Nicklas Vinter

Background: Electrical cardioversion (ECV) is widely used for restoring sinus rhythm in atrial fibrillation (AF). However, population-level trends in use of ECV in individuals with AF remain poorly characterised. Aim: We examined nationwide temporal trends in ECV utilisation between 2010 and 2022 in Denmark. Methods: We conducted a registry-based cohort study using Danish nationwide health data. Two cohorts were defined: (1) individuals with prevalent or newly diagnosed AF were used to quantify annual ECV volume. (2) Individuals with newly diagnosed AF were used to calculate unadjusted and age-adjusted and sex-adjusted ECV rates per 1000 person-years during the first year after diagnosis. Results: The total number of ECVs per year increased almost fourfold between 2010 and 2022 (from 2204 to 8300). The 1-year age-adjusted and sex-adjusted rate of ECVs decreased from 449.5 per 1000 person-years in 2010 to 316.6 per 1000 person-years in 2021. Rates increased among individuals aged ≥75 years but declined among younger patients. When restricted to the first ECV procedure, analyses showed a twofold increase in first-time ECVs. Conclusions: The increasing volume of ECVs reflects growing demand for rhythm control, while declining rates may suggest more targeted use of ECV. The findings highlight the need for resource planning and monitoring of procedural burden to support guideline implementation and equitable rhythm control delivery.

Aims: Comparing temporal trends in the incidence and prevalence of major cardiovascular diseases (CVDs) provides insights into their evolving relative burden. We examined incidence and prevalence trends of atrial fibrillation (AF), heart failure (HF), myocardial infarction (MI), and stroke from 2000 to 2022 and projected these measures to 2040. Methods and results: In this Danish nationwide cohort study, we analysed data from national registries and Statistics Denmark for individuals aged 20–94 years. Each CVD was modelled separately using a statistical framework combining parametric survival modelling with an age-period-cohort incidence model, accounting for temporal trends and enabling future burden extrapolation. From 2000 to 2022, AF incidence increased, while HF, MI, and stroke incidences decreased. The prevalence of all four conditions increased. By 2040, AF incidence in Denmark is projected to rise by 28% from 20 683 to 26 376 new cases, and prevalence by 56% from 175 697 to 274 379 cases. HF and stroke incidences are expected to decrease by 2%, while MI incidence will decline by 30%. HF and stroke prevalence are projected to increase by 52% and 31%, respectively, whereas MI prevalence will decrease by 3%. Among individuals aged 65–94 years, new AF cases are projected to surpass the combined new cases of HF, MI, and stroke in 2040. Conclusion: AF has become the most frequently diagnosed and prevalent major CVD, with a growing burden surpassing HF, MI, and stroke in older adults. These findings underscore the urgent need for updated healthcare policies and integrated care strategies to address the growing burden of AF.

Background: Heart failure (HF) is a global health challenge characterized by high mortality, morbidity, and economic burden. The development of digital health technologies offers promising tools for prevention, early detection, and management of HF, potentially improving prognoses and reducing costs. However, these innovations may also widen existing health disparities related to socioeconomic status, geography, and race/ethnicity. Objective: This scoping review will examine and map existing evidence on socioeconomic, geographic, and racial/ethnic differences in access to and use of digital health technologies for HF care in routine practice. Methods: The writing of this protocol followed the methodological framework by Arksey and O’Malley, including (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies to be included in the review; (4) charting the data; and (5) collating, summarizing, and reporting the results. Eligible studies must examine digital health technologies in adults (aged ≥18 years) with any type of HF and report on social determinants of health, geography, or race/ethnicity. Observational study designs will be included. Searches will be conducted in Embase, PubMed, Google Scholar, and Scopus. A 2-stage screening process will determine study eligibility, and data will be extracted using a standardized form. Results: The project is funded. Data collection is expected to begin by the beginning of 2026. Conclusions: This scoping review will map existing evidence on differences in access to and use of digital health technologies for HF care. The findings are anticipated to highlight patterns and gaps in the literature, informing future research and strategies for equitable implementation.

