 87.02 | 96.12 | 56.56 | 63.71 |
| Massachusetts | 92.81 | 104.92 | 57.79 | 66.63 |
| Michigan | 85.8 | 95.06 | 57.47 | 64.78 |
| Minnesota | 82.97 | 90.59 | 52.32 | 55.24 |
| Mississippi | 77.55 | 80.64 | 52.88 | 55.89 |
| Missouri | 87 | 96.15 | 59.61 | 67.76 |
| Montana | 84.42 | 94.14 | 55.87 | 62.86 |
| Nebraska | 83.98 | 92.45 | 54.73 | 60.5 |
| Nevada | 81.16 | 86.92 | 54.85 | 59.5 |
| New Hampshire | 92.26 | 104.76 | 58.12 | 66.27 |
| New Jersey | 88.87 | 99.04 | 57.19 | 63.71 |
| New Mexico | 73.15 | 75.06 | 49.08 | 50.12 |
| New York | 91.09 | 101.77 | 59.09 | 66.42 |
| North Carolina | 85.42 | 93.84 | 56.1 | 61.65 |
| North Dakota | 76.54 | 78.51 | 54.36 | 60.05 |
| Ohio | 89.7 | 99.76 | 60.71 | 68.92 |
| Oklahoma | 82.83 | 90.19 | 57.22 | 63.94 |
| Oregon | 84.55 | 93.4 | 55.59 | 63.06 |
| Pennsylvania | 90.94 | 100.79 | 59.36 | 66.2 |
| Rhode Island | 87.4 | 95.79 | 56.77 | 62.53 |
| South Carolina | 87.13 | 95.68 | 55.95 | 61.19 |
| South Dakota | 81.57 | 88.48 | 55.62 | 61.88 |
| Tennessee | 83.56 | 91.06 | 56.31 | 62.11 |
| Texas | 83.32 | 91.38 | 56.64 | 64.45 |
| Utah | 77.18 | 82 | 52.85 | 56.33 |
| Vermont | 87.5 | 97.25 | 56.26 | 62.93 |
| Virginia | 84.16 | 92.07 | 56.59 | 61.62 |
| Washington | 86.06 | 96.37 | 56.18 | 64.14 |
| West Virginia | 86.57 | 94.53 | 60.92 | 68.56 |
| Wisconsin | 85.84 | 94 | 55.76 | 61.67 |
| Wyoming | 75.52 | 78.53 | 50.87 | 52.39 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
