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Metabolic syndrome and ischaemic stroke in non-anticoagulated atrial fibrillation with low CHA2DS2-VASc scores
  1. Hyo-Jeong Ahn1,
  2. So-Ryoung Lee1,
  3. Eue-Keun Choi1,2,
  4. Seung-Woo Lee3,
  5. Kyung-Do Han4,
  6. Soonil Kwon1,
  7. Seil Oh1,2,
  8. Gregory Y.H. Lip5
  1. 1Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
  2. 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
  3. 3Department of Medical Statistics, Catholic University of Korea College of Medicine, Seoul, Korea
  4. 4Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
  5. 5Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
  1. Correspondence to Dr Eue-Keun Choi, Seoul National University Hospital, Jongno-gu 03080, Korea; choiek417{at}


Objective Conflicting results have been reported on whether metabolic syndrome (MetS) confers an increased risk of ischaemic stroke in atrial fibrillation (AF). We investigated the risk of ischaemic stroke according to MetS in patients with AF who are not indicated for oral anticoagulants.

Methods A total of 76 015 oral anticoagulant-naïve patients with AF with low Congestive Heart Failure, Hypertension, Age ≥75 years (Doubled), Diabetes Mellitus, Stroke (Doubled), Vascular Disease, Age 65–74 years, Sex Category (Female) (CHA2DS2-VASc) score (0 and 1) were included from the National Health Information Database. The risk of ischaemic stroke was evaluated according to MetS, the number of MetS components (metabolic burden), and individual metabolic components defined by health examination data within 2 years of AF diagnosis.

Results MetS was prevalent among 21 570 (28.4%) of the entire study population (mean age 49.8±11.1 years, mean CHA2DS2-VASc score 0.7±0.5). During a mean follow-up of 5.1 years, ischaemic stroke occurred in 1395 (1.84%) patients. MetS was associated with a higher risk of ischaemic stroke (adjusted HR (aHR) 1.19, 95% CI 1.06 to 1.33, p=0.002). Patients with the highest number of MetS components (4 or 5) showed the greatest aHR of 1.38 (95% CI 1.13 to 1.69), whereas those with a single component had a marginal risk of ischaemic stroke (aHR 1.17, 95% CI 0.97 to 1.40). Elevated blood pressure and increased waist circumference were independent components associated with 1.48-fold and 1.15-fold higher risks of ischaemic stroke, respectively.

Conclusion Among AF patients with CHA2DS2-VASc scores of 0 and 1 with no anticoagulation, MetS is associated with an increased risk of ischaemic stroke. Given the linear incremental association between metabolic burden and ischaemic stroke, the integrated management of metabolic derangements in AF is required.

  • atrial fibrillation
  • metabolic syndrome
  • stroke

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • H-JA and S-RL contributed equally.

  • Contributors HJA and had primary responsibility for writing of the article. HJA and SRL conceived the idea, initiated the analysis plan and carried out data analyses for the current study. HJA, SRL, EKC, SWL and KDH contributed to the data collection and design of the work. EKC supervised the current study. EKC, SO and GYHL reviewed the draft. All authors coordinated the study and provided comments on drafts of the manuscript, and revised and approved the manuscript. EKC is the guarantor of this work and takes responsibility for the integrity and the accuracy of the data analysis. All authors read and approved the final manuscript.

  • Funding This research was supported by a grant from the Patient-Centered Clinical Research Coordinating Center funded by the Ministry of Health and Welfare, Republic of Korea (grant number HC21C0028). This work was supported in part by the Korea Medical Device Development Fund grant funded by the Korea government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health and Welfare and the Ministry of Food and Drug Safety; project numbers HI20C1662, 1711138358 and KMDF_PR_20200901_0173) and by the Korea National Research Foundation funded by the Ministry of Education, Science and Technology (grant number 2020R1F1A106740).

  • Competing interests EKC: research grants or speaking fees from Abbott, Bayer, BMS/Pfizer, Biosense Webster, Chong Kun Dang, Daewoong Pharmaceutical Co., Daiichi-Sankyo, DeepQure, Dreamtech Co., Ltd., Jeil Pharmaceutical Co. Ltd, Medtronic, Samjinpharm, Seers Technology and Skylabs. GYHL: International advisory board member of BMJ Heart and consultant and speaker for BMS/Pfizer, Boehringer Ingelheim and Daiichi-Sankyo.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • 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.