Impact of lifestyle on adverse outcomes in people with atrial fibrillation: insights from two prospective observational registries from europe and east asia
E Tartaglia, T Bucci, A Askarinejad, A G Rigutini, M Rossi, M Mantovani, W Shimizu, H F Tse, W S Teo, T F Chao, G Boriani, G Y H LipAbstract
Background
Despite increasing recognition of their importance in cardiovascular health, the prognostic impact of lifestyle behaviours in atrial fibrillation (AF) remains poorly characterized, when comparing different regions or ethnicities.
Purpose
To evaluate the prevalence and clinical impact of unhealthy lifestyle behaviours in people with AF from two different geographical regions.
Methods
Post-hoc analysis of two international prospective registries from Europe and East Asia. An "unhealthy lifestyle" was defined by the presence of ≥1 of the following: physical inactivity (defined as none or occasional activity: no exercise or <3 hours/week for <2 years, or occasional activity <3 hours/week for ≥2 years), daily alcohol consumption (≥1 drink/day), or current/former smoking; a "healthy lifestyle" was defined as the absence of all three. The primary outcome was a composite of all-cause death and major adverse cardiovascular events (MACE: cardiovascular death, acute coronary syndrome, or thromboembolism). Secondary outcomes included the individual components and major bleeding. Multivariable Cox regression models were used to assess the associations between unhealthy lifestyle and outcomes. Sensitivity analyses evaluated the risk pattern according to the cumulative number and type of unhealthy behaviours, and subgroup analyses explored consistency across geographical regions and clinically relevant categories.
Results
8,862 (83.4%) people with AF reported at least one unhealthy lifestyle behaviour, while 1,763 (16.6%) had a healthy lifestyle. People with AF and an unhealthy lifestyle were older, more often male, more frequently European, and had a higher cardiovascular burden than those with a healthy lifestyle. They were associated with an increased risk of the composite outcome (HR 1.69, 95% CI 1.32–2.16), all-cause death (HR 2.28, 95% CI 1.58–3.27), MACE (HR 1.40, 95% CI 1.05–1.87), and cardiovascular death (HR 1.98, 95% CI 1.10–3.55) compared to those with a healthy lifestyle (Table 1). A clear dose–response relationship was observed, with risk progressively increasing across individuals reporting one, two, or three unhealthy behaviours (Figure 1, Panel A). Among individual behaviours, physical inactivity showed the strongest and most consistent associations with adverse outcomes (Figure 1, Panel B and C). Subgroup analyses demonstrated broadly consistent findings across categories, with a stronger association between unhealthy lifestyle and adverse outcomes among individuals with hypertension (p(int) = 0.039). No heterogeneity was detected across geographical regions.
Conclusion
People with AF who report an unhealthy lifestyle face a higher risk of adverse events compared to those with a healthy lifestyle. This risk increases with the number of unhealthy behaviours and is mainly driven by physical inactivity. Structured lifestyle optimisation should be integrated as a core component of comprehensive, risk-tailored AF management.