Category | Specific features | Sex-related difference |
Epidemiology | Age-adjusted incidence | Generally 1.5-fold to 2.0-fold higher in M compared with F. |
Age-adjusted prevalence | Higher in M worldwide (excluding China, where the reported AF prevalence was higher in F). | |
Lifetime risk for AF | Similar for both M and F (excluding China, where the reported lifetime risk for AF was higher in F). | |
Secular trends in the sex-specific incidence a nd prevalence of AF | Similar for both M and F. | |
Demographics | Age | F significantly older than M in all AF cohorts (eg, first-diagnosed AF, AF ablation, acute stroke patients, etc). |
Risk factors for AF | Sex preponderance | Older age, arterial hypertension, valvular heart disease and HFpEF are more prevalent in F, whereas CAD and HFrEF are more prevalent in M. The role of physical activity as AF risk factor might be different in M (a ‘U’-shaped relationship) and F (no such relationship). Inconsistent findings regarding the genetic risk for AF. |
Pathophysiology | Electrical characteristics | Extrapulmonary vein foci may have greater importance in F. Atrial myocyte action potential duration is shorter and resting membrane potential is more negative in F. Sex-related alterations in Ca and K ion currents and hormone-related alterations are also likely. |
Structural characteristics | M generally have larger hearts, including LV mass, LV wall thickness and LA size, whereas a greater extent of LA fibrosis has been described in F. | |
Clinical presentations | Sex preponderance | AF is more often symptomatic in F, who generally present with higher ventricular rates than M, but more frequently describe atypical symptoms (eg, weakness, fatigue). Asymptomatic AF more common in M. Depression more frequently seen in F. Generally greater AF-related quality of life impairment in F. |
Prognosis | Heart failure | No clear difference between M and F; however, HFpEF more commonly develops in F. |
MI | A greater association of AF and MI or CAD has been suggested in F, but further research is needed. | |
Dementia | No signal of sex preponderance. | |
Stroke | Female sex is an independent risk factor for AF-related stroke or systemic embolism, particularly in F aged ≥65 years. | |
Stroke presentation and outcome | Younger age and less severe neurological deficit at AF-related stroke presentation, but no significant difference between the sexes in the severity of 90-day stroke outcome. | |
All-cause mortality | Available data show conflicting results, but F might have a greater AF-related mortality compared with M. | |
Therapy | Sex-specific utilisation | Sex-specific outcomes |
Rate control | More likely in F. The use of beta-blockers and digoxin more frequent in F. | No difference between F and M. |
Rhythm control | In general, less likely in F compared with M. | |
Pharmacological cardioversion | May be more likely in F. | No sex-specific difference in success rates. It has been suggested that proarrhythmic complications (eg, torsades de pointes) or sick sinus syndrome may occur more often in F.* |
Electrical cardioversion | May be more likely in M. | No significant difference in success rates in M compared with F. |
AF ablation | May be more likely in M. Re-do procedures more likely in M. | No clear difference in the success rates between M and F (although a lower success rate in F has been reported*). Complications may be more frequent in F (particularly vascular complications, bleeding and pericardial effusion*). |
Stroke prevention | Lower use of OAC for primary stroke prevention in earlier observational studies. Secondary stroke prevention using OAC less likely in F. | |
Vitamin K antagonists | Similar utilisation rates in M and F in more recent cohorts (earlier reports showed that F were less likely to be prescribed warfarin). | Residual risk of stroke with vitamin K antagonist therapy may be higher in F. Higher risk of OAC-related bleeding in F. Lower time in therapeutical range in F. |
Non-vitamin K antagonists | Similar utilisation rates in M and F, but F might be more likely to be prescribed lower doses (particularly with dabigatran). | No sex-specific differences in the efficacy of non-vitamin K antagonist oral anticoagulants. The risk of OAC-related bleeding risk may be lower in F. |
Aspirin use | F might be more likely to be prescribed aspirin for stroke prevention. M more likely to receive aspirin concomitantly with OAC. | NA |
Left atrial appendage closure | Data are lacking. F were under-represented in the pertinent trials. | Inconsistent reports, complications might be more frequent in F. |
*Unadjusted analyses.
AF, atrial fibrillation; CAD, coronary artery disease; F, female individuals; HFpEF, heart failure with preserved left ventricular ejection fraction; HFrEF, heart failure with reduced left ventricular ejection fraction; LA, left atrium; LV, left ventricle; M, male individuals; MI, myocardial infarction; NA, not applicable; OAC, oral anticoagulant.