Predictors of atrial fibrillation in patients with heart failure
Keywords:
atrial fibrillation, heart failure, atrial remodeling, predictors, prognostic potentialAbstract
Abstract. Atrial fibrillation (AF) and heart failure (HF) are closely interconnected clinical conditions associated with high prevalence among the general population, substantial morbidity, and unfavorable long-term prognosis. This literature review aims to summarize current evidence regarding clinical, electrocardiographic, echocardiographic, and laboratory predictors of incident AF across the major HF phenotypes: reduced, mildly reduced, and preserved left ventricular ejection fraction. Advanced age, arterial hypertension, diabetes mellitus, coronary artery disease, and obesity emerge as the most consistently reported clinical risk factors. Markers of atrial structural and electrical remodeling including abnormalities in P-wave indices, left atrial enlargement, and parameters of left ventricular diastolic dysfunction demonstrate significant predictive value. Biomarkers such as natriuretic peptides, galectin-3, CA-125, and inflammatory mediators further refine risk assessment by reflecting myocardial stress, fibrosis, and congestion. Although phenotype-specific determinants exist, the substantial overlap in predictors suggests a shared pathophysiological substrate underlying AF development in HF patients. Early identification of individuals at increased risk may facilitate improved risk stratification, closer surveillance, and the implementation of personalized therapeutic strategies. Future prospective studies are warranted to validate integrated predictive models and optimize clinical management in this high-risk population.
References
Van Gelder IC, Rienstra M, Bunting KV et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal. 2024 Sep 29;45(36):3314–414.
Karatela MF, Calkins H. The Global Impact of Atrial Fibrillation. Arrhythm Electrophysiol Rev. 2025 Nov 8;14:e28.
Joglar JA, Chung MK, Armbruster AL et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation [Internet]. 2024 Jan 2 [cited 2026 Jan 6];149(1). Available from: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001193
Elliott AD, Middeldorp ME, Van Gelder IC et al. Epidemiology and modifiable risk factors for atrial fibrillation. Nat Rev Cardiol. 2023 Jun;20(6):404–17.
Cheng Y, Deng H, Wei H et al. Association Between Age at Diagnosis of Atrial Fibrillation and Subsequent Risk of Ischemic Stroke. JAHA. 2025 Feb 18;14(4):e038367.
Al-Shoaibi NA, Ashram WY, Mokhtar AT et al. Non-genetic Risk Factors for Atrial Fibrillation in Individuals Aged 60 and Above. J Pioneering Med Sci. 2025 Oct 5;14(09):1–5.
Aune D, Mahamat-Saleh Y, Kobeissi E et al. Blood pressure, hypertension and the risk of atrial fibrillation: a systematic review and meta-analysis of cohort studies. Eur J Epidemiol. 2023 Feb;38(2):145–78.
Bidaoui G, Assaf A, Marrouche N. Atrial Fibrillation in Heart Failure: Novel Insights, Challenges, and Treatment Opportunities. Curr Heart Fail Rep. 2025 Dec;22(1):3.
Frederiksen TC, Dahm CC, Preis SR et al. The bidirectional association between atrial fibrillation and myocardial infarction. Nat Rev Cardiol. 2023 Sep;20(9):631–44.
Frost L, Joensen A, Dam-Schmidt U et al. The Danish Atrial Fibrillation Registry: A Multidisciplinary National Pragmatic Initiative for Monitoring and Supporting Quality of Care Based on Data Retrieved from Administrative Registries. CLEP. 2023 Dec; 15:1259–72.
McDonagh TA, Metra M, Adamo M et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. 2021 Sep 21;42(36):3599–726.
McDonagh TA, Metra M, Adamo M et al. 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. 2023 Oct 1;44(37):3627–39.
Heidenreich PA, Bozkurt B, Aguilar D et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation [Internet]. 2022 May 3 [cited 2026 Jan 5];145(18). Available from: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063
Khan MS, Shahid I, Bennis A et al. Global epidemiology of heart failure. Nat Rev Cardiol. 2024 Oct;21(10):717–34.
Atabekov T, Batalov R, Archakov E et al. Predictors of Atrial Fibrillation in Heart Failure Patients with Indications for ICD Implantation. JCM. 2025 Jun 18;14(12):4358.
