Body mass index and all-cause mortality in patients with atrial fibrillation: insights from the China atrial fibrillation registry study

  • Lu Wang
  • Xin Du
  • Jian-Zeng DongEmail author
  • Wen-Na Liu
  • Ying-Chun Zhou
  • Song-Nan Li
  • Xue-Yuan Guo
  • Chen-Xi Jiang
  • Rong-Hui Yu
  • Cai-Hua Sang
  • Ri-Bo Tang
  • De-Yong Long
  • Nian Liu
  • Rong Bai
  • Laurent Macle
  • Chang-Sheng Ma
Original Paper



Impact of body mass index (BMI) on all-cause mortality in atrial fibrillation (AF) patients remains controversial.


A total of 10,942 AF patients were prospectively enrolled and categorized into four BMI groups: underweight (BMI < 18.5 kg/m2), normal weight (BMI 18.5–24 kg/m2), overweight (BMI 24–28 kg/m2) and obesity (BMI ≥ 28 kg/m2). The primary outcome was all-cause mortality. Different Cox proportional hazards models were performed to evaluate the association between BMI and all-cause mortality.


During a median follow-up of 30 months (IQR 18–48 months), 862 deaths events occurred. Compared to normal BMI, higher BMI was associated with a lower mortality risk (overweight: HR 0.70; 95% CI 0.61–0.81, P < 0.0001 and obesity: HR 0.54; 95% CI 0.44–0.67, P < 0.0001) and lower BMI was associated with a higher mortality risk (HR 2.23, 95% CI 1.67–2.97, P < 0.0001).


A reversed relationship between BMI and all-cause mortality in AF patients was found. Higher risk of mortality was observed in underweight patients compared to patients with a normal BMI, while overweight and obese patients had a lower risk of all-cause mortality.

Clinical trial registration

URL: Unique identifier: ChiCTR-OCH-13003729.


Body mass index Arial fibrillation All-cause mortality 



We sincerely thank all the hospitals which involved in the China-AF study.


This work was supported by the National Key Research and Development Program of China (2016YFC0900901, 2016YFC1301002), Grant from the National Science Foundation of China (81530016), and Grants from Beijing Municipal Commission of Science and Technology (D151100002215003, D151100002215004).

Compliance with ethical standards

Conflict of interest

Dr. Jian-Zeng Dong received honoraria from Johnson & Johnson for giving lectures. Dr. Chang-Sheng Ma received honoraria from Bristol-Myers Squibb (BMS), Pfizer, Johnson & Johnson, Boehringer-Ingelheim (BI), and Bayer for giving lectures. The other authors report no conflicts of interest.

Supplementary material

392_2019_1473_MOESM1_ESM.docx (17 kb)
Supplementary material 1 (DOCX 17 kb)
392_2019_1473_MOESM2_ESM.docx (16 kb)
Supplementary material 2 (DOCX 15 kb)


