Abstract
AIMS: The aim of this study was to systematically quantify the global, regional, and national burden of heart failure (HF) attributable to atrial fibrillation/flutter (AF/AFL) from 1990 to 2021, and project trends to 2040. METHODS AND RESULTS: Using Global Burden of Disease (GBD) 2021 data, we analysed AF/AFL-attributed HF prevalence and years lived with disability (YLDs) across 204 countries, stratified by age, sex, and socio-demographic index (SDI). Joinpoint regression identified temporal inflection points; decomposition analysis quantified contributions from population growth, ageing, and epidemiological change; Bayesian age-period-cohort (BAPC) models forecasted burden to 2040. Globally, AF-attributed HF cases increased 3.4-fold, from 162 561 (95% UI: 120 008-213 951) in 1990 to 714 137 (95% UI: 520 543-940 901) in 2021, with age-standardized prevalence rates (ASPRs) rising from 5.36 to 8.85 per 100 000 (EAPC: 1.76%, 95% UI: 1.66-1.85%). YLDs increased more than four-fold, from 14 615 (95% UI: 8848-23 114) to 63 943 (95% UI: 39 058-96 196; EAPC: 1.76%, 95% CI: 1.67-1.85%). High-SDI regions exhibited the highest burden (ASPR: 13.97 (95% UI: 10.31 to 18.36) per 100 000), with epidemiological changes contributing 44% of the absolute increase in high-SDI regions to case growth. Women outnumbered men beyond age 65 (female-to-male ratio: 1.1 at age 65-69, widening to 2.4 at ≥95 years), yet age-standardized rates showed no significant sex difference (female ASPR: 8.91 vs. male ASPR: 8.78 per 100 000). Joinpoint analysis revealed accelerated growth during 1990-2007 (APC: 2.12%, P < .05), which decelerated during 2007-2018 (APC: 1.41%, P < .05) and plateaued during 2018-2021 (APC: -0.36%, P > .05). Projections indicate a near-doubling of global cases to 1 307 469 (95% UI: 661 547-1 953 391) by 2040, corresponding to an ASPR of 8.45 per 100 000 (95% UI: 4.28-12.63). CONCLUSION: AF/AFL is a major and growing driver of global HF burden, projected to affect 1.3 million individuals by 2040, with disproportionate impact in older adults (≥65 years) and high-SDI regions. Integrating standardized AF management-including systematic screening, anticoagulation, and early rhythm control-into HF prevention pathways represents a critical strategy to mitigate projected increases.