Body Mass Index and Adverse Events in Patients with Incident Atrial Fibrillation



      Obesity is associated with the development of atrial fibrillation and may impact atrial fibrillation-related outcomes. To date, no anthropometric measure is included in any risk stratification scheme for stroke and death in atrial fibrillation patients.


      The prospective Danish Diet, Cancer and Health study is a cohort including 57,053 participants (27,178 men and 29,875 women) aged between 50 and 64 years. The study population for this study included the 3135 patients (2025 men and 1110 women) who developed incident atrial fibrillation during follow-up.


      Of the subjects with atrial fibrillation, 1414 (45%) had a body mass index (BMI) in the overweight category (BMI 25 to <30 kg/m2) and 767 (24%) were categorized as obese (BMI ≥30 kg/m2). During a median follow-up of 4.9 years, 609 deaths and 216 thromboembolic events (98% ischemic strokes) occurred. Using normal-weight patients as reference, the risk of a composite end point of “ischemic stroke, thromboembolism, or death” was significantly higher in overweight (crude hazard ratio [HR] 1.31; 95% confidence interval [CI], 1.09-1.56) and obese patients (crude HR 1.55; 95% CI 1.27-1.90). After adjustment for CHADS2 and CHA2DS2-VASc scores, the HRs for the composite end point were 1.21 (95% CI 1.02-1.45) and 1.31 (95% CI 1.10-1.56), respectively, for overweight and 1.25 (95% CI 1.03-1.53) and 1.36 (95% CI 1.11-1.65), respectively, for obese. Continuous analyses of BMI stratified by sex identified obese men and normal-weight women as the sex-specific “high-risk” categories.


      Overweight and obesity are risk factors for “ischemic stroke, thromboembolism or death” in patients with atrial fibrillation, even after adjustment for CHADS2 and CHA2DS2-VASc scores. The association between BMI and outcomes among atrial fibrillation patients may be modified by sex.


