Atrial Fibrillation and the Risk of Myocardial Infarction | Acute Coronary Syndromes | JAMA Internal Medicine | JAMA Network
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Author Elsayed Z. Soliman, MD, MSc, MS, discusses Atrial Fibrillation and the Risk of Myocardial Infarction.

Go  AS, Hylek  EM, Phillips  KA,  et al.  Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study.  JAMA. 2001;285(18):2370-2375.PubMedGoogle ScholarCrossref
Miyasaka  Y, Barnes  ME, Gersh  BJ,  et al.  Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence.  Circulation. 2006;114(2):119-125.PubMedGoogle ScholarCrossref
Benjamin  EJ, Wolf  PA, D’Agostino  RB, Silbershatz  H, Kannel  WB, Levy  D.  Impact of atrial fibrillation on the risk of death: the Framingham Heart Study.  Circulation. 1998;98(10):946-952.PubMedGoogle ScholarCrossref
Miyasaka  Y, Barnes  ME, Bailey  KR,  et al.  Mortality trends in patients diagnosed with first atrial fibrillation: a 21-year community-based study.  J Am Coll Cardiol. 2007;49(9):986-992.PubMedGoogle ScholarCrossref
Conen  D, Chae  CU, Glynn  RJ,  et al.  Risk of death and cardiovascular events in initially healthy women with new-onset atrial fibrillation.  JAMA. 2011;305(20):2080-2087.PubMedGoogle ScholarCrossref
Kannel  WB, Benjamin  EJ.  Status of the epidemiology of atrial fibrillation.  Med Clin North Am. 2008;92(1):17-40.PubMedGoogle ScholarCrossref
Benjamin  EJ, Chen  PS, Bild  DE,  et al.  Prevention of atrial fibrillation: report from a national heart, lung, and blood institute workshop.  Circulation. 2009;119(4):606-618.PubMedGoogle ScholarCrossref
Schmitt  J, Duray  G, Gersh  BJ, Hohnloser  SH.  Atrial fibrillation in acute myocardial infarction: a systematic review of the incidence, clinical features and prognostic implications.  Eur Heart J. 2009;30(9):1038-1045.PubMedGoogle ScholarCrossref
Garg  RK, Jolly  N.  Acute myocardial infarction secondary to thromboembolism in a patient with atrial fibrillation.  Int J Cardiol. 2007;123(1):e18-e20.PubMedGoogle ScholarCrossref
Van de Walle  S, Dujardin  K.  A case of coronary embolism in a patient with paroxysmal atrial fibrillation receiving tamoxifen.  Int J Cardiol. 2007;123(1):66-68.PubMedGoogle ScholarCrossref
Sakai  K, Inoue  K, Nobuyoshi  M.  Aspiration thrombectomy of a massive thrombotic embolus in acute myocardial infarction caused by coronary embolism.  Int Heart J. 2007;48(3):387-392.PubMedGoogle ScholarCrossref
Kleczyński  P, Dziewierz  A, Rakowski  T,  et al.  Cardioembolic acute myocardial infarction and stroke in a patient with persistent atrial fibrillation.  Int J Cardiol. 2012;161(3):e46-e47.PubMedGoogle ScholarCrossref
Hernández  F, Pombo  M, Dalmau  R,  et al.  Acute coronary embolism: angiographic diagnosis and treatment with primary angioplasty.  Catheter Cardiovasc Interv. 2002;55(4):491-494.PubMedGoogle ScholarCrossref
Iwama  T, Asami  K, Kubo  I, Kitazume  H.  Hypertrophic cardiomyopathy complicated with acute myocardial infarction due to coronary embolism.  Intern Med. 1997;36(9):613-617.PubMedGoogle ScholarCrossref
Takenaka  T, Horimoto  M, Igarashi  K, Yoshie  H, Tsujino  I, Morihira  M.  Multiple coronary thromboemboli complicating valvular heart disease and atrial fibrillation.  Am Heart J. 1996;131(1):194-196.PubMedGoogle ScholarCrossref
Camaro  C, Aengevaeren  WR.  Acute myocardial infarction due to coronary artery embolism in a patient with atrial fibrillation.  Neth Heart J. 2009;17(7-8):297-299.PubMedGoogle ScholarCrossref
Howard  VJ, Cushman  M, Pulley  L,  et al.  The reasons for geographic and racial differences in stroke study: objectives and design.  Neuroepidemiology. 2005;25(3):135-143.PubMedGoogle ScholarCrossref
