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The Journal of Clinical Hypertension logoLink to The Journal of Clinical Hypertension
. 2022 Oct 10;24(11):1461–1472. doi: 10.1111/jch.14584

Global burden of atrial fibrillation/flutter due to high systolic blood pressure from 1990 to 2019: estimates from the global burden of disease study 2019

Yaqiong Jin 1, Keke Wang 1, Bing Xiao 1, Mengxiao Wang 1, Xueying Gao 1, Jie Zhang 1, Jingchao Lu 1,✉
PMCID: PMC9659877  PMID: 36210736

Abstract

Atrial fibrillation/atrial flutter (AF/AFL) has progressed to be a public health concern, and high systolic blood pressure (HSBP) remains the leading risk factor for AF/AFL. This study estimated the HSBP attributable AF/AFL burden based on the data from the Global Burden of Disease (GBD) study 2019. Numbers, age‐standardized rates (ASR) of deaths, disability‐adjusted life years (DALYs), and corresponding estimated annual percentage change (EAPC) were analyzed by age, sex, sociodemographic index (SDI), and locations. Gini coefficient was calculated to evaluate health inequality. Globally, HSBP‐related AF/AFL caused 107 091 deaths and 3 337 876 DALYs in 2019, an increase of 142.5% and 105.9% from 1990, respectively. The corresponding mortality and DALYs ASR declined by 5.8% and 7.7%. High‐income Asia Pacific experienced the greatest decrease in mortality and DALYs ASR, whereas the largest increase was observed in Andean Latin America. Almost half of the HSBP‐related AF/AFL burden was carried by high and high‐middle SDI regions, and it was experiencing a shift to lower SDI regions. A negative correlation was detected between EAPC and SDI. Females and elderly people tended to have a higher AF/AFL burden, whereas young adults (30–49 years old) experienced an annual increase in AF/AFL burden. The Gini index of DALYs rate decreased from 0.224 in 1990 to 0.183 in 2019. Despite improved inequality having been observed over the past decades, the HSBP‐related AF/AFL burden varied across regions, sexes, and ages. Cost‐effective preventive, diagnostic, and therapeutic tools are required to be implemented in less developed regions.

Keywords: atrial fibrillation/atrial flutter, deaths and DALYs, global disease burden 2019, high systolic blood pressure

1. INTRODUCTION

Atrial fibrillation/atrial flutter (AF/AFL) is the most common sustained cardiac arrhythmia, associated with a five‐fold increase in the risk of stroke, a three‐fold increase in the risk of heart failure, and a two‐fold increase in the risk of mortality. 1 , 2 AF/AFL has progressed to be a serious public health concern over the last decades, with 59.7 million individuals of AF/AFL in 2019 worldwide, a doubling number of estimated cases in 1990. 3

Robust data have identified hypertension as an independent risk factor for AF/AFL and as the most common cardiovascular condition associated with it. 4 , 5 , 6 In the Atherosclerosis Risk in Communities study, elevated or borderline blood pressure (BP) explained 20–25% of AF, ranking first among all risk factors contributing to AF burden. 7 Specifically, 1 mmHg rise in systolic BP (SBP) leads to 1.8% relative increases in the risk of AF. 8 In clinical practice, about 60% to 80% of established AF patients accompany with hypertension. 9 , 10 Anti‐hypertensive drugs, targeting BP and optimizing its control have been established as one of the major approaches in the management of AF. 11

Despite the well‐known association between hypertension and AF/AFL, the detailed epidemiology of AF/AFL burden specifically due to high systolic blood pressure (HSBP) is not well represented in current knowledge. Hypertension is a modifiable risk factor and timely intervention could be highly beneficial in reducing AF/AFL events, deaths, and health care costs. 12 Taking these into consideration, this study aims to assess the current condition and temporal trends of fatal and nonfatal burden of AF/AFL attributable to HSBP from 1990 to 2019, stratified by location, sex, age, and development status. The inequality trend of HSBP related AF/AFL burden was also evaluated.

2. METHODS

2.1. Study design and data source

Our study was based on the Global Burden of Disease (GBD) 2019 database (http://ghdx.healthdata.org/gbd‐results‐tool), an updated estimate of the world's epidemiological data, which provided a comparative assessment of disease burdens for 369 diseases and injuries, and 87 risk factors in 204 countries and territories from 1990 to 2019.

According to a theoretical minimum risk exposure level (TMREL) aimed to capture the maximum attributable burden, HSBP was defined as the SBP of at least 110–115 mmHg in the GBD study. SBP above this level was associated with a higher risk of cardiovascular diseases, including AF/AFL. Detailed information about the process of data selection and data inputs has been published previously. 13 , 14

Annual cases of deaths/DALYs and their corresponding age‐standardized rates (ASRs), by sex, age, and location on the disease burden of AF/AFL due to HSBP were extracted and further analyzed. As reported in the GBD, the deaths/DALYs rate was calculated as the number of cases per 100 000 population, and the ASR of deaths/DALYs was a weighted average of the age‐specific deaths/DALYs rates adjusted by the population size and age structure.

