Higher Right Ventricular Afterload in Older Adults Linked to Greater Risk for AF

ECG example of a pathological 12-lead rhythm, atrial flutter
Researchers sought to determine the relationship between increased right ventricular afterload and risk for atrial fibrillation.

Higher estimated pulmonary artery systolic pressure (PASP) and pulmonary vascular resistance (PVR) were significantly associated with an elevated risk for atrial fibrillation among community-dwelling older adults. These findings were published in the journal Chest.

In a prospective, observational, community-based cohort study (the Atherosclerosis Risk in Communities study; ClinicalTrials.gov identifier: NCT00005131), researchers sought to evaluate whether higher right ventricular (RV) afterload is associated with a greater risk for atrial fibrillation (AF), independent of left atrial (LA) and left ventricular (LV) remodeling. They hypothesized that higher PASP and higher PVR are linked to an increased risk for AF, regardless of LA and LV remodeling.

A total of 2246 patients aged mean 75±5 years at baseline were enrolled in the study. Overall, 64% of the patients were women and 22% were Black. All of the participants reported no known cardiovascular disease, an LV ejection fraction of more than 50%, an LV volume index of less than 34 mL/m2, an E/e’ ratio of less than 14, and a measurable functional tricuspid regurgitation jet velocity. PASP and PVR were estimated with the use of 2D-echocardiography. Incident AF through 2018 was ascertained from hospital discharge codes and death certificates.

During a median follow-up of 6.3 years (IQR, 5.5-6.9 years), a total of 215 participants developed AF. The risk for AF was significantly higher in the top tertile vs the lowest tertile of PASP (hazard ratio [HR], 1.65; 95% CI, 1.08-1.54) and PVR (HR, 1.38; 95% CI, 1.00-2.08). When comparing the 2 exposures of interest (PASP and PVR) PASP was the stronger predictor of risk for AF.

These study findings were independent of LA and LV structure and function; heart rate; systemic blood pressure; body mass index; presence of prevalent sleep apnea; use of antihypertensive medications; and kidney, lung, and thyroid function. The associations persisted even after additional exclusion of participants with tricuspid regurgitation jet velocity of greater than 2.8 m/s, as well as lateral and septal mitral annular velocity above age-specific and sex-specific reference limits.

A key limitation of the study was the fact that although the investigators adjusted for measures of LA and LV structure and function at baseline, changes in left heart structure or function during the 6-year follow-up might occur. This creates the possibility of residual confounding because of the inability to adjust for left heart structure and function parameters at the time of AF diagnosis.

“In older adults, higher RV afterload is associated with greater AF risk independent of LA and LV remodeling,” the study author wrote. “Future research should focus on confirming this novel association and elucidate underlying mechanisms.”

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 


Parikh RR, Norby FL, Wang W, et al. Association of right ventricular afterload with atrial fibrillation risk in older adults: the Atherosclerosis Risk in Communities Study. Chest. Published online May 10, 2022. doi:10.1016/j.chest.2022.05.004