Atrial fibrillation is associated with sudden cardiac death: a systematic review and meta-analysis

  • Pattara Rattanawong
  • Sikarin Upala
  • Tanawan Riangwiwat
  • Veeravich Jaruvongvanich
  • Anawin Sanguankeo
  • Wasawat Vutthikraivit
  • Eugene H. Chung



Recent studies suggest that atrial fibrillation (AF) is associated with increased cardiovascular risk and mortality including sudden cardiac death (SCD). According to the Cardiovascular Heath Study cohort, the incident rate of SCD was higher in the AF population (2.9 per 1000 per year) compared with non-AF controls (1.3 per 1000 per year). In this study, we performed a systematic review and meta-analysis to explore the association between AF and SCD.


We comprehensively searched the databases of MEDLINE and EMBASE from inception to January 2017. Included studies were published prospective or retrospective cohort studies that compared the risk of developing SCD, defined by World Health Organization’s criteria, in AF patients versus non-AF patients. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate the risk ratios and 95% confidence intervals.


Twenty-seven studies from January 1991 to February 2017 involving 8401 AF patients and 67,608 non-AF controls were included in this meta-analysis. Compared with controls, AF patients had a significantly higher risk of SCD in overall analysis (pooled risk ratio = 2.04, 95% confidence interval: 1.77–2.35, p < 0.01, I2 = 42.66) as well as subgroups of general population studies, previous myocardial infarction or coronary artery disease, heart failure, hypertrophic cardiomyopathy (HCM), Brugada syndrome, and patients with either a pacemaker or implantable cardioverter defibrillator (ICD). In subgroup analysis of multivariate-adjusted studies, AF also had a significantly higher risk of SCD (pooled risk ratio = 2.22, 95% confidence interval = 1.59–3.09, p < 0.01, I2 = 73.95). Incident rate of SCD in AF was 2-fold higher than controls but not statistically significant (pooled rate ratio = 2.06, 95% confidence interval = 0.66–7.53, p = 0.292, I2 = 88.58).


Our meta-analysis demonstrates a statistically significant increased risk of SCD with AF in the general population and in those with previous myocardial infarction, coronary artery disease, heart failure, HCM, Brugada syndrome, and an implanted rhythm device.


Atrial fibrillation Sudden cardiac death 



Atrial fibrillation


Atherosclerosis Risk in Communities


Chronic Heart Failure Analysis and Registry in the Tohoku District-2 registry in Japan


Cardiovascular Health Study


Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation Thrombolysis in Myocardial Infarction 48 Trial


Hypertrophic cardiomyopathy


Implantable cardioverter-defibrillator


Muerte Subita en Insuficiencia Cardiaca registry


Sudden cardiac arrest


Sudden cardiac death


Studies of Left Ventricular Dysfunction Trials


Sustained ventricular tachycardia


Ventricular fibrillation


World Health Organization


Authors’ contributions

Pattara Rattanawong is responsible for conception design, data interpretation, and manuscript drafting. Sikarin Upala is responsible for statistical analysis, manuscript revision, final approval, and corresponding. Tanawan Riangwiwat is responsible for data acquisition and data interpretation. Veeravich Jaruvongvanich is responsible for data acquisition and manuscript drafting. Anawin Sanguankeo is responsible for data acquisition and statistic analysis. Wasawat Vutthikraivit is responsible for data interpretation and manuscript drafting. Eugene H Chung is responsible for manuscript revision and critical reading.

Compliance with ethical standards

Financial support


Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

10840_2017_308_MOESM1_ESM.docx (1021 kb)
ESM 1 (DOCX 1020 kb)