Safford  MM, Brown  TM, Muntner  PM,  et al; REGARDS Investigators.  Association of race and sex with risk of incident acute coronary heart disease events.  JAMA. 2012;308(17):1768-1774.PubMedGoogle ScholarCrossref
Prineas  RJ, Crow  RS, Blackburn  H.  The Minnesota Code Manual of Electrocardiographic Findings: Standards and Procedures for Measurement and Classification. Boston, MA: Wright-OSG; 1982.
Soliman  EZ, Howard  G, Meschia  JF,  et al.  Self-reported atrial fibrillation and risk of stroke in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.  Stroke. 2011;42(10):2950-2953.PubMedGoogle ScholarCrossref
Pullicino  PM, McClure  LA, Wadley  VG,  et al.  Blood pressure and stroke in heart failure in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.  Stroke. 2009;40(12):3706-3710.PubMedGoogle ScholarCrossref
Gage  BF, Waterman  AD, Shannon  W, Boechler  M, Rich  MW, Radford  MJ.  Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.  JAMA. 2001;285(22):2864-2870.PubMedGoogle ScholarCrossref
Levey  AS, Stevens  LA, Schmid  CH,  et al; CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration).  A new equation to estimate glomerular filtration rate.  Ann Intern Med. 2009;150(9):604-612.PubMedGoogle ScholarCrossref
Meschia  JF, Merrill  P, Soliman  EZ,  et al.  Racial disparities in awareness and treatment of atrial fibrillation: the REasons for Geographic and Racial Differences in Stroke (REGARDS) study.  Stroke. 2010;41(4):581-587.PubMedGoogle ScholarCrossref
Rothberg  MB, Celestin  C, Fiore  LD, Lawler  E, Cook  JR.  Warfarin plus aspirin after myocardial infarction or the acute coronary syndrome: meta-analysis with estimates of risk and benefit.  Ann Intern Med. 2005;143(4):241-250.PubMedGoogle ScholarCrossref
Lip  GY, Lane  DA.  Does warfarin for stroke thromboprophylaxis protect against MI in atrial fibrillation patients?  Am J Med. 2010;123(9):785-789.PubMedGoogle ScholarCrossref
Watanabe  H, Watanabe  T, Sasaki  S, Nagai  K, Roden  DM, Aizawa  Y.  Close bidirectional relationship between chronic kidney disease and atrial fibrillation: the Niigata preventive medicine study.  Am Heart J. 2009;158(4):629-636.PubMedGoogle ScholarCrossref
Bansal  N, Fan  D, Hsu  CY, Ordonez  JD, Marcus  GM, Go  AS.  Incident atrial fibrillation and risk of end-stage renal disease in adults with chronic kidney disease.  Circulation. 2013;127(5):569-574.PubMedGoogle ScholarCrossref
Wang  TJ, Larson  MG, Levy  D,  et al.  Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study.  Circulation. 2003;107(23):2920-2925.PubMedGoogle ScholarCrossref
Aviles  RJ, Martin  DO, Apperson-Hansen  C,  et al.  Inflammation as a risk factor for atrial fibrillation.  Circulation. 2003;108(24):3006-3010.PubMedGoogle ScholarCrossref
Ridker  PM, Rifai  N, Stampfer  MJ, Hennekens  CH.  Plasma concentration of interleukin-6 and the risk of future myocardial infarction among apparently healthy men.  Circulation. 2000;101(15):1767-1772.PubMedGoogle ScholarCrossref
Ridker  PM, Hennekens  CH, Buring  JE, Rifai  N.  C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women.  N Engl J Med. 2000;342(12):836-843.PubMedGoogle ScholarCrossref
Rienstra  M, Sun  JX, Magnani  JW,  et al.  White blood cell count and risk of incident atrial fibrillation (from the Framingham Heart Study).  Am J Cardiol. 2012;109(4):533-537.PubMedGoogle ScholarCrossref
Issac  TT, Dokainish  H, Lakkis  NM.  Role of inflammation in initiation and perpetuation of atrial fibrillation: a systematic review of the published data.  J Am Coll Cardiol. 2007;50(21):2021-2028.PubMedGoogle ScholarCrossref
Guo  Y, Lip  GY, Apostolakis  S.  Inflammation in atrial fibrillation.  J Am Coll Cardiol. 2012;60(22):2263-2270.PubMedGoogle ScholarCrossref
