Orthostatic change in blood pressure and incidence of atrial fibrillation: results from a bi-ethnic population based study

Sunil K Agarwal, Alvaro Alonso, Seamus P Whelton, Elsayed Z Soliman, Kathryn M Rose, Alanna M Chamberlain, Ross J Simpson Jr, Josef Coresh, Gerardo Heiss, Sunil K Agarwal, Alvaro Alonso, Seamus P Whelton, Elsayed Z Soliman, Kathryn M Rose, Alanna M Chamberlain, Ross J Simpson Jr, Josef Coresh, Gerardo Heiss

Abstract

Background: Autonomic fluctuations are associated with the initiation and possibly maintenance of atrial fibrillation (AF). However, little is known about the relationship between orthostatic blood pressure change, a common manifestation of autonomic dysfunction, and incident AF.

Methods: We examined whether supine-to-standing changes in systolic blood pressure (SBP) are associated with incident AF in 12,071 African American and white men and women aged 45-64 years, enrolled in the Atherosclerosis Risks in Communities (ARIC) study. Orthostatic hypotension (OH) was defined as a supine-standing drop in SBP by ≥20 mmHg or diastolic blood pressure by ≥10 mmHg. AF cases were identified based on study scheduled 12-lead ECG, hospital discharge ICD codes, and death certificates through 2009.

Results: OH was seen in 603 (5%) at baseline. During an average follow-up of 18.1 years, 1438 (11.9%) study participants developed AF. Incident AF occurred more commonly among those with OH than those without, a rate of 9.3 vs. 6.3 per 1000 person years, (p<0.001). The age, gender, and race adjusted hazard ratio (95%CI) of AF among those with OH compared to those without was 1.62 (1.34, 2.14). This association was attenuated after adjustment for common AF risk factors to HR 1.40 (1.15, 1.71), a strength similar to that of diabetes or hypertension with AF in the same model. A non-linear relationship between orthostatic change in SBP and incident AF was present after multivariable adjustment.

Conclusions: OH is associated with higher AF incidence. Whether interventions that decrease OH can reduce AF risk remains unknown.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Orthostatic change in systolic blood…
Figure 1. Orthostatic change in systolic blood pressure (standing-supine) at baseline visit and multivariable adjusted hazard ratio of atrial fibrillation: The Atherosclerosis Risks in Communities Study (1987–89 to 2009).
In the upper panel, the line shows hazard ratio (HR) and the grey bands represents 95% confidence interval (95% CI) for hazard ratio with no change in blood pressure upon standing as reference. In the bottom panel, the line represents smoothed density plots showing distribution of the orthostatic change in systolic blood pressure (SBP) in the study sample. The extreme values of SBP change (0.25 percentile) at each extreme were removed before plotting above to remove the effect on restricted portion from outliers (though including them didn’t change shape much).
Figure 2. Cumulative incidence of atrial fibrillation…
Figure 2. Cumulative incidence of atrial fibrillation by presence of orthostatic hypotension at baseline.
Results from the Atherosclerosis Risks in Communities Study 1987–89 through 2009 (study n = 12, 071, incident atrial fibrillation n = 1438).

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