  1. 1.
    Wyndham CR. Atrial fibrillation: the most common arrhythmia. Tex Heart Inst J. 2000;27(3):257–67.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837–47.CrossRefPubMedGoogle Scholar
  3. 3.
    Chen LY, Sotoodehnia N, Buzkova P, Lopez FL, Yee LM, Heckbert SR, et al. Atrial fibrillation and the risk of sudden cardiac death: the atherosclerosis risk in communities study and cardiovascular health study. JAMA Intern Med. 2013;173(1):29–35.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Eisen A, Ruff CT, Braunwald E, Nordio F, Corbalan R, Dalby A, et al. Sudden cardiac death in patients with atrial fibrillation: insights from the ENGAGE AFTIMI 48 trial. J Am Heart Assoc. 2016;5(7).Google Scholar
  5. 5.
    Reinier K, Marijon E, Uy-Evanado A, Teodorescu C, Narayanan K, Chugh H, et al. The association between atrial fibrillation and sudden cardiac death: the relevance of heart failure. JACC Heart Fail. 2014;2(3):221–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Death WSG on SC OW. Sudden cardiac death: report of a WHO scientific group [meeting held in Geneva from 24 to 27 October 1984]. 1985. http://www.appswhoint//iris/handle/10665/39554. Accessed 10 Mar 2017.
  7. 7.
    Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603–5.CrossRefPubMedGoogle Scholar
  8. 8.
    DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88.CrossRefPubMedGoogle Scholar
  9. 9.
    Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Sterne JA, Egger M. Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. J Clin Epidemiol. 2001;54(10):1046–55.CrossRefPubMedGoogle Scholar
  11. 11.
    Patsopoulos NA, Evangelou E, Ioannidis JP. Sensitivity of between-study heterogeneity in meta-analysis: proposed metrics and empirical evaluation. Int J Epidemiol. 2008;37(5):1148–57.CrossRefPubMedGoogle Scholar
  12. 12.
    Al-Zaiti SS, Fallavollita JA, Canty JM Jr, Carey MG. Electrocardiographic predictors of sudden and non-sudden cardiac death in patients with ischemic cardiomyopathy. Heart Lung. 2014;43(6):527–33.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Algra A, Tijssen JG, Roelandt JR, Pool J, Lubsen J. Contribution of the 24 hour electrocardiogram to the prediction of sudden coronary death. Br Heart J. 1993;70(5):421–7.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Berton G, Cordiano R, Cucchini F, Cavuto F, Pellegrinet M, Palatini P. Atrial fibrillation during acute myocardial infarction: association with all-cause mortality and sudden death after 7-year of follow-up. Int J Clin Pract. 2009;63(5):712–21.CrossRefPubMedGoogle Scholar
  15. 15.
    Calo L, Giustetto C, Martino A, Sciarra L, Cerrato N, Marziali M, et al. A new electrocardiographic marker of sudden death in Brugada syndrome: the s-wave in lead I. J Am Coll Cardiol. 2016;67(12):1427–40.CrossRefPubMedGoogle Scholar
  16. 16.
    Deo R, Vittinghoff E, Lin F, Tseng ZH, Hulley SB, Shlipak MG. Risk factor and prediction modeling for sudden cardiac death in women with coronary artery disease. Arch Intern Med. 2011;171(19):1703–9.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Genovesi S, Valsecchi MG, Rossi E, Pogliani D, Acquistapace I, De Cristofaro V, et al. Sudden death and associated factors in a historical cohort of chronic haemodialysis patients. Nephrol Dial Transplant. 2009;24(8):2529–36.CrossRefPubMedGoogle Scholar
  18. 18.
    Giustetto C, Cerrato N, Gribaudo E, Scrocco C, Castagno D, Richiardi E, et al. Atrial fibrillation in a large population with Brugada electrocardiographic pattern: prevalence, management, and correlation with prognosis. Heart Rhythm. 2014;11(2):259–65.CrossRefPubMedGoogle Scholar
  19. 19.
    Grimm W, Hoffmann JJ, Muller HH, Maisch B. Implantable defibrillator event rates in patients with idiopathic dilated cardiomyopathy, nonsustained ventricular tachycardia on Holter and a left ventricular ejection fraction below 30%. J Am Coll Cardiol. 2002;39(5):780–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Gronefeld GC, Mauss O, Li YG, Klingenheben T, Hohnloser SH. Association between atrial fibrillation and appropriate implantable cardioverter defibrillator therapy: results from a prospective study. J Cardiovasc Electrophysiol. 2000;11(11):1208–14.CrossRefPubMedGoogle Scholar
