1990–2019 Global AF/AFL Disease Burden Trends
The global disease burden of AF/AFL increased significantly from 1990 to 2019 (Table 1). The number of incidences increased from 2.134 million (1.764–2.951 million) in 1990 to 4.720 million (3.644–5.962 million) in 2019, with a 103.9% increase. The standardized prevalence rate decreased from 58.5 per 100,000 (44.9–74.2) to 57.1 per 100,000 (44.1–71.9). The number of prevalence increased from 2.8286 million (2.1493–3.6162 million) in 1990 to 59.695 million (75.287–45.730 million) in 2019, with a 111.0% increase. The standardized prevalence rate decreased from 775.9/100,000 (592.4-990.8) to 743.5/100,000 (571.2-938.3). The number of global AF/AFL deaths increased from 0.117 (0.104–0.138 million) in 1990 to 0.315 (0.268–0.361 million) in 2019, which increased by 169.2%. The standardized deaths rate increased from 4.3 per 100,000 (3.7–5.1) to 4.4 per 100,000 (3.7-5.0) DALYs increased from 3.788 million (2.961–4.832 million) in 1990 to 8.393 million (6.694–10.541 million) in 2019, an increase of 121.6%. The rate of age-standardized DALYs decreased from 110.0 per 100,000 (87.7-139.2) to 107.1/100,000 (86.1-133.7). From 1990 to 2019, the study found an interesting phenomenon: the ASR of incidence, prevalence, and Dalys all showed a gradual decrease until 2001 and reached a minimum in 2001, and the ASR of incidence showed a gradual increase after 2001. Meanwhile, the ASR of prevalence gradually increased after 2001 and leveled off after 2010, while standardized Dalys did not increase significantly afterward(Fig. 1). Figure S1 and Table S1 -S2 show the Nordpred APC model estimated that between 2030 and 2034, the AF/ AFL total incidence of males will be 16.08 million, and the total number of deaths will be 1.01 million. For females, the total number of incidence will be 16.85 million, and the total number of deaths will be 1.49 million.
Table 1
The Prevalence cases and age-standardized incidence of AF/AFL in 1990 and 2019, and its temporal trends from 1990 to 2019.
Characteristics | 1990 | 2019 | 1990–2019 |
Prevalence cases No.x105 (95% UI) | ASR per 100,000 No. (95% UI) | Prevalence cases No.x105 (95% UI) | ASR per 100,000 No. (95% UI) | EAPC No. (95% CI) |
Global | 282.9 (214.9-361.6) | 775.9 (592.4-990.8) | 597.0(457.3-752.9) | 743.5(571.2-938.3) | 0.01 (-0.06-0.08) |
High SDI | 100.6(76.6-127.4) | 947.6(727.7-1199.4) | 175.7(138.7-217.2) | 895.7(707.8-1104.9) | 0.16 (0.01–0.31) |
High-middle SDI | 83.1(63.0-107.0) | 818.6(625.2-1042.3) | 159.7(121.3-203.7) | 780.2 (594.1-996.5) | -0.14(-0.16–0.12) |
Middle SDI | 56.3(42.6–72.2) | 642.3 (486.6-819.1) | 155.1(117.2-199.6) | 672 (507.7-859.3) | 0.19 (0.13–0.25) |
Low-middle SDI | 33.1(25.0-42.8) | 659.3 (500.5-843.5) | 83.8(63.2-107.3) | 677 (511.8-863.1) | 0.13 (0.11–0.15) |
Low SDI | 9.6(7.2–12.4) | 492.3 (374.4-630.2) | 22.5(17.1–29.1) | 514.2(390.1-658.4) | 0.16 (0.15–0.17) |
Andean Latin America | 0.25(0.19–0.32) | 140.5 (106.1–181) | 0.85(0.64–1.1) | 158.1(119.6-202.1) | 0.56 (0.47–0.64) |
