Prevalence of asymptomatic atrial fibrillation and risk factors associated with asymptomatic status: a systematic review and meta-analysis

Abstract

AIM Asymptomatic atrial fibrillation (AF) is frequent and associated with disease progression. This meta-analysis aimed to estimate the prevalence of asymptomatic AF and identify risk factors associated with asymptomatic status. METHODS MEDLINE(Pubmed), Scopus, Cochrane and ClinicalTrials.gov were searched until January 8, 2025. Double-independent study selection, data extraction and quality assessments were performed. Random-effects meta-analysis was used. Estimates are presented with the asymptomatic individuals in the nominator and the symptomatic patients in the denominator. The assessment of the prevalence of asymptomatic AF and the identification of risk factors associated with the asymptomatic status comprised the main endpoints. RESULTS Thirty-seven studies (224273 participants) were included. The prevalence of asymptomatic AF was 27% (95% confidence interval {CI}=[22%,33%]; I2=100%). Risk factors positively associated with the asymptomatic status were male sex (odds ratio {OR}=1.67, 95%CI=[1.48,1.89], p<0.001, I2=85%), diabetes mellitus (OR=1.19, 95%CI=[1.07,1.33], p=0.002, I2=87%), chronic kidney disease (OR=1.21, 95%CI=[1.08,1.36], p<0.001, I2=80%) and stroke/transient ischemic attack (OR=1.43, 95%CI=[1.18,1.73], p<0.001, I2=95%), while heart failure was negatively associated with asymptomatic AF (OR=0.71, 95%CI=[0.54,0.94], p=0.017, I2=97%). Asymptomatic status was also positively associated with permanent AF (OR=2.13, 95%CI=[1.28,3.55]; p=0.004; I2=98%) and negatively associated with catheter ablation (OR=0.63, 95%CI=[0.44,0.91]; p=0.012; I2=95%), beta-blockers (OR=0.90, 95%CI=[0.82,0.98]; p=0.018; I2=68%) and antiarrhythmics (OR=0.53, 95%CI=[0.35,0.79]; p=0.002; I2=95%). CONCLUSIONS Asymptomatic AF was estimated around 27%, with large variability depending on the prevalence of risk factors associated with asymptomatic status. Asymptomatic individuals had distinct characteristics compared to symptomatic patients, regardless of symptoms' assessment methods and rhythm/rate control interventions. Our results could inform AF screening practices to target asymptomatic individuals. Approximately 27% of AF patients are asymptomaticDiabetes mellitus, chronic kidney disease, male sex and stroke/TIA were positively associated with asymptomatic AF, while heart failure was negatively associated with asymptomatic statusLarge variability was noted in the prevalence of asymptomatic AF based on the baseline distribution of risk factors associated with asymptomatic status in each examined populationThe associations remained similar regardless of study design, methods to assess symptoms and whether AF cases were incident (new-onset AF) or a mix of incident/prevalent.