Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis

Abstract

Atrial fibrillation (AF) is the most common sustained arrhythmia in women and men worldwide. During the past century, a range of risk factors has been associated with AF, severe complications from the arrhythmia have been identified, and its prevalence has been increasing steadily. Whereas evidence has accumulated regarding sex-specific differences in coronary heart disease and stroke, the differences between women and men with AF has received less attention. We review the current literature on sex-specific differences in the epidemiology of AF, including incidence, prevalence, risk factors, and genetics, and in the pathophysiology and the clinical presentation and prognosis of patients with this arrhythmia. We highlight current knowledge gaps and areas that warrant future research, which might advance understanding of variation in the risk factors and complications of AF, and ultimately aid more-tailored management of the arrhythmia.

Figure 1. Overview of atrial fibrillation in women compared with in men

A summary of the major findings for each paramenter covered in this Review. Sex differences that are uncertain are italicized.

Figure 2. Prevalence of atrial fibrillation in women and men

Maps showing prevalence (%) in women (blue) and men (black) separately, for all countries with published data available.

Figure 3. Risk factors for atrial fibrillation in women and men

Population-attributable risks of incident atrial fibrillation risk factors in women and men for different time periods in the Framingham Heart Study (unpublished data).

Figure 4. Potential sex differences in pathophysiological mechanisms of atrial fibrillation (AF)

The pathophysiological mechanisms that explain the sex differences in AF incidence and associated complications have been incompletely studied. We present potential mechanisms identified on the basis of reported sex differences in genetics, risk factors, hormones, electrical and structural properties, and other factors that might help explain why women have a lower incidence and prevalence of AF, while experiencing a higher risk of complications. AF causes electrical and structural remodelling that promotes AF, leading to the phrase ‘AF begets AF’. Note that none of these interactions have been rigorously studied – please see Table 1. *See Pathophysiology section for further details. CHD, coronary heart disease; CRP, C-reactive protein; FGF-23, fibroblast growth factor 23; HF, heart failure.