The sociodemographic index (SDI), extracted from the GHDx (http://ghdx.healthdata.org), is a composite index per capita income, educational attainment, and total fertility rate of all areas, identifying the sociodemographic development status of countries or other geographic areas. SDI is calculated as the geometric mean on a scale of 0 to 1, by which countries are divided into five groups: low SDI (0–0.455), low‐middle SDI (0.456–0.608), middle SDI (0.609–0.690), middle‐high SDI (0.690–0.805), and high SDI (0.806–1). Data from 204 countries and territories, five SDI, and 21 GBD regions in terms of epidemiological and geographical conditions were all available and being used to estimate the disease burdens by location.

2.2. Gini coefficient and inequality

Gini coefficient was calculated to evaluate the trend of HSBP‐related AF/AFL inequality between countries from 1990 to 2019. As previously described, 15 , 16 Gini coefficient (or Gini index) is a useful measure to describe the inequality of disease burden distribution at a national or sub‐national level. The Gini coefficient is derived from the Lorenz curve, which estimates how the cumulative distribution of disease burden (the incidence, mortality, or DALYs rates) deviates from a theoretical line of perfect equality. And this deviation is summarized as the Gini coefficient, ranging from 0 (perfect equality) to 1 (total inequality). We used the annual ASR of deaths and DALYs of HSBP‐related AF/AFL at country‐level to calculate the Gini coefficients.

2.3. Statistical analysis

The estimated annual percentage change (EAPC), and its 95% confidence interval (95% CI) were used to assess the temporal trends of AF/AFL burden due to HSBP. EAPC was calculated by a well‐established formula described previously. 17 , 18 And an EAPC of 0, positive, or negative value indicates that rates are stable, in a downward or upward trend over time, respectively. The absolute value of EAPC indicates the extent of rate changes over time. The smoothing splines model was fitted to assess the association between EAPCs and SDI. We also used z‐score hierarchical cluster analysis to display the patterns and temporal trends of ASR of deaths and DALYs for HSBP‐related AF/AFL burden in 21 GBD regions. R program (Version 4.1.1 GUI 1.77; High Sierra build) was used to perform statistics and map the figures. P‐value < .05 was considered as statistically significant.

3. RESULTS

3.1. Global AF/AFL burden due to HSBP in 2019

Globally, in 2019, a total number of 107 091 deaths and 3 337 876 DALYs were caused by HSBP‐related AF/AFL, increasing by 142.5% and 105.9% from 1990, respectively (Tables 1 and 2). China (deaths: 17 513 and DALYs: 700 754) bore the highest absolute AF/AFL burden due to HSBP. India, the United States, Germany, the Russian Federation and Japan were all on the list of the most burdened countries (Figure 1A and B). The corresponding rates of deaths and DALYs were 1.46 and 41.89 per 100 000 population, dropping by 5.8% and 7.7% from 1990, respectively (Tables 1 and 2). Countries with high deaths rates were mainly in Central Asia, Australasia, Central Sub‐Saharan Africa, and Western Europe, whereas countries in Australasia, Eastern Europe, Central Asia, and Central Europe were observed with high DALYs rates (Figure 1C and D, Supplemental Fig. S1). Montenegro had the highest recorded deaths rate (5.6 per 100 000) and DALYs rate (113.3 per 100 000) (Figure 1D).

TABLE 1.

The death cases and age‐standardized deaths rate of HSBP related AF/AFL burden in 1990 and 2019, and its temporal trends from 1990 to 2019

