Incidence, Risk Factors, and Outcomes in Stressor-Associated Atrial Fibrillation: Insights from the VITAL-AF Trial

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Abstract
Background: Stressor-associated atrial fibrillation (AF), defined as newly diagnosed AF in the setting of a reversible physiological stressor, is common. However, risk factors, outcomes, and current management practices remain poorly understood. Methods: We analyzed data from VITAL-AF, a pragmatic, cluster-randomized AF screening trial conducted 2018-2019 comprising adults aged ≥65 across 16 primary care practices affiliated with Massachusetts General Hospital. All participants had longitudinal follow-up for adjudicated incident AF (including whether stressor-associated vs non-stressor-associated [‘primary’]) and clinical outcomes. We compared associations between clinical AF risk factors and incident AF group (stressor-associated vs primary) using Fine-Gray models handling death and each AF group as competing risks. We also quantified anticoagulation (OAC) initiation rates following AF diagnosis. We then fit Cox proportional hazards models to quantify associations between incident AF group (as a time-varying covariate) and a composite endpoint of major bleeding, stroke, and all-cause mortality, with adjustment for CHA ₂ DS ₂ -VASc (stroke) and ATRIA (bleeding) scores and time-varying OAC exposure. Results: We analyzed data from VITAL-AF, a pragmatic, cluster-randomized AF screening trial conducted 2018-2019 comprising adults aged ≥65 across 16 primary care practices affiliated with Massachusetts General Hospital. All participants had longitudinal follow-up for adjudicated incident AF (including whether stressor-associated vs non-stressor-associated [‘primary’]) and clinical outcomes. We compared associations between clinical AF risk factors and incident AF group (stressor-associated vs primary) using Fine-Gray models handling death and each AF group as competing risks. We also quantified anticoagulation (OAC) initiation rates following AF diagnosis. We then fit Cox proportional hazards models to quantify associations between incident AF group (as a time-varying covariate) and a composite endpoint of major bleeding, stroke, and all-cause mortality, with adjustment for CHA ₂ DS ₂ -VASc (stroke) and ATRIA (bleeding) scores and time-varying OAC exposure. Conclusions: Among over 30,000 primary care patients with adjudicated AF events, nearly one-third of incident AF cases were stressor-associated. Despite similar risk factor profiles and comparably high rates of adverse outcomes, OAC initiation is lower when AF is stressor-associated. Future work is needed to define optimal approaches to prevention, surveillance, and management of stressor-associated AF.
Funding Information
  • HHS | NIH | National Heart, Lung, and Blood Institute (R01HL092577)
  • HHS | NIH | NHLBI | Division of Intramural Research NIH | National Heart, Lung, and Blood Institute (R01HL157635)
  • HHS | NIH | National Heart, Lung, and Blood Institute (1R01HL177209)
  • HHS | NIH | National Heart, Lung, and Blood Institute (T32HL007208)
  • Deutsche Forschungsgemeinschaft (521832260)
  • American Heart Association (961045)
  • European Commission (MAESTRIA 965286)
  • Fondation Leducq (24CVD01)
  • HHS | NIH | National Heart, Lung, and Blood Institute (K23HL169839)
  • American Heart Association (23CDA1050571)
  • HHS | NIH | National Heart, Lung, and Blood Institute (T32HL1717799)
  • HHS | NIH | National Heart, Lung, and Blood Institute (U54HL143541)
  • HHS | NIH | National Heart, Lung, and Blood Institute (R01HL155343)
  • HHS | NIH | National Heart, Lung, and Blood Institute (UG3NS135168)
  • Eliot B. and Edith C. Shoolman fund of the Massachusetts General Hospital

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