Australasia | 3.1(2.3–3.9) | 1300.6(982.4-1657.3) | 6.2(4.7–7.9) | 1212.2(927.8-1530.3) | -0.18 (-0.23–0.13) |
Caribbean | 0.83 (0.63–1.1) | 336.1 (254.2-433.9) | 1.8 (1.4–2.3) | 344.3 (262.5-440.9) | 0.11 (0.1–0.13) |
Central Asia | 3.8 (2.8–4.8) | 857 (649.7-1097.6) | 5.9 (4.4–7.6) | 893.6 (680.6-1145.9) | 0.19 (0.17–0.21) |
Central Europe | 15.0 (11.3–19.3) | 1026.8 (778.7–1318) | 22.1(16.6–28.4) | 1001.8 (756.8-1282.3) | 0.03 (-0.05-0.12) |
Central Latin America | 2.7 (2.0-3.5) | 366.2 (278.5–472) | 8.3 (6.3–10.7) | 368.6 (280.4-474.2) | 0.04 (0.03–0.05) |
Central Sub-Saharan Africa | 0.71(0.53–0.92) | 394.6 (297.9-507.7) | 1.7 (1.3–2.1) | 384.5 (291.3-497.7) | -0.11 (-0.13–0.09) |
East Asia | 51.1 (38.5–66.0) | 687.8 (520.9-881.5) | 143.4 (108.3–186.0) | 723.4 (546.9-923.9) | 0.22 (0.1–0.35) |
Eastern Europe | 26.0 (19.6–33.5) | 946.3 (722.9-1209.9) | 37.0 (28.1–47.6) | 1046.9 (797.4-1344.7) | 0.42 (0.39–0.45) |
Eastern Sub-Saharan Africa | 1.4 (1.0-1.8) | 226.9 (172.3–293) | 3.2 (2.4–4.1) | 233.2 (177.4-300.8) | 0.2 (0.14–0.26) |
High-income Asia Pacific | 7.5 (5.7–9.5) | 376.6 (290.8-477.2) | 13.5(10.5–17.1) | 312.1 (242-394.5) | -1.31 (-1.62–1) |
High-income North America | 42.9 (32.7–54.7) | 1173.6 (898.8-1486.1) | 86.2 (70.2-104.4) | 1322.2 (1074.9-1600.7) | 1.21 (0.86–1.55) |
North Africa and Middle East | 7.2(5.4–9.2) | 498.2 (379.2-638.2) | 19.0 (14.5–24.2) | 506.4 (385.7-648.5) | -0.04 (-0.08–0.01) |
Oceania | 0.17 (0.13–0.21) | 707.9 (534.1-905.9) | 0.41 (0.31–0.53) | 733.5 (552.3-942.1) | 0.1 (0.09–0.12) |
South Asia | 34.2(25.8–44.2) | 746.3 (566.1–953) | 96.6 (72.5–124.0) | 763.9 (577.7-972.9) | 0.07 (0.07–0.08) |
Southeast Asia | 16.4 (12.5–21.2) | 755.7 (570.4-967.1) | 42.6 (32.2–54.5) | 781.8 (589.3-998.6) | 0.13 (0.12–0.14) |
Southern Latin America | 2.3 (1.7–2.9) | 504.7 (378.9-645.2) | 4.5 (3.5–5.7) | 529.6 (400.6-675.9) | 0.14 (0.08–0.21) |
Southern Sub-Saharan Africa | 1.1 (0.85–1.4) | 455.5 (347.2–586) | 2.3 (1.7–2.9) | 449.4 (340.6-578.6) | -0.03 (-0.04–0.03) |
Tropical Latin America | 4.1 (3.1–5.3) | 518 (391.9-666.7) | 12.5 (9.5–16.1) | 536 (408.5-690.8) | 0.66 (0.47–0.85) |
Western Europe | 59.1(45.0-75.1) | 996 (764.6-1265.3) | 82.1(62.5-103.8) | 886.7 (680.2-1124.2) | -0.23 (-0.27–0.19) |
Western Sub-Saharan Africa | 3.3 (2.5–4.2.3) | 430.3 (326.8-550.3) | 7.0 (5.3-9.0) | 441.6 (334.5-568.1) | 0.09 (0.06–0.13) |
ASR, age-standardized rate; CI, confidence interval; EAPC, estimated annual percentage change; UI, uncertainty interval |
Global Age Distribution of AF/AFL Disease Burden in 2019
The global prevalence, incidence, deaths, and DALYs ratio of AF/AFL showed an overall increasing trend with age (Fig. 2, Table S3) and the incidence of AF/AFL increased significantly with age, peaking between 75–79 years and gradually decreasing after 80 years(Fig. 2a). The prevalence rate gradually increased with age, peaking between 90–94 years and then dropping(Fig. 2b). The death rate showed an increasing trend with age trend(Fig. 2c), and the rate of DALYs tended to increase with age(Fig. 2d).
