Body mass index and all-cause mortality in patients with atrial fibrillation: insights from the China atrial fibrillation registry study
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: http://www.chictr.org.cn/showproj.aspx?proj=5831. Unique identifier: ChiCTR-OCH-13003729.
KeywordsBody 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.
- 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
- 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.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
- 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.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
- 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
- 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
- 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.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
- 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
- 27.428-2013 WT (2013) Healthy adult weight determinationGoogle Scholar
- 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
- 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
- 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