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Original Investigation |

Atrial Fibrillation and the Risk of Myocardial Infarction

Elsayed Z. Soliman, MD, MSc, MS1,2; Monika M. Safford, MD3; Paul Muntner, PhD4; Yulia Khodneva, MD, PhD3; Farah Z. Dawood, MD2; Neil A. Zakai, MD5; Evan L. Thacker, PhD4; Suzanne Judd, PhD6; Virginia J. Howard, PhD4; George Howard, DrPH6; David M. Herrington, MD, MHS2; Mary Cushman, MD, MSc5
[+] 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.
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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.

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Figure 1.
Unadjusted Cumulative Incidence of Myocardial Infarction by Baseline Atrial Fibrillation Status
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Figure 2.
Sex-Race Stratified Age-Adjusted Incidence Rates and Multivariable-Adjusted Hazard Ratios of Myocardial Infarction by Atrial Fibrillation (AF) Status

Data specified across horizontal braces are reported as hazard ratio (95% CI). All models were adjusted for age, sex, race, region of residence, education level, income, total cholesterol, high-density lipoprotein cholesterol, smoking status, systolic blood pressure, body mass index, diabetes, blood pressure–lowering drug use, warfarin use, aspirin use, statin use, history of noncardiac vascular disease (stroke, peripheral artery disease, and aortic aneurysm), estimated glomerular filtration rate lower than 60 mL/min/1.73 m2, log-transformed C-reactive protein, and log-transformed albumin to creatinine ratio.

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