  1. 1.
    Morin DP, Bernard ML, Madias C, Rogers PA, Thihalolipavan S, Estes NAM (2016) The state of the art: atrial fibrillation epidemiology, prevention, and treatment. Mayo Clin Proc 91:1778–1810CrossRefGoogle Scholar
  2. 2.
    Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, Gillum RF, Kim YH, McAnulty JH Jr, Zheng ZJ, Forouzanfar MH, Naghavi M, Mensah GA, Ezzati M, Murray CJ (2014) Worldwide epidemiology of atrial fibrillation: a global burden of disease 2010 study. Circulation 129:837–847CrossRefGoogle Scholar
  3. 3.
    Jobs A, Schwind J, Katalinic A, Babaev V, Tilz RR, Rausch S, Thiele H, Eitel I, Eitel C (2019) Prognostic significance of atrial fibrillation in acute decompensated heart failure with reduced versus preserved ejection fraction. Clin Res Cardiol 108:74–82CrossRefGoogle Scholar
  4. 4.
    Abed HS, Samuel CS, Lau DH, Kelly DJ, Royce SG, Alasady M, Mahajan R, Kuklik P, Zhang Y, Brooks AG, Nelson AJ, Worthley SG, Abhayaratna WP, Kalman JM, Wittert GA, Sanders P (2013) Obesity results in progressive atrial structural and electrical remodeling: implications for atrial fibrillation. Heart Rhythm 10:90–100CrossRefGoogle Scholar
  5. 5.
    Chau K, Girerd N, Magnusson M, Lamiral Z, Bozec E, Merckle L, Leosdottir M, Bachus E, Frikha Z, Ferreira JP, Després J-P, Rossignol P, Boivin J-M, Zannad F (2018) Obesity and metabolic features associated with long-term developing diastolic dysfunction in an initially healthy population-based cohort. Clin Res Cardiol 107:887–896CrossRefGoogle Scholar
  6. 6.
    Tedrow UB, Conen D, Ridker PM, Cook NR, Koplan BA, Manson JE, Buring JE, Albert CM (2010) 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 55:2319–2327CrossRefGoogle Scholar
  7. 7.
    Rosengren A, Hauptman PJ, Lappas G, Olsson L, Wilhelmsen L, Swedberg K (2009) Big men and atrial fibrillation: effects of body size and weight gain on risk of atrial fibrillation in men. Eur Heart J 30:1113–1120CrossRefGoogle Scholar
  8. 8.
    Lavie CJ, Pandey A, Lau DH, Alpert MA, Sanders P (2017) Obesity and atrial fibrillation prevalence, pathogenesis, and prognosis: effects of weight loss and exercise. J Am Coll Cardiol 70:2022–2035CrossRefGoogle Scholar
  9. 9.
    Tsang TS, Barnes ME, Miyasaka Y, Cha SS, Bailey KR, Verzosa GC, Seward JB, Gersh BJ (2008) Obesity as a risk factor for the progression of paroxysmal to permanent atrial fibrillation: a longitudinal cohort study of 21 years. Eur Heart J 29:2227–2233CrossRefGoogle Scholar
  10. 10.
    Huxley RR, Lopez FL, Folsom AR, Agarwal SK, Loehr LR, Soliman EZ, Maclehose R, Konety S, Alonso A (2011) Absolute and attributable risks of atrial fibrillation in relation to optimal and borderline risk factors: the atherosclerosis risk in communities (ARIC) study. Circulation 123:1501–1508CrossRefGoogle Scholar
  11. 11.
    Wong CX, Sullivan T, Sun MT, Mahajan R, Pathak RK, Middeldorp M, Twomey D, Ganesan AN, Rangnekar G, Roberts-Thomson KC, Lau DH, Sanders P (2015) Obesity and the risk of incident, post-operative, and post-ablation atrial fibrillation. JACC Clin Electrophysiol 1:139–152Google Scholar
  12. 12.
    Ardestani A, Hoffman HJ, Cooper HA (2010) Obesity and outcomes among patients with established atrial fibrillation. Am J Cardiol 106:369–373CrossRefGoogle Scholar
  13. 13.
    Wang JYY, Zhu J, Zhang H, Shao XH, Tian L, Huang B, Yu LT, Gao X, Wang M (2014) Overweight is associated with improved survival and outcomes in patients with atrial fibrillation. Clin Res Cardiol 103:533–542CrossRefGoogle Scholar
  14. 14.
    Sandhu RK, Ezekowitz J, Andersson U, Alexander JH, Granger CB, Halvorsen S, Hanna M, Hijazi Z, Jansky P, Lopes RD, L W (2016) The ‘obesity paradox’ in atrial fibrillation: observations from the ARISTOTLE (apixaban for reduction in stroke and other thromboembolic events in atrial fibrillation) trial. Eur Heart J 37:2869–2878Google Scholar
  15. 15.
    Proietti M, Guiducci E, Cheli P, Lip GY (2017) Is there an obesity paradox for outcomes in atrial fibrillation? A systematic review and meta-analysis of non-vitamin K antagonist oral anticoagulant trials. Stroke 48:857–866CrossRefGoogle Scholar