1990 2019 1990‐2019
Characteristics Death cases No. × 103 (95% CI) ASR per 100 000 No. (95% CI) Death cases No.× 103 (95% CI) ASR per 100 000 No. (95% CI) EAPC No. (95% CI)
Overall 44.16 (35.64‐56.53) 1.55 (1.21‐2.02) 107.10 (83.31‐134.60) 1.46 (1.12‐1.85) ‐0.34 (‐0.30, ‐0.26)
Sex
Male 15.93 (12.15‐21.87) 1.42 (1.04‐1.99) 40.86 (30.81‐52.96) 1.39 (1.02‐1.81) ‐0.14 (0.18, 0.10)
Female 28.23 (22.12‐21.87) 1.61 (1.24‐2.09) 66.23 (50.24‐84.75) 1.51 (1.14‐1.93) ‐0.35 (‐0.39, ‐0.31)
Social‐demographic index
High 19.01 (14.99‐25.01) 1.84 (1.44‐2.41) 35.40 (25.73‐46.16) 1.52 (1.12‐1.95) ‐0.35 (‐0.94, ‐0.75)
High‐middle 13.07 (10.47‐17.33) 1.70 (1.32‐2.30) 28.86 (21.86‐37.24) 1.52 (1.14‐1.98) ‐0.55 (‐0.64, ‐0.46)
Middle 6.87 (5.44‐8.58) 1.15 (0.88‐1.50) 24.56 (19.16‐30.95) 1.37 (1.04‐1.78) 0.67 (0.63, 0.71)
Low‐middle 3.62 (2.74‐4.63) 1.08 (0.78‐1.42) 13.55 (10.39‐17.20) 1.40 (1.04‐1.81) 0.89 (0.84, 0.93)
Low 1.57 (1.02‐2.07) 1.16 (0.73‐1.59) 4.66 (3.26‐5.98) 1.41 (0.95‐1.86) 0.67(0.63, 0.71)
Region
Central Asia 1.31 (0.96‐1.90) 1.31 (0.96‐1.90) 0.99 (0.78‐1.39) 2.21 (1.68‐3.14) 1.55 (1.70, 1.84)
Central Europe 1.79 (1.44‐2.99) 1.79 (1.44‐2.29) 3.96 (2.99‐5.11) 1.75 (1.32‐2.26) ‐0.14 (‐0.23, ‐0.05)
Eastern Europe 1.55 (1.20‐2.23) 1.55 (1.20‐2.23) 6.08 (4.62‐8.21) 1.77 (1.34‐2.41) 0.18 (0.04, 0.32)
Australasia 2.81 (2.11‐3.60) 2.81 (2.11‐3.60) 1.24 (0.87‐1.71) 2.12(1.52‐2.88) ‐1.38 (‐1.52, ‐1.23)
High‐income Asia Pacific 1.21 (0.94‐1.66) 1.21 (0.94‐1.66) 4.64 (3.20‐6.55) 0.76 (0.54‐1.05) ‐1.88 (‐2.00, ‐1.77)
High‐income North America 1.58 (1.24‐2.03) 1.58 (1.24‐2.03) 10.86 (7.85‐14.47) 1.50 (1.09‐2.00) ‐0.47 (‐0.63, ‐0.30)
Southern Latin America 1.41 (1.01‐1.92) 1.41 (1.01‐1.92) 1.58 (1.17‐2.17) 1.82 (1.34‐2.50) 1.03 (0.87, 1.19)
Western Europe 2.34 (1.81‐3.15) 2.34 (1.81‐3.15) 6.08 (4.62‐8.21) 1.97 (1.45‐2.57) ‐0.72 (‐0.80, ‐0.64)
Andean Latin America 0.85 (0.59‐1.15) 0.85 (0.59‐1.15) 0.65 (0.46‐0.88) 1.25 (0.88‐1.70) 2.00 (1.73, 2.27)
Caribbean 1.36 (1.02‐1.76) 1.36 (1.02‐1.76) 0.78 (0.58‐1.04) 1.47 (1.11‐1.97) 0.35 (0.26, 0.44)
Central Latin America 1.33 (1.01‐1.79) 1.33 (1.01‐1.79) 3.29 (2.40‐4.46) 1.50 (1.09‐2.04) 0.34 (0.28, 0.40)
Tropical Latin America 1.58 (1.21‐2.11) 1.58 (1.21‐2.11) 3.86 (2.86‐4.94) 1.74 (1.28‐2.22) 0.60 (0.45, 0.75)
North Africa and Middle East 1.15 (0.83‐1.50) 1.15 (0.83‐1.50) 3.73 (2.91‐4.77) 1.23 (0.93‐1.59) 0.07 (0.18, 0.30)
South Asia 1.04 (0.71‐1.44) 1.04 (0.71‐1.44) 12.82 (9.21‐17.22) 1.33 (0.94‐1.83) 0.76 (0.65, 0.87)
East Asia 1.14 (0.80‐1.56) 1.14 (0.80‐1.56) 18.16 (13.56‐23.98) 1.22 (0.88‐1.65) 0.24 (0.18, 0.30)
Oceania 0.96 (0.64‐1.40) 0.96 (0.64‐1.40) 0.05 (0.04‐0.07) 1.10 (0.79‐1.52) 0.48 (0.46, 0.51)
Southeast Asia 1.14 (0.86‐1.44) 1.14 (0.86‐1.44) 6.20 (4.74‐8.00) 1.47 (1.09‐1.91) 0.95 (0.85, 1.05)
Central Sub‐Saharan Africa 1.94 (1.02‐3.28) 1.94 (1.02‐3.28) 0.67 (0.04‐1.01) 2.09 (1.24‐3.14) 0.19 (0.15, 0.22)
Eastern Sub‐Saharan Africa 1.21 (0.67‐1.73) 1.21 (0.67‐1.73) 1.63 (0.98‐2.19) 1.57 (0.92‐2.16) 0.96 (0.89, 1.02)
Southern Sub‐Saharan Africa 1.18 (0.88‐1.50) 1.18 (0.88‐1.50) 0.60 (0.46‐0.73) 1.53 (1.16‐1.94) 0.86 (0.63, 1.09)
Western Sub‐Saharan Africa 1.37 (0.97‐1.90) 1.37 (0.97‐1.90) 1.97 (1.48‐2.49) 1.79 (1.29‐2.33) 1.06 (0.96, 1.17)
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Abbreviations: AF/AFL, atrial fibrillation/atrial flutter; ASR, age standardized rates; CI, confidential interval; EAPC, estimated annual percentage change; HSBP, high systolic blood pressure.