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        • Savelieva I.
        • Camm J.
        Update on atrial fibrillation: part I.
        Clin Cardiol. 2008; 31: 55-62
        • Majeed A.
        • Moser K.
        • Carroll K.
        Trends in the prevalence and management of atrial fibrillation in general practice in England and Wales, 1994-1998: analysis of data from the general practice research database.
        Heart. 2001; 86: 284-288
        • Smith J.G.
        • Platonov P.G.
        • Hedblad B.
        • Engström G.
        • Melander O.
        Atrial fibrillation in the Malmö diet and cancer study: a study of occurrence, risk factors and diagnostic validity.
        Eur J Epidemiol. 2010; 25: 95-102
        • Jorgensen H.S.
        • Nakayama H.
        • Reith J.
        • Raaschou H.O.
        • Olsen T.S.
        Acute stroke with atrial fibrillation: the Copenhagen Stroke Study.
        Stroke. 1996; 27: 1765-1769
        • Lin H.-J.
        • Wolf P.A.
        • Kelly-Hayes M.
        • et al.
        Stroke severity in atrial fibrillation: the Framingham Study.
        Stroke. 1996; 27: 1760-1764
        • Wolowacz S.
        • Samuel M.
        • Brennan V.
        • Jasso-Mosqueda J.
        • Gelder I.
        The cost of illness of atrial fibrillation: a systematic review of the recent literature.
        Europace. 2011; 13: 1375-1385
        • Hart R.
        • Pearce L.
        • Halperin J.
        • et al.
        Comparison of 12 risk stratification schemes to predict stroke in patients with nonvalvular atrial fibrillation.
        Stroke. 2008; 39: 1901-1910
        • Hughes M.
        • Lip G.Y.H.
        Stroke and thromboembolism in atrial fibrillation: a systematic review of stroke risk factors, risk stratification schema and cost effectiveness data.
        Thromb Haemost. 2008; 99: 295-304
        • Gage B.F.
        • Waterman A.D.
        • Shannon W.
        • et al.
        Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.
        JAMA. 2001; 285: 2864-2870
        • Lip G.Y.H.
        • Nieuwlaat R.
        • Pisters R.
        • Lane D.A.
        • Crijns H.J.G.M.
        Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation.
        Chest. 2010; 137: 263-272
        • Popkin B.M.
        • Adair L.S.
        • Ng S.W.
        Global nutrition transition and the pandemic of obesity in developing countries.
        Nutr Rev. 2012; 70: 3-21
        • Pischon T.
        • Boeing H.
        • Hoffmann K.
        • et al.
        General and abdominal adiposity and risk of death in Europe.
        N Engl J Med. 2008; 359: 2105-2120
        • Whitlock G.
        • Lewington S.
        • Sherliker P.
        • et al.
        Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies.
        Lancet. 2009; 373: 1083-1096
        • Strazzullo P.
        • D'Elia L.
        • Cairella G.
        • et al.
        Excess body weight and incidence of stroke: meta-analysis of prospective studies with 2 million participants.
        Stroke. 2010; 41: e418-e426
        • Long M.J.
        • Jiang C.Q.
        • Lam T.H.
        • et al.
        Atrial fibrillation and obesity among older Chinese: the Guangzhou Biobank Cohort Study.
        Int J Cardiol. 2011; 148: 48-52
        • Tedrow U.B.
        • Conen D.
        • Ridker P.M.
        • et al.
        The long- and short-term impact of elevated body mass index on the risk of new atrial fibrillation The WHS (Women's Health Study).
        J Am Coll Cardiol. 2010; 55: 2319-2327
        • Wanahita N.
        • Messerli F.H.
        • Bangalore S.
        • et al.
        Atrial fibrillation and obesity—results of a meta-analysis.
        Am Heart J. 2008; 155: 310-315
        • Dublin S.
        • French B.
        • Glazer N.L.
        • et al.
        Risk of new-onset atrial fibrillation in relation to body mass index.
        Arch Intern Med. 2006; 166: 2322-2328
        • Frost L.
        • Hune L.J.
        • Vestergaard P.
        Overweight and obesity as risk factors for atrial fibrillation or flutter: the Danish Diet, Cancer, and Health Study.
        Am J Med. 2005; 118: 489-495
        • Badheka A.O.
        • Rathod A.
        • Kizilbash M.A.
        • et al.
        Influence of obesity on outcomes in atrial fibrillation: yet another obesity paradox.
        Am J Med. 2010; 123: 646-651
        • Ardestani A.
        • Hoffman H.J.
        • Cooper H.A.
        Obesity and outcomes among patients with established atrial fibrillation.
        Am J Cardiol. 2010; 106: 369-373
        • Tang R.B.
        • Liu X.H.
        • Kalifa J.
        • et al.
        Body mass index and risk of left atrial thrombus in patients with atrial fibrillation.
        Am J Cardiol. 2009; 104: 1699-1703
        • Novo G.
        • Mansueto P.
        • La Franca M.L.
        • et al.
        Risk factors, atrial fibrillation and thromboembolic events.
        Int Angiol. 2008; 27: 433-438
        • Tjønneland A.
        • Olsen A.
        • Boll K.
        • et al.
        Study design, exposure variables, and socioeconomic determinants of participation in Diet, Cancer and Health: a population-based prospective cohort study of 57,053 men and women in Denmark.
        Scand J Public Health. 2007; 35: 432-441
        • Thygesen L.C.
        • Daasnes C.
        • Thaulow I.
        • Brønnum-Hansen H.
        Introduction to Danish (nationwide) registers on health and social issues: Structure, access, legislation, and archiving.
        Scand J Public Health. 2011; 39: 12-16
        • Olesen J.B.
        • Lip G.Y.H.
        • Hansen M.L.
        • et al.
        Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study.
        BMJ. 2011; 342: d124
        • Kildemoes H.W.
        • Sørensen H.T.
        • Hallas J.
        The Danish National Prescription Registry.
        Scand J Public Health. 2011; 39: 38-41
        • Rix T.A.
        • Riahi S.
        • Overvad K.
        • et al.
        Validity of the diagnoses atrial fibrillation and atrial flutter in a Danish patient registry.
        Scand Cardiovasc J. 2012; 46: 149-153
        • Berentzen T.L.
        • Jakobsen M.U.
        • Halkjaer J.
        • et al.
        Changes in waist circumference and mortality in middle-aged men and women.
        PLoS One. 2010; 5: 5-12
        • Reas D.L.
        • Nygård J.F.
        • Svensson E.
        • Sørensen T.
        • Sandanger I.
        Changes in body mass index by age, gender, and socio-economic status among a cohort of Norwegian men and women (1990-2001).
        BMC Public Health. 2007; 7: 269
        • Banerjee A.
        • Taillandier S.
        • Olesen J.B.
        • et al.
        Pattern of atrial fibrillation and risk of outcomes: the Loire Valley Atrial Fibrillation Project.
        Int J Cardiol. 2013 Jul 13; ([Epub ahead of print])
        • Badheka A.O.
        • Rathod A.
        • Bharadwaj A.
        • et al.
        Obesity paradox in outcomes of atrial fibrillation.
        Am J Cardiol. 2011; 108: 474
        • Tsang T.S.M.
        • Barnes M.E.
        • Miyasaka Y.
        • et al.
        Obesity as a risk factor for the progression of paroxysmal to permanent atrial fibrillation: a longitudinal cohort study of 21 years.
        Eur Heart J. 2008; 29: 2227-2233
        • Guglin M.
        • Maradia K.
        • Chen R.
        • Curtis A.B.
        Relation of obesity to recurrence rate and burden of atrial fibrillation.
        Am J Cardiol. 2011; 107: 579-582
        • Chilukuri K.
        • Dalal D.
        • Gadrey S.
        • et al.
        A prospective study evaluating the role of obesity and obstructive sleep apnea for outcomes after catheter ablation of atrial fibrillation.
        J Cardiovasc Electrophysiol. 2010; 21: 521-525
        • Rosito G.A.
        • D'Agostino R.B.
        • Massaro J.
        • et al.
        Association between obesity and a prothrombotic state: the Framingham Offspring Study.
        Thromb Haemost. 2004; 91: 683-689
        • Yazdan-Ashoori P.
        • Baranchuk A.
        Obstructive sleep apnea may increase the risk of stroke in AF patients: refining the CHADS2 score.
        Int J Cardiol. 2011; 146: 131-133
        • Hart R.G.
        • Pearce L.A.
        • Aguilar M.I.
        Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation.
        Ann Intern Med. 2007; 146: 857-867
        • Larsen T.B.
        • Lip G.Y.H.
        • Skjøth F.
        • et al.
        Added predictive ability of the CHA2DS2VASc risk score for stroke and death in patients with atrial fibrillation: the prospective Danish Diet, Cancer, and Health cohort study.
        Circ Cardiovasc Qual Outcomes. 2012; 5: 335-342
        • Nakagawa K.
        • Hirai T.
        • Takashima S.
        • et al.
        Chronic kidney disease and CHADS2 score independently predict cardiovascular events and mortality in patients with nonvalvular atrial fibrillation.
        Am J Cardiol. 2011; 107: 912-916