Gender distribution of the global AF/AFL disease burden
From 1990 to 2019, the number of incidence, prevalence, deaths, DALYs, and their ratios for both males and females showed an increasing trend over time. In terms of overall numbers and trends, the overall burden of disease was slightly higher for males than females (Figure S2). In 2019, there are significant differences in disease burden between males and females in different age groups, with the female having a greater overall number of incidence than males after 65 years of age, a greater number of prevalence than males after 75 years of age, a significantly higher number of deaths than males after 65 years of age, and a higher total number of DALYs than males after 70 years of age(Fig. 3). From Tables S4-S5, the incidence rates of AF/AFL in 2019 was 60.8/100,000 (46.6–77.1) for females and 61.2/100,000 (47.3–77.6) for males; the prevalence rates was 750.1/100,000 (575.4–947.0) for females and 780.3/100,000 (603.6-987.7) for males. Deaths rates was 5.0/100,000 (4.2–5.8) for female and 3.1 /100,000 (2.5–3.8) for male; DALYs rates was 115.1/100,000 (143.6–92.7) for female and 101.9 /100,000 (79.6-130.1) for male.
Global distribution of AF/AFL disease burden across regions and countries
The geographic distribution heat map(Fig. 4) shows that the disease burden of AF/AFL in 1990 varies significantly by country. The top five countries in terms of prevalence were China (4,927,000), the United States of America (3,881,000), India (2,691,000), the Russian Federation (1,635,000) and Germany (1,396,000). After correcting for age and demographic factors, the top five prevalence countries were New Zealand (1329.1 per 100,000), Sweden (13.09 per 100,000), Australia (1294.9 per 100,000), Canada (1235.9 per 100,000), and Greenland (1227.8 per 100,000) (Fig. 4a). The disease burden of AF/AFL in 2019 varied significantly between countries or regions. The top five countries in terms of prevalence were China (13.883 million), India (7.996 million), the United States of America (7.729 million), the Russian Federation (2.774 million), and Germany (1.824 million). After adjusting for age and population, the top five countries in terms of prevalence were the United States of America (1331.4/100,000), Sweden (1279.0/100,000), Canada (1248.5/100,000), Greenland (1231.3/100,00), and New Zealand (1223.2/100,00) (Fig. 4b). The top five countries in the world in terms of prevalence growth rate by country and region from 1990 to 2019 were the United Arab Emirates (796.1%), Qatar (790.0%), Bahrain (471.5%), Jordan (415.9%), and Djibouti (381.5%)(Fig. 4c). The top 5 countries in terms of change in prevalence (EAPC) after correcting for age and population factors were the United States of America (1.3), Ecuador (1.3), Austria (1.2), Kenya (1.1), and Czechia (0.7) (Fig. 4d). Overall, the disease burden of AF/AFL was higher in countries with larger populations.
Relationship between AF/AFL disease burden and level of socio-economic development.