TABLE 2.

The DALYs cases and age‐standardized DALYs rate of HSBP related AF/AFL burden in 1990 and 2019, and its temporal trends from 1990 to 2019

1990 2019 1990‐2019
Characteristics DALYs cases No.× 103 (95% CI) ASR per 100 000 No. (95% CI) DALYs cases No.× 103 (95% CI) ASR per 100 000 No. (95% CI) EAPC No. (95% CI)
Overall 1621.48 (1222.71‐2103.98) 45.38 (34.36‐59.02) 3337.88 (2510.43‐4361.69) 41.89 (31.62‐54.61) ‐0.26 (‐0.29, ‐0.23)
Sex
Male 758.87 (547.83‐998.57) 47.58 (34.79‐62.44) 1585.17 (1180.12‐2065.08) 43.85 (32.53‐57.02) ‐0.22 (‐0.26, ‐0.17)
Female 862.61 (649.56‐1124.63) 42.98 (32.43‐56.00) 1752.71 (1320.39‐2271.099) 39.89 (30.06‐51.68) ‐0.28 (‐0.31, ‐0.25)
Social‐demographic index
High 622.80 (474.00‐816.53) 58.74 (44.62‐76.93) 915.50 (689.01‐1204.72) 45.85 (34.49‐59.52) ‐0.90 (‐1.00, ‐0.79)
High‐middle 491.21 (365.32‐646.52) 49.79 (37.01‐65.10) 913.88 (676.41‐1201.19) 45.06 (33.31‐59.15) ‐0.39 (‐0.43, ‐0.35)
Middle 286.74 (213.83‐374.73) 33.41 (24.90‐43.53) 878.82 (646.92‐1147.68) 38.81 (28.97‐50.28) 0.62 (0.57, 0.69)
Low‐middle 162.16 (119.49‐212.89) 32.80 (24.42‐42.97) 478.55 (364.98‐617.01) 39.23 (29.98‐50.62) 0.67 (0.65, 0.69)
Low 57.81 (42.19‐74.94) 30.12 (21.72‐39.24) 149.55 (112.54‐189.15) 34.60 (25.83‐44.28) 0.56 (0.51, 0.61)
Region
Central Asia 21.21 (15.28‐28.56) 48.77 (35.31‐66.11) 37.74 (28.19‐50.10) 60.58 (45.54‐80.41) 0.78 (0.73, 0.83)
Central Europe 94.77 (69.78‐124.91) 65.63 (48.68‐85.77) 131.99 (99.39‐175.18) 59.95 (45.02‐79.04) ‐0.25 (‐0.35, ‐0.15)
Eastern Europe 151.11 (107.65‐202.54) 55.89 (40.43‐74.98) 217.99 (158.14‐291.54) 62.25 (45.14‐82.89) 0.32 (0.26, 0.38)
Australasia 19.06 (14.37, 25.17) 81.63 (61.96‐106.83) 32.80 (24.08‐44.53) 63.09 (46.23‐85.86) ‐1.15 (‐1.27, ‐1.03)
High‐income Asia Pacific 60.40 (15.28‐28.56) 31.15 (24.12‐40.12) 94.36 (71.35‐124.53) 20.23 (15.37‐26.41) ‐2.05 (‐2.28, ‐1.83)
High‐income North America 220.98 (164.28‐297.75) 60.43 (44.91‐81.36) 351.23 (257.10‐466.79) 53.76 (39.62‐71.21) ‐0.26 (‐0.42, ‐0.10)
Southern Latin America 13.16 (9.94‐17.41) 30.44 (22.87‐40.19) 33.10 (25.45‐43.38) 38.70 (29.76‐50.71) 1.02 (0.87, 1.16)
Western Europe 411.99 (310.30‐543.28) 69.44 (52.22‐91.51) 521.50 (393.92‐680.17) 53.86 (40.51‐70.26) ‐0.94 (‐1.00, ‐0.88)
Andean Latin America 2.54 (1.89‐3.30) 14.08 (10.32‐18.37) 10.58 (8.03‐13.48) 19.76 (14.92‐25.30) 1.68 (1.45, 1.91)
Caribbean 6.70 (5.28‐8.49) 27.62 (15.03‐30.85) 15.59 (12.14‐19.92) 30.01 (23.37‐38.27) 0.32 (0.27, 0.37)
Central Latin America 20.15 (15.82‐26.08) 27.70 (21.66‐35.95) 70.95 (56.27‐92.04) 31.28 (24.74‐40.66) 0.40 (0.37, 0.43)
Tropical Latin America 29.80 (23.29‐38.45) 37.62 (29.75‐48.13) 93.93 (73.16‐118.96) 40.23 (31.34‐50.95) 0.61 (0.47, 0.75)
North Africa and Middle East 43.63 (33.09‐56.31) 30.47 (23.07‐39.50) 121.15 (91.29‐157.35) 32.31 (24.37‐41.82) 0.10 (0.03, 0.17)
South Asia 159.80 (114.70‐213.78) 35.02 (25.71‐46.87) 508.05 (376.97‐663.52) 40.61 (30.25‐52.83) 0.53 (0.47, 0.58)
East Asia 226.96 (158.26‐312.02) 31.75 (22.33‐43.72) 721.62 (509.72‐980.41) 37.13 (26.67‐49.94) 0.64 (0.54, 0.73)
Oceania 0.76 (0.54‐1.01) 30.26 (21.51‐40.53) 2.26 (1.66‐2.97) 36.09 (27.01‐47.64) 0.63 (0.54, 0.72)
Southeast Asia 88.30 (63.31‐117.76) 40.62 (29.92‐54.26) 243.71 (178.78‐320.05) 45.37 (33.48‐59.40) 0.47 (0.40, 0.54)
Central Sub‐Saharan Africa 7.77 (5.19‐11.57) 42.79 (27.73‐63.34) 18.26 (12.87‐24.78) 43.43 (29.92‐60.17) ‐0.02 (‐0.06, 0.01)
Eastern Sub‐Saharan Africa 14.09 (9.41‐18.38) 23.27 (15.03‐30.85) 38.84 (26.77‐49.64) 29.34 (19.82‐37.96) 0.91 (0.83, 0.98)
Southern Sub‐Saharan Africa 7.82 (5.94‐9.98) 31.92 (24.42‐40.74) 17.58 (13.72‐22.13) 35.86 (27.87‐45.38) 0.42 (0.27, 0.57)
Western Sub‐Saharan Africa 20.46 (15.03‐26,74) 29.22 (21.59‐38.06) 54.66 (41.42‐68.72) 37.30 (28.49‐47.24) 1.04 (0.94, 1.15)
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Abbreviations: AF/AFL, atrial fibrillation/atrial flutter; ASR, age standardized rates; CI, confidential interval; EAPC, estimated annual percentage change; DALYs, disability‐adjusted life‐years; HSBP, high systolic blood pressure.