  21. 21.
    Kofflard MJ, Ten Cate FJ, van der Lee C, van Domburg RT. Hypertrophic cardiomyopathy in a large community-based population: clinical outcome and identification of risk factors for sudden cardiac death and clinical deterioration. J Am Coll Cardiol. 2003;41(6):987–93.CrossRefPubMedGoogle Scholar
  22. 22.
    Marijon E, Trinquart L, Otmani A, Waintraub X, Kacet S, Clementy J, et al. Competing risk analysis of cause-specific mortality in patients with an implantable cardioverter-defibrillator: the EVADEF cohort study. Am Heart J. 2009;157(2):391–7.e1.CrossRefPubMedGoogle Scholar
  23. 23.
    Mazzanti A, Ng K, Faragli A, Maragna R, Chiodaroli E, Orphanou N, et al. Arrhythmogenic right ventricular cardiomyopathy: clinical course and predictors of arrhythmic risk. J Am Coll Cardiol. 2016;68(23):2540–50.CrossRefPubMedGoogle Scholar
  24. 24.
    Middlekauff HR, Stevenson WG, Stevenson LW. Prognostic significance of atrial fibrillation in advanced heart failure. A study of 390 patients. Circulation. 1991;84(1):40–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Minami Y, Haruki S, Yashiro B, Suzuki T, Ashihara K, Hagiwara N. Enlarged left atrium and sudden death risk in hypertrophic cardiomyopathy patients with or without atrial fibrillation. J Cardiol. 2016;68(6):478–84.CrossRefPubMedGoogle Scholar
  26. 26.
    Mosterd A, Cost B, Hoes AW, de Bruijne MC, Deckers JW, Hofman A, et al. The prognosis of heart failure in the general population: the Rotterdam Study. Eur Heart J. 2001;22(15):1318–27.CrossRefPubMedGoogle Scholar
  27. 27.
    Okin PM, Bang CN, Wachtell K, Hille DA, Kjeldsen SE, Dahlof B, et al. Relationship of sudden cardiac death to new-onset atrial fibrillation in hypertensive patients with left ventricular hypertrophy. Circ Arrhythm Electrophysiol. 2013;6(2):243–51.CrossRefPubMedGoogle Scholar
  28. 28.
    Pedersen OD, Abildstrom SZ, Ottesen MM, Rask-Madsen C, Bagger H, Kober L, et al. Increased risk of sudden and non-sudden cardiovascular death in patients with atrial fibrillation/flutter following acute myocardial infarction. Eur Heart J. 2006;27(3):290–5.CrossRefPubMedGoogle Scholar
  29. 29.
    Piccini JP, Zhang M, Pieper K, Solomon SD, Al-Khatib SM, Van de Werf F, et al. Predictors of sudden cardiac death change with time after myocardial infarction: results from the VALIANT trial. Eur Heart J. 2010;31(2):211–21.CrossRefPubMedGoogle Scholar
  30. 30.
    Satake H, Fukuda K, Sakata Y, Miyata S, Nakano M, Kondo M, et al. Current status of primary prevention of sudden cardiac death with implantable cardioverter defibrillator in patients with chronic heart failure--a report from the CHART-2 Study. Circ J. 2015;79(2):381–90.CrossRefPubMedGoogle Scholar
  31. 31.
    Sorajja P, Ommen SR, Nishimura RA, Gersh BJ, Berger PB, Tajik AJ. Adverse prognosis of patients with hypertrophic cardiomyopathy who have epicardial coronary artery disease. Circulation. 2003;108(19):2342–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Tereshchenko LG, McNitt S, Han L, Berger RD, Zareba W. ECG marker of adverse electrical remodeling post-myocardial infarction predicts outcomes in MADIT II study. PLoS One. 2012;7(12):e51812.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Tokioka K, Kusano KF, Morita H, Miura D, Nishii N, Nagase S, et al. Electrocardiographic parameters and fatal arrhythmic events in patients with Brugada syndrome: combination of depolarization and repolarization abnormalities. J Am Coll Cardiol. 2014;63(20):2131–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Urena M, Webb JG, Eltchaninoff H, Munoz-Garcia AJ, Bouleti C, Tamburino C, et al. Late cardiac death in patients undergoing transcatheter aortic valve replacement: incidence and predictors of advanced heart failure and sudden cardiac death. J Am Coll Cardiol. 2015;65(5):437–48.CrossRefPubMedGoogle Scholar
  35. 35.
