Article Text

Original article
Heart rate is associated with progression of atrial fibrillation, independent of rhythm
  1. Fredrik Holmqvist1,
  2. Sunghee Kim1,
  3. Benjamin A Steinberg1,
  4. James A Reiffel2,
  5. Kenneth W Mahaffey3,
  6. Bernard J Gersh4,
  7. Gregg C Fonarow5,
  8. Gerald V Naccarelli6,
  9. Paul Chang7,
  10. James V Freeman8,
  11. Peter R Kowey9,
  12. Laine Thomas1,
  13. Eric D Peterson1,
  14. Jonathan P Piccini1
  15. on behalf of the ORBIT-AF Investigators
  1. 1Duke Clinical Research Institute, Durham, North Carolina, USA
  2. 2Columbia University, New York, New York, USA
  3. 3Department of Medicine, Stanford University, Stanford, California, USA
  4. 4Mayo Clinic College of Medicine, Rochester, Minnesota, USA
  5. 5Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, California, USA
  6. 6Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
  7. 7Janssen Pharmaceuticals, Inc., Raritan, New Jersey, USA
  8. 8Department of Internal Medicine, Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
  9. 9Lankenau Hospital and Medical Research Center, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Fredrik Holmqvist, Department of Cardiology, Lund University, Lund 22185, Sweden; fredrik.holmqvist{at}


Objective Atrial fibrillation (AF) often progresses from paroxysmal or persistent to more sustained forms, but the rate and predictors of AF progression in clinical practice are not well described.

Methods Using the Outcomes Registry for Better Informed Treatment of AF, we analysed the incidence and predictors of progression and tested the discrimination and calibration of the HATCH (hypertension, age, TIA/stroke, chronic obstructive pulmonary disease, heart failure) and CHA2DS2VASc scores for identifying AF progression.

Results Among 6235 patients with paroxysmal or persistent AF at baseline, 1479 progressed, during follow-up (median 18 (IQR 12–24) months). These patients were older and had more comorbidities than patients who did not progress (CHADS2 2.3±1.3 vs 2.1±1.3, p<0.0001). At baseline, patients with AF progression were more often on a rate control as opposed to a rhythm control strategy (66 vs 56%, p<0.0001) and had higher heart rate (72(64–80) vs 68(60–76) bpm, p<0.0001). The strongest predictors of AF progression were AF on the baseline ECG (OR 2.30, 95% CI 1.95 to 2.73, p<0.0001) and increasing age (OR 1.16, 95% CI1.09 to 1.24, p<0.0001, per 10 increase), while patients with lower heart rate (OR 0.84, 95% CI 0.79 to 0.89, p<0.0001, per 10 decrease ≤80) were less likely to progress. There was no significant interaction between rhythm on baseline ECG and heart rate (p=0.71). The HATCH and CHA2DS2VASc scores had modest discriminatory power for AF progression (C-indices 0.55 (95% CI 0.53 to 0.58) and 0.55 (95% CI 0.52 to 0.57)).

Conclusions Within 1.5 years, almost a quarter of the patients with paroxysmal or persistent AF progress to a more sustained form. Progression is strongly associated with heart rate, and age.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Files in this Data Supplement:

Linked Articles