FIGURE 1.

FIGURE 1

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The global HSBP‐related AF/AFL burden in 2019, by 204 countries and territories. The absolute numbers (A&B) and age‐standardized rates (per 100 000 persons) (C&D) of deaths and DALYs in 204 countries and territories. Abbreviations: AF/AFL, atrial fibrillation/atrial flutter; DALYs, disability‐adjusted life years; HSBP, high systolic blood pressure.

3.2. Trends in HSBP‐related AF/AFL burden over time

From 1990 to 2019, the absolute number changes in AF/AFL deaths related to HSBP were spatially heterogeneous. Generally, Asia, Africa, Australasia, and Latin America showed sharp growth of more than 50%. At the same time, countries in Eastern and Western Europe exhibited a slight increase (<50%) (Supplemental Fig. S2A). The large increases were observed in Bahrain and the United Arab Emirates, which increased by 697.12% and 667.30%, respectively. The DALYs number caused by AF/AFL due to HSBP showed a similar trend from 1990 to 2019 (Supplemental Fig. S2B).

In terms of ASR of deaths and DALYs, most regions exhibited upward patterns in 21 GBD regions in the past decades, except for Central Europe, Western Europe, high‐income North America, Australasia, and high‐income Asia Pacific (Figure 2 and Supplemental Fig. S4). The greatest increase was observed in Andean Latin America with an EAPC of 2.00 (1.73, 2.27) in mortality rate and 1.68 (1.45, 1.91) in DALYs rate (Figure 2A–C, Tables 1 and 2). High‐income Asia Pacific countries had the largest decrease, with an EAPC of ‐1.88 (‐2.00, ‐1.77) in mortality rate and ‐2.05 (‐2.28, ‐1.83) in DALYs rate. It is notable that high‐income North America and Central Sub‐Saharan Africa experienced a decline at first and then had a slight increase in DALYs rate during 1990–2019 (Supplemental Fig. S4B).

FIGURE 2.

FIGURE 2

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The annual variation of HSBP‐related AF/AFL burden from 1990 to 2019, by location. EAPCs of deaths (A) and DALYs (B) rates (per 100,000 persons) in 204 countries and territories, as well as in 5 SDI quintiles and 21 GBD world regions, by sex (C). Abbreviations: EAPC, estimated annual percentage changes; SDI, social‐demographic index; GBD, Global Burden of Disease; Other abbreviations as in Figure 1.

3.3. Disparities across SDI quintiles

The global HSBP‐related AF/AFL burden varied among five SDI quintiles. Over the last three decades, all SDI quintiles experienced increases in the absolute number of HSBP‐related AF/AFL burden (Figure 3A). The high (deaths: 35 403 and DALYs: 915 499) and high‐middle (deaths: 28 859 and DALYs: 913 884) SDI quintiles bore almost half of the absolute burden in 2019 (Tables 1 and 2). The low SDI quintile had the least burden with 4660 deaths and 149 550 DALYs. As for the deaths and DALYs rates, the high and high‐middle SDI quintiles showed downward trends, whereas the middle, low‐middle, and low SDI quintiles have experienced rapid increases (Figures 2C and 3B). The highest deaths rate (1.52 per 100 000) and DALYs rate (45.9 per 100 000) were observed in the high SDI quintile (Figure 3B, Tables 1 and 2).

