title: Long-term outcomes of secondary atrial fibrillation in the community: the Framingham Heart Study.
abstract: BACKGROUND
  Guidelines have proposed that atrial fibrillation (AF) can occur as an isolated event, particularly when precipitated by a secondary, or reversible, condition. However, knowledge of long-term AF outcomes after diagnosis during a secondary precipitant is limited.
  
  
  RESULTS
  In 1409 Framingham Heart Study participants with new-onset AF, we examined associations between first-detected AF episodes occurring with and without a secondary precipitant and both long-term AF recurrence and morbidity. We selected secondary precipitants based on guidelines (surgery, infection, acute myocardial infarction, thyrotoxicosis, acute alcohol consumption, acute pericardial disease, pulmonary embolism, or other acute pulmonary disease). Among 439 patients (31%) with AF diagnosed during a secondary precipitant, cardiothoracic surgery (n=131 [30%]), infection (n=102 [23%]), noncardiothoracic surgery (n=87 [20%]), and acute myocardial infarction (n=78 [18%]) were most common. AF recurred in 544 of 846 eligible individuals without permanent AF (5-, 10-, and 15-year recurrences of 42%, 56%, and 62% with versus 59%, 69%, and 71% without secondary precipitants; multivariable-adjusted hazard ratio, 0.65 [95% confidence interval, 0.54-0.78]). Stroke risk (n=209/1262 at risk; hazard ratio, 1.13 [95% confidence interval, 0.82-1.57]) and mortality (n=1098/1409 at risk; hazard ratio, 1.00 [95% confidence interval, 0.87-1.15]) were similar between those with and without secondary precipitants, although heart failure risk was reduced (n=294/1107 at risk; hazard ratio, 0.74 [95% confidence interval, 0.56-0.97]).
  
  
  CONCLUSIONS
  AF recurs in most individuals, including those diagnosed with secondary precipitants. Long-term AF-related stroke and mortality risks were similar between individuals with and without secondary AF precipitants. Future studies may determine whether increased arrhythmia surveillance or adherence to general AF management principles in patients with reversible AF precipitants will reduce morbidity.
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA. slubitz@mgh.harvard.edu.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Lubitz
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA.
authors.forename: Xiaoyan
authors.initials: X
authors.lastname: Yin
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA.
authors.forename: Michiel
authors.initials: M
authors.lastname: Rienstra
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA.
authors.forename: Renate B
authors.initials: RB
authors.lastname: Schnabel
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA.
authors.forename: Allan J
authors.initials: AJ
authors.lastname: Walkey
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA.
authors.forename: Jared W
authors.initials: JW
authors.lastname: Magnani
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA.
authors.forename: Faisal
authors.initials: F
authors.lastname: Rahman
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA.
authors.forename: David D
authors.initials: DD
authors.lastname: McManus
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Tadros
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Levy
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA.
authors.forename: Ramachandran S
authors.initials: RS
authors.lastname: Vasan
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA.
authors.forename: Martin G
authors.initials: MG
authors.lastname: Larson
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA.
authors.forename: Patrick T
authors.initials: PT
authors.lastname: Ellinor
authors.affiliation: From Cardiovascular Research Center (S.A.L., P.T.E.) and Cardiac Arrhythmia Service (S.A.L., P.T.E.), Massachusetts General Hospital, Boston; Boston University and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, MA (X.Y., J.W.M., D.L., R.S.V., M.G.L., E.J.B.); Department of Cardiology, University of Groningen, University Medical Center Groningen, The Netherlands (M.R.); Department of General and Interventional Cardiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.B.S.); Pulmonary Center and Section of Pulmonary and Critical Care Medicine (A.J.W.), Section of Cardiovascular Medicine (J.W.M., R.S.V., E.J.B.), and Section of Preventive Medicine (R.S.V., E.J.B.), Department of Medicine, Boston University School of Medicine, MA; Department of Medicine, Boston University Medical Center, MA (F.R.); Departments of Medicine and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester (D.D.M.); Sutter Medical Group, Sacramento, CA (T.M.T.); Population Sciences Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.); Department of Mathematics and Statistics, Boston University, MA (M.G.L.); and Departments of Biostatistics (M.G.L.) and Epidemiology (E.J.B., R.S.V.), Boston University School of Public Health, MA.
authors.forename: Emelia J
authors.initials: EJ
authors.lastname: Benjamin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000435:Alcoholic Intoxication / Q000150:complications; D001281:Atrial Fibrillation / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology; D005260:Female; D006331:Heart Diseases / Q000150:complications; D006333:Heart Failure / Q000453:epidemiology / Q000209:etiology; D006801:Humans; D007239:Infections / Q000150:complications; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D017410:Practice Guidelines as Topic; D011379:Prognosis; D011655:Pulmonary Embolism / Q000150:complications; D012008:Recurrence; D020521:Stroke / Q000453:epidemiology; D016019:Survival Analysis; D013971:Thyrotoxicosis / Q000150:complications; D016896:Treatment Outcome
keywords: atrial fibrillation; atrial flutter; epidemiology; heart failure; risk factors; stroke