  16. 16.
    Senoo K, Lip GY (2016) Body mass index and adverse outcomes in elderly patients with atrial fibrillation: the AMADEUS trial. Stroke 47:523–526CrossRefGoogle Scholar
  17. 17.
    Pandey A, Gersh BJ, McGuire DK, Shrader P, Thomas L, Kowey PR, Mahaffey KW, Hylek E, Sun S, Burton P, Piccini J, Peterson E, Fonarow GC (2016) Association of body mass index with care and outcomes in patients with atrial fibrillation results from the ORBIT-AF registry. JACC Clin Electrophysiol 2:355–363Google Scholar
  18. 18.
    Inoue H, Kodani E, Atarashi H, Okumura K, Yamashita T, Origasa H (2016) Impact of body mass index on the prognosis of japanese patients with non-valvular atrial fibrillation. Am J Cardiol 118:215–221CrossRefGoogle Scholar
  19. 19.
    Flegal KM, Graubard BI, Williamson DF, Cooper RS (2011) Reverse causation and illness-related weight loss in observational studies of body weight and mortality. Am J Epidemiol 173:1–9CrossRefGoogle Scholar
  20. 20.
    Stokes A, Preston SH (2015) Smoking and reverse causation create an obesity paradox in cardiovascular disease. Obesity (Silver Spring). 23:2485–2490CrossRefGoogle Scholar
  21. 21.
    Sattar N, Preiss D (2017) Reverse causality in cardiovascular epidemiological research: more common than imagined? Circulation 135:2369–2372CrossRefGoogle Scholar
  22. 22.
    Shakiba M, Soori H, Mansournia MA, Nazari SSH, Salimi Y (2016) Adjusting for reverse causation to estimate the effect of obesity on mortality after incident heart failure in the atherosclerosis risk in communities (ARIC) study. Epidemiol Health 38:e2016025CrossRefGoogle Scholar
  23. 23.
    Lawlor DA, Hart CL, Hole DJ, G. DS (2006) Reverse causality and confounding and the associations of overweight and obesity with mortality. Obesity (Silver Spring) 14:2294–2304Google Scholar
  24. 24.
    Global BMI Mortality Collaboration, Di Angelantonio E, Bhupathiraju ShN, Wormser D, Gao P, Kaptoge S, Berrington de Gonzalez A, Cairns BJ, Huxley R, Jackson ChL, Joshy G, Lewington S, Manson JE, Murphy N, Patel AV, Samet JM, Woodward M and Zheng W ZM, Bansal N, Barricarte A, Carter B, Cerhan JR, Smith GD, Fang X, Franco OH, Green J, Halsey J, Hildebrand JS, Jung KJ, Korda RJ, McLerran DF, Moore SC, O’Keeffe LM, Paige E, Ramond A, Reeves GK, Rolland B, Sacerdote C, Sattar N, Sofianopoulou E, Stevens J, Thun M, Ueshima H, Yang L, Yun YD, Willeit P, Banks E, Beral V, Chen Zh, Gapstur SM, Gunter MJ, Hartge P, Jee SH, Lam TH, Peto R, Potter JD, Willett WC, Thompson SG, Danesh J, Hu FB (2016) Body-mass index and all-cause mortality: individual participant-data meta-analysis of 239 prospective studies in four continents. Lancet 20:779–786Google Scholar
  25. 25.
    Du X, Ma C, Wu J, Li S, Ning M, Tang R, Guo X, Long D, Yu R, Sang C, Jiang C, Zhang T, Pan J, Liu X, Dong J, Lip GY, Investigators C (2016) Rationale and design of the Chinese Atrial Fibrillation Registry Study. BMC Cardiovasc Disord 16:1–7CrossRefGoogle Scholar
  26. 26.
    McNamara RLBL, Drozda JP Jr, Go AS, Halperin JL, Kerr CR et al (2004) ACC/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with atrial fibrillation: a Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Data Standards on Atrial Fibrillation). Circulation 109:3223–3243CrossRefGoogle Scholar
  27. 27.
    428-2013 WT (2013) Healthy adult weight determinationGoogle Scholar
  28. 28.
    Zhu W, Wan R, Liu F, Hu J, Huang L, Li J, Hong K (2016) Relation of body mass index with adverse outcomes among patients with atrial fibrillation: a meta-analysis and systematic review. J Am Heart Assoc 5:e004006Google Scholar
  29. 29.
    Curtis JP, Selter JG, Wang Y, Rathore SS, Jovin IS, Jadbabaie F, Kosiborod M, Portnay EL, Sokol SI, Bader F, Krumholz HM (2005) The obesity paradox: body mass index and outcomes in patients with heart failure. Arch Intern Med 165:55–61CrossRefGoogle Scholar
  30. 30.