FIGURE 3.

FIGURE 3

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The changing trends of HSBP‐related AF/AFL burden during 1990 to 2019, by sex and SDI quintiles. The changing trends of deaths and DALYs numbers (A) and age‐standardized rates (B) in 5 SDI quintiles, by sex. Abbreviations as in Figure 1&2.

We further analyzed the relationship between HSBP‐related AF/AFL burden and SDI. Generally, in 21 GBD world regions, an asymmetrically inverted V‐shaped correlation was detected between SDI and deaths rates (Supplemental Fig. S5A). Central Sub‐Saharan Africa, Central Asia, Australasia, and Western Europe had much higher deaths rates than expected based on SDI for all years. Conversely, high‐income Asia Pacific had much lower deaths rates than expected SDI. The DALYs rates had a similar association with SDI (Supplemental Fig. S5B). Regarding the annual changes, negative relationships were observed between SDI and EAPCs of mortality (r = ‐0.430, P < .001) and DALYs (r = ‐0.458, P < .001, Pearson correlation analysis) in 204 countries and territories (Supplemental Fig. S5C and D).

3.4. Sex and age heterogeneity

During 1990–2019, significant sex differences were observed in the AF/AFL burden due to HSBP (Figures 2, 3, 4 and Supplemental Fig. S3). The absolute numbers of deaths and DALYs for females surpassed those for males globally. Females had a higher deaths rate, while males had a higher DALYs rate. In terms of discrepancy across the SDI quintiles, females had higher rates of deaths and DALYs than males in the middle, low‐middle, and low SDI quintiles, while the opposite occurred in the high SDI quintile (Figure 3B). Some notable patterns were observed in South Asia and central Europe, where the mortality rates showed an annual increase in males (Figure 2C).

FIGURE 4.

FIGURE 4

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The gender and age distribution of HSBP‐related AF/AFL burden in 1990 and 2019. (A) Deaths and DALYs rates (per 100 000 persons) in 21 GBD world regions, by sex, in 1990 and 2019. (B) Global numbers of deaths and DALYs in different age stratifications, by sex, in 2019. (C&D). Abbreviations as in Figure 1&2.

The numbers of HSBP‐related AF/AFL deaths and DALYs increased with age and reached a peak at 85–89 years in both males and females (Figure 4B, Tables S1 and S2). Notably, young adults (30‐49 years old) experienced an annual increase in global deaths and DALYs rates. And all age groups (30‐49, 50–69, and over 70 years) exhibited upward trends in the in the middle, low‐middle, and low SDI quintiles (Supplemental Fig. S6).

3.5. Proportion of HSBP attributable AF/AFL burden

HSBP was the leading risk factor contributing to AF/AFL among the six main risk factors in GBD 2019, including HSBP, high body‐mass index, diet high in sodium, alcohol use, smoking, and lead exposure. Dramatic heterogeneities were observed in different geographic locations, SDI quintiles, age groups, and genders with regard to risk factors (Figure 5 and Supplemental Fig. S7). The low SDI region had the highest proportion of HSBP contributing to AF/AFL (deaths 57.98%, DALYs 56.73%), while the high SDI region had the lowest proportion of HSBP contributing to AF/AFL (deaths 42.35%, DALYs 40.31%) (Figure 5A). In 21 GBD regions, HSBP was pumped out in Central Sub‐Saharan Africa (deaths 64.65%, DALYs 62.65%) and Western Sub‐Saharan Africa (deaths 59.96%, DALYs 58.37%) (Figure 5B). Young adults aged 30–34 years were found to have a high percentage of HSBP (deaths 45.38%, DALYs 44.58%) in all six risk factors related to AF/AFL. And the proportion of HSBP increased progressively with age, peaking in the 75 to 79‐year‐old group for both death (48.95%) and DALYs (44.58%) (Supplemental Fig. S7A and B). Females had a higher proportion of HSBP attributable AF/AFL (deaths 50.71%, DALYs 51.44%) than males (Supplemental Fig. S7C and D).

FIGURE 5.

FIGURE 5

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The proportion of risk factors contributing to AF/AFL, by SDI (A) and 21 GBD world regions (B), in 2019.

3.6. Global health inequality of AF/AFL burden due to HSBP

Next, we calculated the Gini coefficient to assess the inequality of HSBP‐related AF/AFL burden. According to the Gini coefficient, improved geographical health inequality between countries was observed from 1990 to 2019 (Figure 6). During 1990–2019, the inequality for age‐standardized deaths rate decreased from 0.211 (95% CI: 0.194, 0.224) to 0.181 (95% CI: 0.168, 0.193). Similarly, the Gini coefficient for age‐standardized DALYs rate declined significantly from 0.224 (95% CI: 0.214, 0.234) in 1990 to 0.183 (95% CI: 0.174, 0.192) in 2019.