    Vazquez R, Bayes-Genis A, Cygankiewicz I, Pascual-Figal D, Grigorian-Shamagian L, Pavon R, et al. The MUSIC Risk score: a simple method for predicting mortality in ambulatory patients with chronic heart failure. Eur Heart J. 2009;30(9):1088–96.CrossRefPubMedGoogle Scholar
  36. 36.
    Yashiro B, Minami Y, Terajima Y, Hagiwara N. Prognostic difference between paroxysmal and non-paroxysmal atrial fibrillation in patients with hypertrophic cardiomyopathy. J Cardiol. 2014;63(6):432–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Zehender M, Buchner C, Meinertz T, Just H. Prevalence, circumstances, mechanisms, and risk stratification of sudden cardiac death in unipolar singlechamber ventricular pacing. Circulation. 1992;85(2):596–605.CrossRefPubMedGoogle Scholar
  38. 38.
    Chen LY, Benditt DG, Alonso A. Atrial fibrillation and its association with sudden cardiac death. Circ J. 2014;78(11):2588–93.CrossRefPubMedGoogle Scholar
  39. 39.
    Bardai A, Blom MT, van Hoeijen DA, van Deutekom HW, Brouwer HJ, Tan HL. Atrial fibrillation is an independent risk factor for ventricular fibrillation: a largescale population-based case-control study. Circ Arrhythm Electrophysiol. 2014;7(6):1033–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Chugh SS, Reinier K, Teodorescu C, Evanado A, Kehr E, Al Samara M, et al. Epidemiology of sudden cardiac death: clinical and research implications. Prog Cardiovasc Dis. 2008;51(3):213–28.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Roy D, Brugada P, Wellens HJ. Atrial tachycardia facilitating initiation of ventricular tachycardia. Pacing Clin Electrophysiol. 1983;6(1 Pt 1):47–52.CrossRefPubMedGoogle Scholar
  42. 42.
    Stein KM, Euler DE, Mehra R, Seidl K, Slotwiner DJ, Mittal S, et al. Do atrial tachyarrhythmias beget ventricular tachyarrhythmias in defibrillator recipients? J Am Coll Cardiol. 2002;40(2):335–40.CrossRefPubMedGoogle Scholar
  43. 43.
    Suzuki M, Hirayama T, Marumoto K, Okayama H, Iwata T. Paroxysmal atrial fibrillation as a cause of potentially lethal ventricular arrhythmia with myocardial ischemia in hypertrophic cardiomyopathy--a case report. Angiology. 1998;49(8):653–7.CrossRefPubMedGoogle Scholar
  44. 44.
    Farshi R, Kistner D, Sarma JS, Longmate JA, Singh BN. Ventricular rate control in chronic atrial fibrillation during daily activity and programmed exercise: a crossover open-label study of five drug regimens. J Am Coll Cardiol. 1999;33(2):304–10.CrossRefPubMedGoogle Scholar
  45. 45.
    Blitzer M, Costeas C, Kassotis J, Reiffel JA. Rhythm management in atrial fibrillation--with a primary emphasis on pharmacological therapy: part 1. Pacing Clin Electrophysiol. 1998;21(3):590–602.CrossRefPubMedGoogle Scholar
  46. 46.
    Garcia-Alberola A, Yli-Mayry S, Block M, Haverkamp W, Martinez-Rubio A, Kottkamp H, et al. RR interval variability in irregular monomorphic ventricular tachycardia and atrial fibrillation. Circulation. 1996;93(2):295–300.CrossRefPubMedGoogle Scholar
  47. 47.
    Cranefield PF, Aronson RS. Torsade de pointes and other pause-induced ventricular tachycardias: the short-long-short sequence and early after depolarizations. Pacing Clin Electrophysiol. 1988;11(6 Pt 1):670–8.CrossRefPubMedGoogle Scholar
  48. 48.
    Rienstra M, Smit MD, Nieuwland W, Tan ES, Wiesfeld AC, Anthonio RL, et al. Persistent atrial fibrillation is associated with appropriate shocks and heart failure in patients with left ventricular dysfunction treated with an implantable cardioverter defibrillator. Am Heart J. 2007;153(1):120–6.CrossRefPubMedGoogle Scholar
  49. 49.
    Zareba W, Steinberg JS, McNitt S, Daubert JP, Piotrowicz K, Moss AJ, et al. Implantable cardioverter-defibrillator therapy and risk of congestive heart failure or death in MADIT II patients with atrial fibrillation. Heart Rhythm. 2006;3(6):631–7.CrossRefPubMedGoogle Scholar
  50. 50.
    Marijon E, Le Heuzey JY, Connolly S, Yang S, Pogue J, Brueckmann M, et al. Causes of death and influencing factors in patients with atrial fibrillation: a competing-risk analysis from the randomized evaluation of long-term anticoagulant therapy study. Circulation. 2013;128(20):2192–201.CrossRefPubMedGoogle Scholar
