Racial and Ethnic Differences in Atrial Fibrillation Diagnosis, Management, and Outcomes

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EP LAB DIGEST. 2025;25(2):1,7-10.

Nishka Dalal¹; Brian C Boursiquot, MD, MS²; Larry R Jackson II, MD, MHSc^3 
1Duke University, Durham, North Carolina; ²Division of Cardiology, Columbia University Irving Medical Center, New York, New York; ³Division of Cardiology, Duke University Medical Center & Duke Clinical Research Institute, Durham, North Carolina

Atrial fibrillation (AF) is the most common arrhythmia, currently affecting greater than 59 million individuals worldwide, with a prevalence that is expected to increase exponentially over the next 2 decades.^1,2 Although AF affects individuals of all racial and ethnic groups, there are notable differences in the diagnosis, treatment, and outcomes of patients with AF as a function of race and ethnicity.^3,4 The risk of AF is lower in individuals from underrepresented racial and ethnic groups (UREG) than in non-Hispanic White individuals, despite having a higher burden of risk factors traditionally associated with AF. Unfortunately, UREG patients with AF are understudied in clinical trials and undertreated compared to their non-Hispanic White counterparts and face a disproportionate burden of adverse outcomes including increased stroke, heart failure, and mortality. This review will focus on the epidemiologic differences in the incidence and prevalence of AF by race and ethnicity, as well as racial and ethnic disparities in the management and outcomes of patients with AF. In addition, we will discuss potential drivers of disparities in management and suggest next steps toward remediating racial and ethnic disparities in AF care.  

Differences in AF Epidemiology

Epidemiologic studies have consistently shown that AF is more common among non-Hispanic White individuals than in those from other racial and ethnic groups.^3,4 In the Multi-Ethnic Study of Atherosclerosis (MESA), for example, the age- and sex-adjusted incidence of AF was 49% lower in non-Hispanic Black participants, 46% lower in Hispanic participants, and 65% lower in Chinese participants, as compared to non-Hispanic White participants.⁵ The observations of increased AF risk among non-Hispanic White individuals are puzzling when considering differences in AF risk profiles across race and ethnicity. It has long been recognized that non-Hispanic Black individuals have a lower incidence and prevalence of AF compared to their non-Hispanic White counterparts, despite having a higher burden of traditional AF risk factors such as obesity, diabetes, and hypertension.^3,4 This phenomenon has been described as the AF racial paradox, and similar paradoxes have been noted in Hispanic and South Asian populations (Figure 1).^6,7  

Several theories have been postulated to explain the racial and ethnic differences in AF epidemiology. One hypothesis is that observed differences in AF risk are due to ascertainment bias, ie, that non-Hispanic White individuals are diagnosed with AF more often because they have greater access to health care and testing in comparison to UREG populations.⁴ While access to care plays a role, it is unlikely to fully explain the differences. In a recent study of the UK Biobank, in which the study population has universal access to health care, White participants still had a higher risk of AF compared to Black, Chinese, or South Asian participants.⁸ Studies involving continuous ambulatory rhythm monitoring have sought to clarify the concerns of ascertainment bias but have shown mixed results. One study from the MESA cohort demonstrated that while clinical AF was diagnosed more often in non-Hispanic White individuals, AF was detected at similar rates with 14-day ambulatory electrocardiographic monitors across the 4 studied racial and ethnic groups.⁹ Other studies of continuous rhythm monitoring, on the other hand, continue to support a higher prevalence of AF in non-Hispanic White individuals.⁴

Genetics appear to play at least a modest role in the variation of AF risk as a function of race and ethnicity. European ancestry itself has been shown to be a risk factor for AF, even in self-identified Black individuals. Among non-Hispanic Black and non-Hispanic White participants of the Cardiovascular Health Study (CHS) and Atherosclerosis Risk in Communities (ARIC) study, every 10% increase in European ancestry was associated with a 13% increased risk of AF.¹⁰ There have also been efforts to identify specific genes that may mediate the difference in AF risk between non-Hispanic White and non-Hispanic Black individuals, including a genetic analysis involving CHS, ARIC, and the Health, Aging, and Body Composition (Health ABC) study.¹¹ Among 9 single nucleotide polymorphisms (SNPs) known to be associated with AF, the minor protective allele of SNP rs10824026 was more common among non-Hispanic Black participants and was estimated to mediate between 11% and 32% of the difference in AF risk as compared to non-Hispanic White participants. Because the association was only modest, and no additional SNPs were identified in the accompanying genome-wide admixture mapping study, genetics alone are likely not sufficient to explain the epidemiologic differences in AF risk. 