Lim  HS, Willoughby  SR, Schultz  C,  et al.  Effect of atrial fibrillation on atrial thrombogenesis in humans: impact of rate and rhythm.  J Am Coll Cardiol. 2013;61(8):852-860.PubMedGoogle ScholarCrossref
Mondillo  S, Sabatini  L, Agricola  E,  et al.  Correlation between left atrial size, prothrombotic state and markers of endothelial dysfunction in patients with lone chronic nonrheumatic atrial fibrillation.  Int J Cardiol. 2000;75(2-3):227-232.PubMedGoogle ScholarCrossref
Lip  GY, Lowe  GD, Rumley  A, Dunn  FG.  Increased markers of thrombogenesis in chronic atrial fibrillation: effects of warfarin treatment.  Br Heart J. 1995;73(6):527-533.PubMedGoogle ScholarCrossref
Willoughby  SR, Roberts-Thomson  RL, Lim  HS,  et al.  Atrial platelet reactivity in patients with atrial fibrillation.  Heart Rhythm. 2010;7(9):1178-1183.PubMedGoogle ScholarCrossref
Freedman  JE, Loscalzo  J.  Platelet-monocyte aggregates: bridging thrombosis and inflammation.  Circulation. 2002;105(18):2130-2132.PubMedGoogle ScholarCrossref
Akar  JG, Jeske  W, Wilber  DJ.  Acute onset human atrial fibrillation is associated with local cardiac platelet activation and endothelial dysfunction.  J Am Coll Cardiol. 2008;51(18):1790-1793.PubMedGoogle ScholarCrossref
Watson  T, Shantsila  E, Lip  GY.  Mechanisms of thrombogenesis in atrial fibrillation: Virchow’s triad revisited.  Lancet. 2009;373(9658):155-166.PubMedGoogle ScholarCrossref
Frustaci  A, Chimenti  C, Bellocci  F, Morgante  E, Russo  MA, Maseri  A.  Histological substrate of atrial biopsies in patients with lone atrial fibrillation.  Circulation. 1997;96(4):1180-1184.PubMedGoogle ScholarCrossref
Fukuchi  M, Watanabe  J, Kumagai  K,  et al.  Increased von Willebrand factor in the endocardium as a local predisposing factor for thrombogenesis in overloaded human atrial appendage.  J Am Coll Cardiol. 2001;37(5):1436-1442.PubMedGoogle ScholarCrossref
Matsue  Y, Suzuki  M, Abe  M,  et al.  Endothelial dysfunction in paroxysmal atrial fibrillation as a prothrombotic state: comparison with permanent/persistent atrial fibrillation.  J Atheroscler Thromb. 2011;18(4):298-304.PubMedGoogle ScholarCrossref
Wong  CX, Lim  HS, Schultz  CD, Sanders  P, Worthley  MI, Willoughby  SR.  Assessment of endothelial function in atrial fibrillation: utility of peripheral arterial tonometry.  Clin Exp Pharmacol Physiol. 2012;39(2):141-144.PubMedGoogle ScholarCrossref
Minamino  T, Kitakaze  M, Sato  H,  et al.  Plasma levels of nitrite/nitrate and platelet cGMP levels are decreased in patients with atrial fibrillation.  Arterioscler Thromb Vasc Biol. 1997;17(11):3191-3195.PubMedGoogle ScholarCrossref
Skalidis  EI, Zacharis  EA, Tsetis  DK,  et al.  Endothelial cell function during atrial fibrillation and after restoration of sinus rhythm.  Am J Cardiol. 2007;99(9):1258-1262.PubMedGoogle ScholarCrossref
Prizel  KR, Hutchins  GM, Bulkley  BH.  Coronary artery embolism and myocardial infarction.  Ann Intern Med. 1978;88(2):155-161.PubMedGoogle ScholarCrossref
Thygesen  K, Alpert  JS, White  HD; Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction.  Universal definition of myocardial infarction.  Eur Heart J. 2007;28(20):2525-2538.PubMedGoogle ScholarCrossref
Saaby  L, Poulsen  TS, Hosbond  S,  et al.  Classification of myocardial infarction: frequency and features of type 2 myocardial infarction.  Am J Med. 2013;126(9):789-797.PubMedGoogle ScholarCrossref
Fonseca  C, Oliveira  AG, Mota  T,  et al; EPICA Investigators.  Evaluation of the performance and concordance of clinical questionnaires for the diagnosis of heart failure in primary care.  Eur J Heart Fail. 2004;6(6):813-822.PubMedGoogle ScholarCrossref
Original Investigation
January 2014

