Article Text

Download PDFPDF
Original research article
Ethnic differences in atrial fibrillation in patients with heart failure from Asia-Pacific
  1. Eugene S J Tan1,
  2. Wan Ting Tay2,
  3. Tiew-Hwa Katherine Teng2,
  4. David Sim2,3,
  5. Kui Toh Gerard Leong4,
  6. Poh Shuan Daniel Yeo5,
  7. Hean Yee Ong6,
  8. Fazlur Jaufeerally3,7,
  9. Tze Pin Ng8,
  10. Katrina Poppe9,
  11. Mayanna Lund10,
  12. Gerard Devlin11,
  13. Richard W Troughton12,
  14. Lieng Hsi Ling1,
  15. Arthur Mark Richards1,12,13,
  16. Robert N Doughty9,
  17. Carolyn S P Lam2,3,14
  1. 1 National University Heart Centre, Singapore (NUHCS), Singapore
  2. 2 National Heart Centre Singapore, Singapore
  3. 3 Duke-NUS Graduate Medical School, Singapore
  4. 4 Department of Cardiology, Changi General Hospital, Singapore
  5. 5 Department of Cardiology, Tan Tock Seng Hospital, Singapore
  6. 6 Department of Cardiology, Khoo Teck Puat Hospital, Singapore
  7. 7 Department of Internal Medicine, Singapore General Hospital, Singapore
  8. 8 Yong Loo Lin School of Medicine, National University Singapore, Singapore
  9. 9 Heart Health Research Group, University of Auckland, Auckland, New Zealand
  10. 10 Department of Cardiology, Middlemore Hospital, Auckland, New Zealand
  11. 11 Department of Cardiology, Waikato Hospital, Hamilton, New Zealand
  12. 12 Christchurch Heart Institute, University of Otago, Otago, New Zealand
  13. 13 Cardiovascular Research Institute, National University Health System, Singapore
  14. 14 University Medical Centre Groningen, Groningen, The Netherlands
  1. Correspondence to Dr Carolyn S P Lam, National Heart Centre, Singapore 169609, Singapore; carolyn.lam{at}


Objective Ethnic differences in the prevalence of atrial fibrillation (AF) in heart failure (HF) remain unclear. We compared the prevalence and clinical correlates of AF among different ethnicities in an Asian-Pacific population with HF.

Methods Patients with validated HF were prospectively studied across Singapore and New Zealand (NZ).

Results Among 1746 patients with HF (62% Asian, 26% women, mean age 66 (SD 13) years, mean ejection fraction (EF) 37 (SD 16%), 39% had AF. The prevalence of AF was markedly lower in Singapore-Asians than NZ-Europeans (24% vs 63%; p<0.001), even after adjusting for age, clinical and echocardiographic covariates, regardless of EF group (pinteraction for EF=0.39). Patients with AF were older, had higher body mass index and were more likely to have a history of hypertension, stroke, peripheral vascular disease, renal disease, chronic respiratory disease and increased alcohol intake, but less likely to have diabetes. Clinical correlates were similar for Asians and NZ-Europeans, except diabetes: Asian diabetic patients with HF had less AF compared with Asian patients without diabetes (OR 0.66, 95% CI 0.50 to 0.88), whereas among NZ-Europeans there was no significant association between diabetes and AF (OR 1.22, 95% CI 0.85 to 1.75) (pinteraction for ethnicity=0.01). AF was associated with a higher crude composite outcome of mortality and HF hospitalisations at 2 years (HR 1.19, 95% CI 1.02 to 1.38).

Conclusion There is a strikingly lower prevalence of AF among Asian compared with NZ-European patients with HF. The underlying mechanisms for the lower prevalence of AF among Asians, particularly in the presence of diabetes, deserve further study.

Trial registration number ACTRN12610000374066.

  • atrial fibrillation
  • heart failure
  • diabetes

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.


  • Contributors All the coauthors listed in this manuscript fulfill criteria of authorship. ESJT, WTT and T-HKT contributed to the planning, data analysis, interpretation of data, reporting and writing of the manuscript. DS, KTGL, PSDY, HYO, FJ, TPN, KP, ML, GD, RT, LHL contributed to the conduction of the study, data acquisition, reporting and review of the manuscript. AMR, RND and CSPL contributed to the planning, interpretation of data, reporting, writing and review of the manuscript.

  • Funding National Medical Research Council, Singapore (grant number: R-172-003-219-511); A*STAR-NZ HRC (grant number: JGC 10_027); Clinician Scientist Award (CSPL); NZ Heart Foundation Project Grant, TM Hosking Trust (Auckland); Waikato Medical Research Foundation; HRC Programme Grant; New Zealand Heart Foundation Chair in Cardiovascular Studies (AMR); New Zealand Heart Foundation Chair of Heart Health (RND), Auckland Medical Research Foundation.

  • Competing interests CSPL reports grants from National Medical Research Council of Singapore during the course of the study, research support from Boston Scientific, Bayer, Thermofisher, Medtronic, Vifor Pharma; personal fees from consultation for Bayer, Novartis, Takeda, Merck, AstraZeneca, Janssen Research & Development, Menarini, Boehringer Ingelheim, Abbott Diagnostics, Corvia, Stealth BioTherapeutics, Roche and Amgen, outside the submitted work; RT reports grants from Roche Diagnostics and Merck outside the submitted work; RND reports grants from Health Research Council of NZ, New Zealand Heart Foundation and Auckland Medical Research Foundation, during the conduct of the study; AMR reports grants from Government and Charitable Funding Bodies, non-financial support from Roche Diagnostics during the conduct of the study; personal fees and non-financial support from Roche Diagnostics outside the submitted work; KP reports grants from Heart Foundation of New Zealand and Health Research Council of New Zealand, outside the submitted work; ML reports grants from Health Research Council, Auckland Medical Research Foundation, and New Zealand Lottery Grants Board, during the conduct of the study; VAC reports grants from Health Research Council of New Zealand, during the conduct of the study.

  • Ethics approval Ethics approval was obtained from the National Healthcare Group Domain Specific Review Board (reference number 2010/00114), Singhealth Centralised Institutional Review Board (reference number 2010/196/C) and Upper South A Ethics Committee (reference number CTY/01/05/062).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice Since this paper was first published online, a change has been made to the text in the section Lower prevalence of AF in diabetic patients with HF.

  • Patient consent for publication Not required.

Linked Articles