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Original research
Sex-specific differences in adverse outcome events among patients with atrial fibrillation
  1. Simone Evers-Dörpfeld1,2,
  2. Stefanie Aeschbacher1,2,
  3. Elisa Hennings1,2,
  4. Ceylan Eken1,2,
  5. Michael Coslovsky1,2,3,
  6. Nicolas Rodondi4,5,
  7. Jürg H Beer6,
  8. Giorgio Moschovitis7,
  9. Peter Ammann8,
  10. Richard Kobza9,
  11. Selinda Ceylan1,2,
  12. Melina Krempke1,2,
  13. Christine S Meyer-Zürn1,2,
  14. Elisavet Moutzouri4,5,
  15. Anne Springer1,2,
  16. Christian Sticherling1,2,
  17. Leo H Bonati10,
  18. Stefan Osswald1,2,
  19. Michael Kuehne1,2,
  20. David Conen11
  21. for the Swiss-AF Investigators
  1. 1 Department of Medicine, Cardiology Division, University Hospital Basel, Basel, Switzerland
  2. 2 Cardiovascular Research Institute, University Hospital Basel, Basel, Switzerland
  3. 3 Department of Clinical Research, Clinical Trial Unit, University Hospital Basel, Switzerland
  4. 4 University of Bern Institute of Primary Health Care, Bern, Switzerland
  5. 5 Department of General Internal Medicine, Inselspital University Hospital Bern, Bern, Switzerland
  6. 6 Department of Medicine, Baden Cantonal Hospital, Baden, Switzerland
  7. 7 Division of Cardiology, Ospedale Regionale di Lugano-Civico e Italiano, Lugano, Switzerland
  8. 8 Department of Cardiology, Kantonsspital Sankt Gallen, Sankt Gallen, Switzerland
  9. 9 Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
  10. 10 Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland
  11. 11 Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
  1. Correspondence to Dr David Conen, Population Health Research Institute, McMaster University, Hamilton, ON L8S 4L8, Canada; David.Conen{at}


Objective To assess whether women with atrial fibrillation (AF) have a higher risk of adverse events than men during long-term follow-up since controversial data have been published.

Methods In the context of two very similar observational multicentre cohort studies, we prospectively followed 3894 patients (28% women) with previously documented AF for a median of 4.02 (3.00–5.83) years. The primary outcome was a composite of ischaemic stroke, myocardial infarction and cardiovascular death. Secondary outcomes included the individual components of the composite outcome, hospitalisation for heart failure, major and clinically relevant non-major bleeding, stroke or systemic embolism and non-cardiovascular death.

Results Mean age was 73.1 years in women vs 70.8 years in men. The incidence of the primary endpoint in women versus men was 2.46 vs 3.24 per 100 patient-years, respectively (adjusted HR (aHR) 0.74, 95% CI 0.58 to 0.94; p=0.01). Women died less frequently from cardiovascular (aHR 0.57, 95% CI 0.41 to 0.78; p<0.001) and non-cardiovascular causes (aHR 0.68, 95% CI 0.47 to 0.98; p=0.04). There were no significant sex-specific differences in stroke (incidence 1.05 vs 1.00; aHR 1.02, 95% CI 0.70 to 1.49, p=0.93), myocardial infarction (incidence 0.67 vs 0.72; aHR 0.98, 95% CI 0.61 to 1.57, p=0.94), major and clinically relevant non-major bleeding (incidence 4.51 vs 4.34; aHR 0.95, 95% CI 0.79 to 1.15, p=0.63) or heart failure hospitalisation (incidence 3.28 vs 3.07; aHR 1.06, 95% CI 0.85 to 1.32, p=0.60).

Conclusion In this large study of patients with established AF, women had a lower risk of death than men, but there were no sex-specific differences in other adverse outcomes.

  • atrial fibrillation
  • outcome assessment
  • healthcare
  • risk factors
  • stroke
  • epidemiology

Data availability statement

No data are available.

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  • SE-D and SA are joint first authors.

  • Presented at This paper has previously been presented by SE-D as an abstract at the Joint Annual Meeting of the Swiss Society of Cardiology (SSC) and the Swiss Society of Cardiac and Thoracic Vascular Surgery (SSCC) 9–11 June 2021.

  • Collaborators All Swiss-AF and Beat-AF investigators are listed in the supplement.

  • Contributors Conception and design—DC, SE-D, SA, MK and SO. Analysis and interpretation of the data—SA, SE-D, EH, DC and MC; all authors provided input in the interpretation of the data. Drafting of the manuscript—SE-D, SA and DC. Critical revision for important intellectual content—all authors. Final approval of the manuscript—all authors. Guarantor—DC.

  • Funding The Beat-AF Study was supported by the Swiss National Science Foundation (grant number PP00P3_159322), the Swiss Heart Foundation, the University of Basel, Boehringer Ingelheim, SanofiAventis, Merck Sharp & Dome, Bayer, Daiichi-Sankyo and Pfizer/Bristol-Myers Squibb. The Swiss-AF cohort study is supported by grants of the Swiss National Science Foundation (grant numbers 33CS30_148474 and 33CS30_177520), the Foundation for Cardiovascular Research Basel and the University of Basel.

  • Disclaimer None of the funders had any role in manuscript preparation or in the decision to submit the manuscript for publication.

  • Competing interests CSM-Z reports a research grant from Medtronic and speaker fees from Vifor Pharma and Novartis. DC has received consultant/speaker fees from Servier Canada and Roche Diagnostics, outside of the submitted work. GM has received consultant fees for taking part in advisory boards from Novartis, AstraZeneca, Bayer and Böhringer Ingelheim, outside of the submitted work. JHB reports grants from the Swiss National Foundation of Science, the Swiss Heart Foundation, grants from Bayer, lecture fees from Sanofi Aventis and Amgen, to the institution outside the submitted work. LHB received grants from the Swiss National Science Foundation (PBBSB-116873, 33CM30-124119, 32003B-156658; Bern, Switzerland), the Swiss Heart Foundation (Bern, Switzerland, and the University of Basel (Basel, Switzerland). LHB has received an unrestricted research grant from AstraZeneca, and consultancy or advisory board fees or speaker’s honoraria from Amgen, Bayer, Bristol-Myers Squibb, and Claret Medical, and travel grants from AstraZeneca and Bayer. MK reports personal fees from Bayer, personal fees from Böhringer Ingelheim, personal fees from Pfizer BMS, personal fees from Daiichi Sankyo, personal fees from Medtronic, personal fees from Biotronik, personal fees from Boston Scientific, personal fees from Johnson&Johnson, grants from Bayer, grants from Pfizer BMS, grants from Boston Scientific and grants from Daiichi Sankyo. He is supported by the Swiss National Science Foundation (32473B_176178) and the Swiss Heart Foundation. NR received a grant from the Swiss Heart Foundation. RK receives institutional grants from Abbott, Biosense-Webster, Boston-Scientific, Biotronik, Medtronic and Sis-Medical.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.