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Thomas J. Wang, MD; Helen Parise, ScD; Daniel Levy, MD; Ralph B. D’Agostino Sr, PhD; Philip A. Wolf, MD; Ramachandran S. Vasan, MD; Emelia J. Benjamin, MD, ScM

JAMA. 2004;292:2471-2477.

Context  Obesity is associated with atrial enlargement and ventricular diastolic dysfunction, both known predictors of atrial fibrillation (AF). However, it is unclear whether obesity is a risk factor for AF.

Objective  To examine the association between body mass index (BMI) and the risk of developing AF.

Design, Setting, and Participants  Prospective, community-based observational cohort in Framingham, Mass. We studied 5282 participants (mean age, 57 [SD, 13] years; 2898 women [55%]) without baseline AF (electrocardiographic AF or arterial flutter). Body mass index (calculated as weight in kilograms divided by square of height in meters) was evaluated as both a continuous and a categorical variable (normal defined as <25.0; overweight, 25.0 to <30.0; and obese, 30.0). In addition to adjusting for clinical confounders by multivariable techniques, we also examined models including echocardiographic left atrial diameter to examine whether the influence of obesity was mediated by changes in left atrial dimensions.

Main Outcome Measure  Association between BMI or BMI category and risk of developing new-onset AF.

Results  During a mean follow-up of 13.7 years, 526 participants (234 women) developed AF. Age-adjusted incidence rates for AF increased across the 3 BMI categories in men (9.7, 10.7, and 14.3 per 1000 person-years) and women (5.1, 8.6, and 9.9 per 1000 person-years). In multivariable models adjusted for cardiovascular risk factors and interim myocardial infarction or heart failure, a 4% increase in AF risk per 1-unit increase in BMI was observed in men (95% confidence interval [CI], 1%-7%; P = .02) and in women (95% CI, 1%-7%; P = .009). Adjusted hazard ratios for AF associated with obesity were 1.52 (95% CI, 1.09-2.13; P = .02) and 1.46 (95% CI, 1.03-2.07; P = .03) for men and women, respectively, compared with individuals with normal BMI. After adjustment for echocardiographic left atrial diameter in addition to clinical risk factors, BMI was no longer associated with AF risk (adjusted hazard ratios per 1-unit increase in BMI, 1.00 [95% CI, 0.97-1.04], P = .84 in men; 0.99 [95% CI, 0.96-1.02], P = .56 in women).

Conclusions  Obesity is an important, potentially modifiable risk factor for AF. The excess risk of AF associated with obesity appears to be mediated by left atrial dilatation. These prospective data raise the possibility that interventions to promote normal weight may reduce the population burden of AF.

Author Affiliations: Framingham Heart Study, Framingham, Mass (Drs Wang, Parise, Levy, D’Agostino, Wolf, Vasan, and Benjamin); Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston (Dr Wang); Department of Mathematics, Boston University, Boston (Drs Parise and D’Agostino); National Heart, Lung, and Blood Institute, Bethesda, Md (Dr Levy); and Department of Neurology (Dr Wolf), Cardiology Section (Drs Levy, Vasan, and Benjamin), and Preventive Medicine Section (Drs Levy, Wolf, Vasan, and Benjamin), Boston Medical Center, Boston University School of Medicine, Boston.

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