FIGURE 6.

FIGURE 6

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The Gini coefficients of HSBP‐related AF/AFL burden during 1990–2019. Trends in the Gini coefficients calculated based on (A) age‐standardized deaths rates, (B) age‐standardized DALYs rates across 204 countries and territories globally between 1990 and 2019.

4. DISCUSSION

In general, our study provided a comprehensive assessment of the global burden of AF/AFL due to HSBP. HSBP was the leading risk contributing to AF/AFL and the HSBP attributable AF/AFL burden has been an incremental public health concern worldwide, with 107 091 deaths and 3 337 876 DALYs cases in 2019, making a 142.5% and 105.9% increase from 1990, respectively. Although the inequality of HSBP‐related AF/AFL burden has been improved over the past decades, substantive discrepancies existed across SDI quintiles, sexes, and age groups. The HSBP‐related AF/AFL burden gradually transited from high and high‐middle to lower SDI regions. Females largely outpaced males in absolute fatal and non‐fatal AF/AFL burdens associated with HSBP. Elderly people aged 85–89 years bore the highest AF/AFL burden, whereas young adults (30‐49 years) experienced an annual increase. These findings demonstrated the importance of intensive BP control and provided relevant information for policymakers to formulate tailored strategies for the prevention and treatment of HSBP‐related AF/AFL burden.

To date, the majority of clinical studies have shown a direct and linear relationship between BP levels and the risk of AF. 9 , 19 The MESA (Multi‐Ethnic Study of Atherosclerosis) study reported that prehypertension (120–139/80–89 mmHg) was associated with a significant 80% higher risk of AF after adjustment. 20 Hypertension increases the risk of thromboembolism and bleeding in patients with documented AF and facilitates the progression from paroxysmal to persistent or permanent AF. Optimal management of hypertension not only improves the outcomes in patients with AF, but also prevents the risk of major adverse cardiovascular events. 9 However, methods on AF control mostly concentrate on rate control or sinus rhythm restoration, as well as anticoagulation for the prevention of stroke. The incidence of stroke in individuals with AF is still substantial (about 1.5% per year) even with good anticoagulation and rate or rhythm management, and it is most likely to be caused by related risk factors rather than inadequate treatment. 21 Therefore, management of associated cardiovascular risk factors, especially BP, the largest independent risk factor of AF, seems a priority in AF treatment to improve cardiovascular outcomes.

By analyzing the data from GBD 2019 database, our findings implied that there were significant heterogeneities in the global burden of the HSBP‐related AF/AFL, despite improvements in health inequities over the previous few decades. The AF/AFL burden was associated with the socioeconomic development and skewed more toward middle, low‐middle, and low‐SDI countries. The inequalities in disease burden can partially be attributable to the treatment conditions, such as the use of new oral anticoagulants, left atrial appendage occlusion, and catheter or cryogenic balloon ablation, which are distributed unequally in different socioeconomic regions. 22 , 23 It is reported that patients living in the most deprived areas were 15% less likely to receive oral anticoagulation, compared to patients living in the least deprived areas. 24 In addition, population aging as well as some metabolic and behavioral risk factors, including diabetes, obesity, tobacco use, and sedentary lifestyle, tend to increase with development. 25 Thus, it is obvious that the AF/AFL burden will be highly concentrated in some developing countries with large population, such as Brazil, Russia, India, and China (BRIC), where the populations of individuals aged >60 years are predicted to at least double by 2050. 26 Work priority should certainly be given to the BRIC, not only for their heavy burden, but also for their increasing global significance as an economic grouping. 27 Among these countries, the Russia Federation deserves more attention for its high absolute burden and annually increasing deaths and DALYs rates.

The available data also indicated that exposure to elevated BP caused a rapid rise of AF/AFL burden in Andean Latin America, Southern Latin America, and Sub‐Saharan Africa, suggesting that these regions need to develop more effective interventions in BP control. Sarfo and colleagues have revealed several issues contributing to poor BP control rate in Sub‐Saharan Africa. 28 In their report, physician‐related barriers such as clinical inertia, which refers to a physician's decision not to alter antihypertensive medication when BP was above 140/90 mmHg, resulted in 90% of patients with uncontrolled BP. And this situation may blame to a lack of clinical practice guidelines for the management of hypertension, as well as insufficient training of health care professionals in implementing these guidelines. Therefore, further efforts should be made to help physicians actively initial and intensify BP‐lowering medication in Sub‐Saharan Africa to achieve optimal BP control. At the same time, evidence shows that acute SARS‐CoV‐2 infection may increase the susceptibility to AF and promote the evolution of a prothrombotic state. 29 , 30 These regions with limited resources are suffering a double whammy in the AF/AFL burden. Thus, a comprehensive strategy is highlighted to guide the allocation of resources in local regions towards effectively monitoring BP and reducing the AF/AFL burden. 31

There was undoubtedly a sex preponderance in the HSBP‐related AF/AFL burden. Compared with males, females suffered a higher absolute AF/AFL burden caused by HSBP and the gender differences widened with age. First, inherent sex heterogeneity, especially estrogen, could contribute to the sex difference. 32 In our observation, females outnumbered males in mortality and DALYs after 65 years of age, a postmenopausal stage, illustrated this point well. Second, females were less likely to receive invasive rhythm control therapy than males, including electrical cardioversion and catheter ablation. 33 Third, compared with men, women with AF/AFL tend to have more severe symptoms with higher proportional risk of death and cardiovascular diseases. 34 This significant sex difference requires to adopt sex‐specific BP control for AF prevention.