Atrial Fibrillation and the Risk of Myocardial Infarction

Author Affiliations
  • 1Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston Salem, North Carolina
  • 2Section on Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina
  • 3Division of Preventive Medicine, University of Alabama at Birmingham
  • 4Department of Epidemiology, University of Alabama at Birmingham
  • 5Department of Medicine, University of Vermont, Burlington
  • 6Department of Biostatistics, University of Alabama at Birmingham
JAMA Intern Med. 2014;174(1):107-114. doi:10.1001/jamainternmed.2013.11912

Importance  Myocardial infarction (MI) is an established risk factor for atrial fibrillation (AF). However, the extent to which AF is a risk factor for MI has not been investigated.

Objective  To examine the risk of incident MI associated with AF.

Design, Setting, and Participants  A prospective cohort of 23 928 participants residing in the continental United States and without coronary heart disease at baseline were enrolled from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort between 2003 and 2007, with follow-up through December 2009.

Main Outcomes and Measures  Expert-adjudicated total MI events (fatal and nonfatal).

Results  Over 6.9 years of follow-up (median 4.5 years), 648 incident MI events occurred. In a sociodemographic-adjusted model, AF was associated with about 2-fold increased risk of MI (hazard ratio [HR], 1.96 [95% CI, 1.52-2.52]). This association remained significant (HR, 1.70 [95% CI, 1.26-2.30]) after further adjustment for total cholesterol, high-density lipoprotein cholesterol, smoking status, systolic blood pressure, blood pressure–lowering drugs, body mass index, diabetes, warfarin use, aspirin use, statin use, history of stroke and vascular disease, estimated glomerular filtration rate, albumin to creatinine ratio, and C-reactive protein level. In subgroup analysis, the risk of MI associated with AF was significantly higher in women (HR, 2.16 [95% CI, 1.41-3.31]) than in men (HR, 1.39 [95% CI, 0.91-2.10]) and in blacks (HR, 2.53 [95% CI, 1.67-3.86]) than in whites (HR, 1.26 [95% CI, 0.83-1.93]); for interactions, P = .03 and P = .02, respectively. On the other hand, there were no significant differences in the risk of MI associated with AF in older (≥75 years) vs younger (<75 years) participants (HR, 2.00 [95% CI, 1.16-3.35] and HR, 1.60 [95% CI, 1.11-2.30], respectively); for interaction, P = .44.

Conclusions and Relevance  AF is independently associated with an increased risk of incident MI, especially in women and blacks. These findings add to the growing concerns of the seriousness of AF as a public health burden: in addition to being a well-known risk factor for stroke, AF is also associated with increased risk of MI.