Corica B, Romiti GF, Proietti M et al. Heart failure in patients with recently diagnosed atrial fibrillation: findings from the GLORIA-AF Registry Phase III. European Journal of Preventive Cardiology. 2025 Sep 1;zwaf485.
Ariyaratnam JP, Elliott AD, Mishima RS et al. Heart failure with preserved ejection fraction: An alternative paradigm to explain the clinical implications of atrial fibrillation. Heart Rhythm O2. 2021 Dec;2(6):771–83.
Chen P, Yin X, Ren L. Construction and validation of a predictive model for the risk of atrial fibrillation in patients with heart failure with preserved ejection fraction: a single-center retrospective analysis. BMC Cardiovasc Disord. 2025 Dec 23;25(1):873.
Gorter TM, Van Veldhuisen DJ, Mulder BA et al. Prevalence and Incidence of Atrial Fibrillation in Heart Failure with Mildly Reduced or Preserved Ejection Fraction: (Additive) Value of Implantable Loop Recorders. JCM. 2023 May 26;12(11):3682.
Mamas MA, Caldwell JC, Chacko S et al. A meta-analysis of the prognostic significance of atrial fibrillation in chronic heart failure. Eur J Heart Fail. 2009 Jul;11(7):676–83.
Kim YG. Interaction Between Heart Failure and Atrial Fibrillation. Int J Heart Fail. 2022;4(3):139.
Peigh G, Shah SJ, Patel RB. Left Atrial Myopathy in Atrial Fibrillation and Heart Failure: Clinical Implications, Mechanisms, and Therapeutic Targets. Curr Heart Fail Rep. 2021 Jun;18(3):85–98.
Bozkurt B, Ahmad T, Alexander K et al. HF STATS 2024: Heart Failure Epidemiology and Outcomes Statistics An Updated 2024 Report from the Heart Failure Society of America. Journal of Cardiac Failure. 2025 Jan;31(1):66–116.
Jia Z, Du X. Epidemiology and Burden of Heart Failure. Cardiology Discovery. 2025 Dec;5(4):281–4.
Shahim B, Kapelios CJ, Savarese G, Lund LH. Global Public Health Burden of Heart Failure: An Updated Review. Card Fail Rev. 2023 Jul 27;9:e11.
Shams P, Malik A, Chhabra L. Heart Failure (Congestive Heart Failure). In: StatPearls [Internet]. Treasure Island (FL): Stat-Pearls Publishing; 2025 [cited 2026 Jan 5]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK430873/
Khurshid S, Ashburner JM, Ellinor PT et al. Prevalence and Incidence of Atrial Fibrillation Among Older Primary Care Patients. JAMA Netw Open. 2023 Feb 13;6(2):e2255838.
Schramm S, Schlechter P, Reiberg A et al. Prevalence and incidence of atrial fibrillation and atrial flutter: results of the population-based Heinz Nixdorf Recall study. Open Heart. 2025 Jul;12(2):e003543.
Gomez SE, Fazal M, Nunes JC et al. Racial, ethnic, and sex disparities in atrial fibrillation management: rate and rhythm control. J Interv Card Electrophysiol. 2022 Oct 13;66(5):1279–90.
Gopinathannair R, Chen LY, Chung MK et al. Managing Atrial Fibrillation in Patients With Heart Failure and Reduced Ejection Fraction: A Scientific Statement From the American Heart Association. Circ: Arrhythmia and Electrophysiology [Internet]. 2021 Jul [cited 2026 Feb 3];14(7). Available from: https://www.ahajournals.org/doi/10.1161/HAE.0000000000000078
Boehmer AA, Ehrlich JR, Nattel S. Atrial Fibrillation and Heart Failure With Reduced Ejection Fraction. JACC: Clinical Electrophysiology. 2025 Dec;11(12):2774–90.
Pimentel M, Simonetto Faganello L, Magalhães APA et al. Treating Patients with Heart Failure with Reduced Ejection Fraction (HFrEF) and Atrial Fibrillation: We Need to Talk About the Fifth Pillar. Arq Bras Cardiol. 2025;122(4):e20240585.
Mboweni N, Maseko M, Tsabedze N. Heart Failure with Reduced Ejection Fraction and Atrial Fibrillation: A Sub-Saharan African Perspective. ESC Heart Failure. 2023 Jun 1;10(3):1580–96.
Grigoriou K, Karakasis P, Pamporis K et al. Atrial Fibrillation in Diabetes: Pathogenesis and Targeted Rhythm Control Strategies. CIMB. 2025 Jul 17;47(7):559.