Aims: Monitoring trends in mortality of atrial fibrillation (AF) in comparison with other major cardiovascular conditions indirectly gives insights into the relative progress in management. We examined trends in relative survival metrics of AF compared with heart failure (HF), myocardial infarction (MI), and stroke. Methods and results: This nationwide cohort study included all individuals newly diagnosed with AF, HF, MI, or stroke between 2000 and 2021. Relative survival and excess mortality rates were examined at 1, 5, and 10 years after diagnosis. The general Danish population served as the comparator, adjusted for age, sex, and calendar year. The study included 364 199 patients with AF, 242 570 with HF, 172 552 with MI, and 281 407 with stroke. For relative survival, AF had the smallest average improvement over calendar years at 1 and 5 years after diagnosis (0.35% and 0.58% per year), while at 10 years, AF, MI, and stroke had the smallest average improvements (0.77, 0.72, and 0.80% per year). For excess mortality rate, AF and stroke had the smallest average improvements over calendar years at 1 year (−1.02 and −0.96 additional deaths per 1000 person-years per year) and MI at 5 years (−0.13 additional deaths per 1000 person-years per year). No average improvement was observed in the 10-year excess mortality rate for MI. Conclusion: Atrial fibrillation was the condition or was among those with the smallest improvement in relative survival, and AF and stroke showed the smallest improvement in 1-year excess mortality. The findings highlight the need for renewed efforts in prevention, early detection, and post-acute care for these conditions.

Aims: While advancements in care may improve the clinical course of atrial fibrillation (AF), data on trends in lost lifetime after developing cardiovascular complications are sparse. Methods and results: In this nationwide registry-based matched cohort study (1 January 2000–31 December 2022), we followed patients with ischaemic stroke, gastrointestinal bleeding, intracranial bleeding, heart failure (HF), and myocardial infarction (MI) after AF and matched referents with AF. We estimated the average loss of life expectancy as the difference in restricted mean survival time between patients with AF with and without a complication and compared the loss between 2000–10 and 2011–22. We followed 27 809 patients with ischaemic stroke, 28 938 with gastrointestinal bleeding, 7710 with intracranial bleeding, 50 914 with HF, and 14 141 with MI and their matched referents. The loss of lifetime improved for ischaemic stroke [−2.1 vs. −1.8 years; difference 4.0 months, 95% confidence interval (CI) 2.4–5.6; P < 0.001]. We found no evidence of trends for gastrointestinal (−1.7 vs. −1.8 years; difference −0.8 months, 95% CI −2.5 to 0.8; P = 0.32) or intracranial bleeding (−3.3 vs. −3.1 years; difference 1.6 months, 95% CI −1.3 to 4.6; P = 0.28). The loss of lifetime improved for HF (−2.1 vs. −1.9 years; difference 2.4 months, 95% CI 0.9–3.8; P = 0.001) and MI (−1.6 vs. −1.1 years; difference 5.9 months, 95% CI 3.3–8.5; P < 0.001). Conclusion: Among patients with AF, the loss of expected lifetime after incident ischaemic stroke, HF, and MI improved modestly over the past two decades but not after gastrointestinal or intracranial bleeding. These findings support the development and evaluation of interventions that prevent and reduce severity of complications after AF, particularly for bleeding.

The importance of social drivers of health (SDOH) in the occurrence, detection, treatment, and outcome of atrial fibrillation (AF) has attracted increasing attention. Addressing SDOH factors may suggest opportunities to prevent AF and its complications. We aimed to conduct a structured narrative review and summarize current knowledge on the association between race and ethnicity, SDOH, including rural vs. urban habitation, education, income, and neighbourhood, and the risk of AF, its management, and complications. We identified 537 references in PubMed and 473 references in Embase. After removal of duplicates, we screened the abstracts of 975 references, resulting in 113 references that were examined for eligibility. Subsequently, 34 references were excluded leaving 79 references for the review. Evidence of a social gradient in AF incidence and prevelance were conflicting. However, we found substantial evidence indicating social inequities in the detection of AF, access to treatment, and outcomes such as healthcare utilization, bleeding, heart failure, stroke, dementia, work disability, and death. Inequities are reported across various health care systems and constitute a global problem affecting several continents, although data from Africa and South America are lacking. Given the documented social inequities in AF detection, management, and outcomes, there is an urgent need for healthcare systems, policymakers, and society to identify and implement effective interventions that can reduce inequities and improve outcomes in individuals with AF.