    Romero-Corral A, Montori VM, Somers VK, Korinek J, Thomas RJ, Allison TG, Mookadam F, Lopez-Jimenez F (2006) Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies. Lancet 368:666–678CrossRefGoogle Scholar
  31. 31.
    Costanzo P, Cleland JGF, Pellicori P, Clark AL, Hepburn D, Kilpatrick ES, Perrone-Filardi P, Zhang J, Atkin SL (2015) The obesity paradox in type 2 diabetes mellitus: relationship of body mass index to prognosis. Ann Intern Med 162:1–26CrossRefGoogle Scholar
  32. 32.
    Zhang J, Begley A, Jackson R, Harrison M, Pellicori P, Clark AL, Cleland JGF (2019) Body mass index and all-cause mortality in heart failure patients with normal and reduced ventricular ejection fraction: a dose-response meta-analysis. Clin Res Cardiol 108:119–132CrossRefGoogle Scholar
  33. 33.
    Stovitz SD, Banack HR, Kaufman JS (2018) Structural bias in studies of cardiovascular disease: let’s not be fooled by the “obesity paradox”. Can J Cardiol 34:540–542CrossRefGoogle Scholar
  34. 34.
    Sanders P, Lau DH (2016) Mortality paradox in obesity and atrial fibrillation: true clinical phenomenon or red herring in atrial fibrillation care? JACC Clin Electrophysiol 2:364–366Google Scholar
  35. 35.
    Preston SHSA (2014) Obesity paradox: conditioning on disease enhances biases in estimating the mortality risks of obesity. Epidemiology 25:454–461CrossRefGoogle Scholar
  36. 36.
    Boriani G, Laroche C, Diemberger I, Fantecchi E, Meeder J, Kurpesa M, Baluta MM, Proietti M, Tavazzi L, Maggioni AP, Lip GYH, Investigators E-AGPR (2018) Overweight and obesity in patients with atrial fibrillation: sex differences in 1-year outcomes in the EORP-AF general pilot registry. J Cardiovasc Electrophysiol 29:566–572Google Scholar
  37. 37.
    Wu S, Yang YM, Zhu J, Wan HB, Wang J, Zhang H, Shao XH (2017) Impact of age on the association between body mass index and all-cause mortality in patients with atrial fibrillation. J Nutr Health Aging 21:1125–1132CrossRefGoogle Scholar
  38. 38.
    Sramko M, Wichterle D, Melenovsky V, Franekova J, Clemens M, Fukunaga M, Kautzner J (2019) Independent effect of atrial fibrillation on natriuretic peptide release. Clin Res Cardiol 108:142–149CrossRefGoogle Scholar
  39. 39.
    Wang TJ, Larson MG, Levy D, Benjamin EJ, Leip EP, Wilson PW, Vasan RS (2004) Impact of obesity on plasma natriuretic peptide levels. Circulation 109:594–600CrossRefGoogle Scholar
  40. 40.
    Lavie CJ, De Schutter A, Patel DA, Romero-Corral A, Artham SM, Milani RV (2012) Body composition and survival in stable coronary heart disease: impact of lean mass index and body fat in the “obesity paradox”. J Am Coll Cardiol 60:1374–1380CrossRefGoogle Scholar
  41. 41.
    Dorner TE, Rieder A (2012) Obesity paradox in elderly patients with cardiovascular diseases. Int J Cardiol 155:56–65CrossRefGoogle Scholar
  42. 42.
    Oktay AA, Lavie CJ, Kokkinos PF, Parto P, Pandey A, Ventura HO (2017) The interaction of cardiorespiratory fitness with obesity and the obesity paradox in cardiovascular disease. Prog Cardiovasc Dis 60:30–44CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Lu Wang
    • 1
  • Xin Du
    • 1
    • 2
    • 3
  • Jian-Zeng Dong
    • 1
    • 4
    Email author
  • Wen-Na Liu
    • 5
  • Ying-Chun Zhou
    • 5
  • Song-Nan Li
    • 1
  • Xue-Yuan Guo
    • 1
  • Chen-Xi Jiang
    • 1
  • Rong-Hui Yu
    • 1
  • Cai-Hua Sang
    • 1
  • Ri-Bo Tang
    • 1
  • De-Yong Long
    • 1
  • Nian Liu
    • 1
  • Rong Bai
    • 1
  • Laurent Macle
    • 6
  • Chang-Sheng Ma
    • 1
  1. 1.Department of Cardiology, Beijing Anzhen HospitalCapital Medical University, National Clinical Research Centre for Cardiovascular DiseasesBeijingChina
  2. 2.Heart Health Research CenterBeijingChina
  3. 3.University of New South WalesSydneyAustralia
  4. 4.Cardiovascular HospitalFirst Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
  5. 5.School of Statistics, Faculty of Economics and ManagementEast China Normal UniversityShanghaiChina
  6. 6.Montreal Heart InstituteUniversité de MontréalMontrealCanada

Personalised recommendations