title: Occurrence of death and stroke in patients in 47 countries 1 year after presenting with atrial fibrillation: a cohort study.
abstract: Atrial fibrillation is an important cause of morbidity and mortality worldwide, but scant data are available for long-term outcomes in individuals outside North America or Europe, especially in primary care settings.
  
  
  
  We did a cohort study using a prospective registry of patients in 47 countries who presented to a hospital emergency department with atrial fibrillation or atrial flutter as a primary or secondary diagnosis. 15 400 individuals were enrolled to determine the occurrence of death and strokes (the primary outcomes) in this cohort over eight geographical regions (North America, western Europe, and Australia; South America; eastern Europe; the Middle East and Mediterranean crescent; sub-Saharan Africa; India; China; and southeast Asia) 1 year after attending the emergency department. Patients from North America, western Europe, and Australia were used as the reference population, and compared with patients from the other seven regions
  
  
  
  Between Dec 24, 2007, and Oct 21, 2011, we enrolled 15 400 individuals to the registry. Follow-up was complete for 15 361 (99·7%), of whom 1758 (11%) died within 1 year. Fewer deaths occurred among patients presenting to the emergency department with a primary diagnosis of atrial fibrillation compared with patients who had atrial fibrillation as a secondary diagnosis (377 [6%] of 6825 patients vs 1381 [16%] of 8536, p<0·0001). Twice as many patients had died by 1 year in South America (192 [17%] of 1132) and Africa (225 [20%] of 1137) compared with North America, western Europe, and Australia (366 [10%] of 3800, p<0·0001). Heart failure was the most common cause of death (519 [30%] of 1758); stroke caused 148 (8%) deaths. 604 (4%) of 15361 patients had had a stroke by 1 year; 170 (3%) of 6825 for whom atrial fibrillation was a primary diagnosis and 434 (5%) of 8536 for whom it was a secondary diagnosis (p<0·0001). The highest number of strokes occurred in patients in Africa (89 [8%] of 1137), China (143 [7%] of 2023), and southeast Asia (88 [7%] of 1331) and the lowest occurred in India (20 [<1%] of 2536). 94 (3%) of 3800 patients in North America, western Europe, and Australia had a stroke.
  
  
  
  Marked unexplained inter-regional variations in the occurrence of stroke and mortality suggest that factors other than clinical variables might be important. Prevention of death from heart failure should be a major priority in the treatment of atrial fibrillation.
  
  
  
  Boehringer Ingelheim.
authors: Population Health Research Institute, McMaster University, Hamilton, ON, Canada. Electronic address: Jeff.Healey@phri.ca.
authors: Jeff S
authors: JS
authors: Healey
authors: Uppsala Clinical Research, Uppsala, Sweden.
authors: Jonas
authors: J
authors: Oldgren
authors: Lankenau Institute for Medical Research, Wynnewood, PA, USA.
authors: Michael
authors: M
authors: Ezekowitz
authors: Fuwai Hospital CAMS and PUMC, Beijing, China.
authors: Jun
authors: J
authors: Zhu
authors: St John's Medical College and Bangalore Research Institute, Bangalore, India.
authors: Prem
authors: P
authors: Pais
authors: Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
authors: Jia
authors: J
authors: Wang
authors: Department of Medicine, University of Cape Town, Cape Town, South Africa.
authors: Patrick
authors: P
authors: Commerford
authors: University Hospital Motol, Prague, Czech Republic.
authors: Petr
authors: P
authors: Jansky
authors: Instituto Dante Pazzanesse de Cardiologia, Sao Paulo, Brazil.
authors: Alvaro
authors: A
authors: Avezum
authors: St John's Medical College and Bangalore Research Institute, Bangalore, India.
authors: Alben
authors: A
authors: Sigamani
authors: Eduardo Mondlane University, Maputo, Mozambique.
authors: Albertino
authors: A
authors: Damasceno
authors: Boehringer Ingelheim, Bieberach, Germany.
authors: Paul
authors: P
authors: Reilly
authors: Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
authors: Alex
authors: A
authors: Grinvalds
authors: Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
authors: Juliet
authors: J
authors: Nakamya
authors: University College Hospital, Ibadan, Nigeria.
authors: Akinyemi
authors: A
authors: Aje
authors: Sheikh Khalifa Medical City and Cleveland Clinic, Abu Dhabi, United Arab Emirates.
authors: Wael
authors: W
authors: Almahmeed
authors: Craigavon Area Hospital, Craigavon, County Armagh, UK.
authors: Andrew
authors: A
authors: Moriarty
authors: Uppsala Clinical Research, Uppsala, Sweden.
authors: Lars
authors: L
authors: Wallentin
authors: Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
authors: Salim
authors: S
authors: Yusuf
authors: Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
authors: Stuart J
authors: SJ
authors: Connolly
mesh_terms: D000328:Adult; D000368:Aged; D001281:Atrial Fibrillation / Q000150:complications* / Q000175:diagnosis / Q000453:epidemiology*; D015331:Cohort Studies; D015897:Comorbidity; D003643:Death; D005260:Female; D014943:Global Health; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000453:epidemiology* / Q000209:etiology / Q000401:mortality