Leopoulou M, Theofilis P, Kordalis A et al. Diabetes mellitus and atrial fibrillation-from pathophysiology to treatment. World J Diabetes. 2023 May 15;14(5):512–27.
Kim EJ, Yin X, Fontes JD et al. Atrial fibrillation without comorbidities: Prevalence, incidence and prognosis (from the Framingham Heart Study). American Heart Journal. 2016 Jul;177:138–44.
Middlekauff HR, Stevenson WG, Stevenson LW. Prognostic significance of atrial fibrillation in advanced heart failure. A study of 390 patients. Circulation. 1991 Jul;84(1):40–8.
Park JJ, Park JH, Hwang IC et al. Left Atrial Strain as a Predictor of New-Onset Atrial Fibrillation in Patients With Heart Failure. JACC: Cardiovascular Imaging. 2020 Oct;13(10):2071–81.
Ghelani KP, Chen LY, Norby FL et al. Thirty-Year Trends in the Incidence of Atrial Fibrillation: The ARIC Study. JAHA. 2022 Apr 19;11(8):e023583.
Groenewegen A, Zwartkruis VW, Cekic B et al. Incidence of atrial fibrillation, ischaemic heart disease and heart failure in patients with diabetes. Cardiovasc Diabetol. 2021 Dec;20(1):123.
Nguyen KT, Vittinghoff E, Dewland TA et al. Electrocardiographic Predictors of Incident Atrial Fibrillation. The American Journal of Cardiology. 2016 Sep;118(5):714–9.
Gorczyca-Głowacka I, Galas A, Tymińska A et al. Atrial fibrillation in patients with heart failure with reduced, mildly reduced, and preserved ejection fraction: A report from the HEart failuRe ObsErvational Study (HEROES). Pol Heart J. 2025 Jun 30;83(6):701–8.
Ammar LA, Massoud GP, Chidiac C et al. BNP and NT-proBNP as prognostic biomarkers for the prediction of adverse outcomes in HFpEF patients: A systematic review and meta-analysis. Heart Fail Rev. 2024 Oct 7;30(1):45–54.
Kaya H, Zorlu A, Yucel H et al. Higher cancer antigen 125 level is associated with the presence of permanent atrial fibrillation in systolic heart failure patients. Acta Cardiologica. 2016 Feb;71(1):61–6.
Ianos RD, Iancu M, Pop C et al. Predictive Value of NT-proBNP, FGF21, Galectin-3 and Copeptin in Advanced Heart Failure in Patients with Preserved and Mildly Reduced Ejection Fraction and Type 2 Diabetes Mellitus. Medicina. 2024 Nov 8;60(11):1841.
Hazarapetyan L, Zelveian P, Hayrapetyan H, Grigoryan S. Possible Risk Factors Contributing to Atrial Fibrillation Occurrence in Heart Failure With Mildly Reduced Ejection Fraction. J Clin Med Res. 2024 Nov;16(11):547–53.
Zhu K, Ma T, Su Y et al. Heart Failure With Mid-range Ejection Fraction: Every Coin Has Two Sides. Front Cardiovasc Med. 2021 Jul 21;8:683418.
O’Neal WT, Sandesara P, Patel N et al. Echocardiographic predictors of atrial fibrillation in patients with heart failure with preserved ejection fraction. European Heart Journal – Cardiovascular Imaging. 2017 Jul 1;18(7):725–9.
Gori M, Iacovoni A, Senni M. Haemodynamics of Heart Failure With Preserved Ejection Fraction: A Clinical Perspective. Cardiac Failure Review [Internet]. 2016 [cited 2026 Jan 26]; Available from: https://www.cfrjournal.com/articles/haemodynamics-heart-failure-preserved-ejection-fraction-clinical-perspective
Bertoni M, Traini AM, Celli A et al. Galectin-3 in Heart Failure with Preserved Ejection Fraction and Persistent Atrial Fibrillation Versus Sinus Rhythm. Correlation with Left Atrial Volume and N-Terminal Pro B-Type Natriuretic Peptide [Internet]. Available from: https://austinpublishinggroup.com/cardiovascular-disorders/fulltext/jcd-v7-id1043.php
Downloads
Published
Issue
Section
License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
You are free to share, copy and redistribute the material in any medium or format under these terms.