HSBP‐related AF/AFL burden in young adults showed an annual upward trend in most SDI quintiles except for the high SDI quintile. AF‐related cardiovascular diseases, particularly stroke in the young lead to increased long‐term morbidity, which affect social relationships, education, and employment. 35 According to a study on stroke patients younger than 55 years, the prevalence of AF as an underlying cause of stroke has risen from 2.4% to 3.8% in recent years. 36 The situation seems to be worse for young adults in less developed areas. By analyzing 5.6 million population, Chung and associates indicated that individuals from the highest deprived areas in socioeconomic and living status had a 12% greater risk of developing AF and a 26% higher AF fatality than people living in the wealthiest areas. Despite being younger than those from wealthy areas, AF patients from the most deprived areas had more comorbidities when first diagnosed. 37 This highlights the importance of systematic surveillance and risk factor control in young hypertensive individuals to prevent AF development.

Hypertension is a modifiable risk factor and, therefore, carries a potential for AF prevention, lowering AF recurrence rates, and avoiding the debilitating complications, such as stroke. From a public health perspective, emphasizing BP control helps to lower the AF/AFL burden and health care costs for the entire population. From a clinical standpoint, strict BP management slows the progression of AF and improves outcomes in established AF patients. The management of associated cardiovascular risk factors, particularly BP control, has been incorporated into the 2020 European Society of Cardiology (ESC) guidelines as part of the “ABC” approach to AF management (avoid stroke, better symptom management, and cardiovascular and comorbidity risk reduction). 38 The currently recommended BP target is below 130/80 mmHg based upon the current ESC hypertension guidelines 38 , 39 and observational evidence showing greatest benefit of SBP between 120 and 129 mmHg. 40 , 41 Whether this target is optimal for the reduction of future major adverse cardiovascular events in patients with AF remains to be discussed. However, for practicing clinicians, the consultation for AF patients should always involve a conversation about managing hypertension, no matter whether it be lifestyle modification or pharmacological treatment.

4.1. Study limitations

There were some inherent limitations in this study. First, the GBD database extracts AF/AFL cases by using international classification of diseases (ICD) codes, in which process AF/AFL cases may have been over‐ or underestimated. Whereas detailed information about different subsets of AF/AFL, such as paroxysmal, persistent, or permanent, could not be obtained from the GBD database, which may limit the comprehensive and stratified analysis of AF/AFL burden due to HSBP. 1 Second, there was deviation in the process of calculating Gini index, because there may be intra‐group differences in some countries that span a large territory, such as China and India. 42 Third, due to the limitation of GBD data, effects from direct or indirect factors related to HSBP were incorporated when aggregating the AF/AFL burden attributable to HSBP. 43 Finally, in addition to a rise in cases, increased AF/AFL awareness and diagnostic rates, as well as frequent hospital visits, have all contributed to the increased AF/AFL burden, which cannot be quantified.

5. CONCLUSION

The global HSBP‐related AF/AFL burden has increased significantly since 1990. Despite improvements in health inequality, the HSBP‐related AF/AFL burden varied with considerable spatiotemporal, sexual, and age heterogeneity. This study highlighted the importance of strict BP control and offered insights into developing geographically tailored strategies to reduce the HSBP attributable AF/AFL burden.

AUTHOR CONTRIBUTIONS

YQJ and KKW performed the data analysis and wrote the manuscript. JCL planned the study and revised this paper. MXW and XYG helped to analyze the data. JZ and BX was responsible for software and data visualization. All authors provided critical comments on the manuscript. All authors read and approved the final manuscript.

CONFLICT OF INTEREST

The authors have no conflicts of interest to declare that are relevant to the content of this article.

Supporting information

Supplementary material

Click here for additional data file. (20.9MB, docx)

ACKNOWLEDGEMENTS

This work was supported by the Program for Excellent Talents in Clinical Medicine of Hebei Province (No.303‐16‐20‐09) and Key Project of Medical Science Research in Hebei Province (No.20210155).

Jin Y, Wang K, Xiao B, et al. Global burden of atrial fibrillation/flutter due to high systolic blood pressure from 1990 to 2019: estimates from the global burden of disease study 2019. J Clin Hypertens. 2022;24:1461–1472. 10.1111/jch.14584

Yaqiong Jin and Keke Wang contributed equally.

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