Trends in AF/AFL disease burden by SDI level
The study included 204 countries and 21 regions with the 5 SDI regions to which they belonged, with significant differences in changes in disease burden across SDI groups(Fig. 5). As seen in Figure S3, the standardized incidence, prevalence, deaths, and DALYs were higher in the middle-high and high-SDI regions, but their standardized deaths and DALYs changes showed a decreasing trend, while the standardized deaths rates and DALYs increased faster in the lower SDI regions. The prevalence of AF/AFL was still high in the high-SDI regions. Standardized prevalence rates were high in all high SDI regions except the High-income Asia Pacific. The patterns observed varied widely in many of the middle SDI regions. Some regions had little change in age-standardized rates throughout the study period, while others had fluctuating or increasing age-standardized rates, ρ = 0.49, P < 0.001 (Fig. 5a). At the global level, the age-standardized prevalence of SDI countries in 2019 showed a gradual increase with increasing SDI, ρ = 0.54, P < 0.001(Fig. 5b).
EAPC and ASR/HDI relationship
As shown in Fig. 6, EAPC was significantly correlated with the Age-standardized deaths rate in 1990(ASDR 1990) and the Human Development Index in 2019(HDI 2019). ASDR 1990 for AF/AFL reflects the baseline disease reservoir, and 2019 HDI can be a proxy for the level and accessibility of health care in each country. There was a significant negative correlation between EAPC and ASDR, when ASDR was limited to less than 150/100,000 (ρ=-0.26, p < 0.001). In contrast, this association disappeared when the ASDR was higher than 150/100,000(Fig. 6a). The EAPC of DALYs in the middle HDI region was higher than that in the low and high HDI regions, with an inverted U-shape (ρ=-0.29, p < 0.001), countries with higher HDI experienced a decrease in ASDR for AF/AFL(Fig. 6b).
Impact of AF/AFL risk factors on disease burden
At the global 2019 AF/AFL risk factor level, a substantial proportion of DALYs were attributable to the five GBD-estimated risk factors, including high systolic blood pressure 34.0% (95%UI 27.3–41.0%), high body-mass index(BMI) 20.2% (95%UI 27.3–39.9), alcohol use 19.5% (95%UI 6.3–36.0), smoking 19.1% (95%UI 4.2–34.6) and diet high in sodium 7.5% (95%UI 5.2–9.6) (Fig. 7). The effects of these risk factors varied by region. For example, the effect of high systolic blood pressure was highest in Southern Sub-Saharan Africa (47.6% of DALYs attributed to high systolic blood pressure) and Central Asia (46.2%). The effect of the high body-mass index was highest in Eastern Europe (32.3% of DALYs attributed to high BMI) and Central Europe (32.2%).
Figure S4 shows that the burden of disease due to all risk factors was highest in high SDI regions, with a standardized deaths rate of 2.5/100,000 (1.9–3.1) and standardized DALYS of 145.8/100,000 (112.9-191.1), followed by middle-high SDI regions, with a standardized deaths rate of 2.3/100,000 (1.8–2.9) and standardized DALYS of 91.8/100,000 (68.4–121.0). The middle SDI regions have standardized death rates of 2.3/100,000 (1.8–2.9) and standardized DALYs of 91.8/100,000 (68.4–121.0). Metabolic factors (high systolic blood pressure) were the most critical risk factor in all SDI regions, with a significantly higher risk share than other risk factors. In the low SDI, low-middle SDI, and middle SDI groups, the effect of alcohol on AF/AFL was much lower than in the high SDI group. The impact of high BMI on AF was higher in the high and middle-high SDI regions than in the low, middle-low and middle SDI regions.
As shown in Figure S5, the risk factor level from 1990 to 2019 in the 5 SDI regions, among the 5 risk factors attributed to DALYs, no significant change was seen in the effect of alcohol. The impact of high sodium intake was gradually decreasing, with the most significant decrease in the moderate SDI regions. High BMI showed varying degrees of elevation in all SDI regions, and its baseline level was positively correlated with SDI levels. The effect of smoking showed a decreasing trend in all five SDI regions, with the most significant decrease in the high SDI region. Interestingly, in terms of high systolic blood pressure on DALYs, the trend was decreasing in the high and middle-high SDI regions, with the largest decrease in the high SDI region. The middle, middle-low and low SDI regions showed an increasing trend until 2010–2011, after which they decreased year by year but remained above their 1990 base values. The change in risk factors attributed to Deaths was nearly identical to that of Daly.