Objectives: To examine how the lifetime risks of atrial fibrillation and of complications after atrial fibrillation changed over time. Design: Danish, nationwide, population based cohort study. Setting: Population of Denmark from 1 January 2000 to 31 December 2022. Participants: 3.5 million individuals (51.7% women and 48.3% men) who did not have atrial fibrillation at 45 years of age or older were followed up until incident atrial fibrillation, migration, death, or end of follow-up, whichever came first. All 362 721 individuals with incident atrial fibrillation (46.4% women and 53.6% men), but with no prevalent complication, were further followed up until incident heart failure, stroke, or myocardial infarction. Main outcome measures: Lifetime risk of atrial fibrillation and lifetime risks of complications after atrial fibrillation over two prespecified periods (2000-10 v 2011-22). Results: The lifetime risk of atrial fibrillation increased from 24.2% in 2000-10 to 30.9% in 2011-22 (difference 6.7% (95% confidence interval 6.5% to 6.8%)). After atrial fibrillation, the most frequent complication was heart failure with a lifetime risk of 42.9% in 2000-10 and 42.1% in 2011-22 (−0.8% (−3.8% to 2.2%)). Individuals with atrial fibrillation lost 14.4 years with no heart failure. The lifetime risks of stroke and of myocardial infarction after atrial fibrillation decreased slightly between the two periods, from 22.4% to 19.9% for stroke (−2.5% (−4.2% to −0.7%)) and from 13.7% to 9.8% for myocardial infarction (−3.9% (−5.3% to −2.4%). No evidence was reported of a differential decrease between men and women. Conclusion: Lifetime risk of atrial fibrillation increased over two decades of follow-up. In individuals with atrial fibrillation, about two in five developed heart failure and one in five had a stroke over their remaining lifetime after atrial fibrillation diagnosis, with no or only small improvement over time. Stroke risks and heart failure prevention strategies are needed for people with atrial fibrillation.

Background: The incidence of atrial fibrillation (AF) shows substantial temporal trends, but the contribution of birth cohort effects is unknown. These effects refer to the relationship between birth year and the likelihood of developing AF. We aimed to assess trends in cumulative incidence of diagnosed AF across birth cohorts and to disentangle the effects of age, birth cohort and calendar period by using age–period–cohort analyses. Methods: In a Danish nationwide population-based cohort study, 4.7 million individuals were selected at a given index age (45, 55, 65 and 75 years) free of AF and followed up for diagnosed AF. For each index age, we assessed trends in 10-year cumulative incidence of AF across six 5-year birth cohorts. An age–period–cohort model was estimated using Poisson regression with constrained spline functions collapsing data into 1-year intervals across ages and calendar years. Results: Cumulative incidence of AF diagnosis increased across birth cohorts for all index ages (p_trend<0.001). Compared with the first birth cohort, the diagnosed AF incidence rate ratio in the last birth cohort was 3.0 (95% CI 2.9 to 3.2) for index age 45 years, 2.9 (2.8 to 3.0) for 55 years, 2.8 (2.7 to 2.8) for 65 years and 2.7 (2.6 to 2.7) for 75 years. Age–period–cohort analyses showed substantial birth cohort effects independent of age, with no clear period effect. Compared with individuals born in 1930, the diagnosed AF incidence rate was 0.125 smaller among individuals born in 1885 and was four times larger among individuals born in 1975. Conclusion: Substantial birth cohort effects, independent of age and calendar period, influence trends in diagnosed AF incidence.