  51. 51.
    Odutayo A, Wong CX, Hsiao AJ, Hopewell S, Altman DG, Emdin CA. Atrial fibrillation and risks of cardiovascular disease, renal disease, and death: systematic review and meta-analysis. BMJ. 2016;354:i4482.CrossRefPubMedGoogle Scholar
  52. 52.
    Ohsawa M, Okamura T, Ogasawara K, Ogawa A, Fujioka T, Tanno K, et al. Relative and absolute risks of all-cause and cause-specific deaths attributable to atrial fibrillation in middle-aged and elderly community dwellers. Int J Cardiol. 2015;184:692–8.CrossRefPubMedGoogle Scholar
  53. 53.
    Baldasseroni S, Orso F, Fabbri G, De Bernardi A, Cirrincione V, Gonzini L, et al. Age-dependent prognostic significance of atrial fibrillation in outpatients with chronic heart failure: data from the Italian Network on Congestive Heart Failure Registry. Cardiology. 2010;116(2):79–88.CrossRefPubMedGoogle Scholar
  54. 54.
    Borleffs CJ, van Rees JB, van Welsenes GH, van der Velde ET, van Erven L, Bax JJ, et al. Prognostic importance of atrial fibrillation in implantable cardioverterdefibrillator patients. J Am Coll Cardiol. 2010;55(9):879–85.CrossRefPubMedGoogle Scholar
  55. 55.
    Kleemann T, Hochadel M, Strauss M, Skarlos A, Seidl K, Zahn R. Comparison between atrial fibrillation-triggered implantable cardioverter-defibrillator (ICD) shocks and inappropriate shocks caused by lead failure: different impact on prognosis in clinical practice. J Cardiovasc Electrophysiol. 2012;23(7):735–40.CrossRefPubMedGoogle Scholar
  56. 56.
    Barold S, Herweg B. Cardiac resynchronization in patients with atrial fibrillation. J Atr Fibrillation. 2015;8(4):1383.PubMedPubMedCentralGoogle Scholar
  57. 57.
    Gasparini M, Leclercq C, Lunati M, Landolina M, Auricchio A, Santini M, et al. Cardiac resynchronization therapy in patients with atrial fibrillation: the CERTIFY study (Cardiac Resynchronization Therapy in Atrial Fibrillation Patients Multinational Registry). JACC Heart Fail. 2013;1(6):500–7.CrossRefPubMedGoogle Scholar
  58. 58.
    Maron BJ, Shen WK, Link MS, Epstein AE, Almquist AK, Daubert JP, et al. Efficacy of implantable cardioverter-defibrillators for the prevention of sudden death in patients with hypertrophic cardiomyopathy. N Engl J Med. 2000;342(6):365–73.CrossRefPubMedGoogle Scholar
  59. 59.
    Robinson K, Frenneaux MP, Stockins B, Karatasakis G, Poloniecki JD, McKenna WJ. Atrial fibrillation in hypertrophic cardiomyopathy: a longitudinal study. J Am Coll Cardiol. 1990;15(6):1279–85.CrossRefPubMedGoogle Scholar
  60. 60.
    Siontis KC, Geske JB, Ong K, Nishimura RA, Ommen SR, Gersh BJ. Atrial fibrillation in hypertrophic cardiomyopathy: prevalence, clinical correlations, and mortality in a large high-risk population. J Am Heart Assoc. 2014;3(3):e001002.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Rodriguez-Manero M, Namdar M, Sarkozy A, Casado-Arroyo R, Ricciardi D, de Asmundis C, et al. Prevalence, clinical characteristics and management of atrial fibrillation in patients with Brugada syndrome. Am J Cardiol. 2013;111(3):362–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Pattara Rattanawong
    • 1
    • 2
  • Sikarin Upala
    • 3
    • 4
  • Tanawan Riangwiwat
    • 1
  • Veeravich Jaruvongvanich
    • 1
  • Anawin Sanguankeo
    • 4
    • 5
  • Wasawat Vutthikraivit
    • 2
    • 6
  • Eugene H. Chung
    • 7
  1. 1.University of Hawaii Internal Medicine Residency ProgramHonoluluUSA
  2. 2.Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
  3. 3.Section of Endocrinology, Diabetes, and Metabolism, Department of MedicineUniversity of ChicagoChicagoUSA
  4. 4.Department of Preventive and Social Medicine, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
  5. 5.Division of NephrologyJohns Hopkins University School of MedicineBaltimoreUSA
  6. 6.Department of MedicineTexas Tech University Health Sciences CenterLubbockUSA
  7. 7.Department of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborUSA

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