Anatomic and physiologic differences may be important mediators of the racial and ethnic differences in AF risk. Larger left atrial (LA) size, which has been associated with higher AF risk, has been observed in White individuals, as compared to Asian and Black individuals.¹² Similarly, serum levels of N-terminal pro–B-type natriuretic peptide (NT-proBNP), which correlate with atrial natriuretic peptide, are higher in White individuals as compared to Black individuals. Higher NT-proBNP levels have been shown to predict incident AF, and appear to mediate some of the racial and ethnic differences in AF risk.¹³ 

It is possible that differences in AF risk across race and ethnicity are influenced by external factors such as stress, environmental exposures, diet, and physical activity. Studies of assimilation to the United States have given us insight on the impact of cultural exposure on cardiovascular disease, including AF. Among Hispanic individuals, English language preference—indicating more assimilation to American culture—has been associated with increased AF prevalence.¹⁴ Although assimilation is not relevant to all UREG individuals, these findings support that there may be cultural factors more common among non-Hispanic White individuals that increase their risk for AF.

Disparities in AF Management and Outcomes

Therapies for stroke risk reduction are underutilized and more likely to be of suboptimal quality in UREG patients with AF. When warfarin was the predominant form of oral anticoagulation, multiple studies demonstrated lower utilization of warfarin in UREG patients with AF as compared to non-Hispanic White patients with AF.^3,4 Furthermore, UREG patients were less likely to have consistent international normalized ratio (INR) monitoring and spent less time in the therapeutic range for INR. In more recent studies, UREG individuals with AF have remained less likely than non-Hispanic White individuals with AF to receive any form of oral anticoagulation, and less likely to receive a direct oral anticoagulant (DOAC).^4,15–17 Percutaneous left atrial appendage occlusion (LAAO) is an increasingly used nonpharmacologic alternative to oral anticoagulation; however, compared to non-Hispanic White patients, the utilization of LAAO is lower and the periprocedural complication rates are higher in UREG patients.⁴

Racial and ethnic disparities exist in the use of rhythm control strategies. After the Atrial Fibrillation Follow-up Investigation of Rhythm Management

(AFFIRM) trial suggested equivalent efficacy and more adverse events with rhythm control as compared to rate control, rhythm control strategies were often reserved for patients with refractory symptoms.¹⁸ In the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF), non-Hispanic Black patients with AF had worse symptoms and poorer quality of life than non-Hispanic White patients.¹⁹ Yet, in the same study, Hispanic and non-Hispanic Black patients with AF were less likely to be on antiarrhythmic medications as well as less likely to undergo electrical cardioversion or catheter ablation. Other studies have redemonstrated racial and ethnic disparities in rhythm control, with similar underutilization also noted in Asian patients, American Indian patients, and Alaska Native patients.⁴ More recently, catheter ablation has gained a more prominent role in clinical practice and guideline recommendations, but in recent studies, racial and ethnic disparities in catheter ablation still exist.^20,21 

Unfortunately, the racial and ethnic disparities in AF outcomes mirror the disparities in management (Figure 2). Stroke rates are higher in UREG patients with AF as compared to non-Hispanic White patients, even among those on oral anticoagulation.^3,4 In addition, rates of major bleeding, including intracranial bleeding, are also higher in UREG patients with AF than in non-Hispanic White patients with AF.^3,4 Notably, this increased bleeding risk has been shown in those not on anticoagulation, in those on warfarin, and in those on DOACs.¹⁷ Underrepresented racial and ethnic groups with AF also have a higher risk of developing heart failure and coronary artery disease as compared to non-Hispanic White patients with AF.⁴ In several studies, UREG patients with AF were shown to have a significantly higher risk of mortality.^3,4 

Drivers of Disparities in AF Management and Outcomes

The drivers of racial and ethnic disparities in the management and outcomes of AF are multifactorial (Figure 2). Several individual-level social determinants of health, such as income, educational level, and insurance status, are associated with race and ethnicity and have been shown to impact AF management and outcomes.²² In a single-center study in the United States of patients who were hospitalized for AF, lower socioeconomic status (SES) was a predictor of AF mortality, and the lower SES quartiles had a disproportionately high number of Hispanic and non-Hispanic Black patients.²³ Geographic factors such as rurality and neighborhood deprivation are also associated with suboptimal AF management, likely reflecting a combination of individual financial resources as well as access to care, among other factors.²² 

Additional social determinants of health have emerged but remain understudied in AF. Low health literacy and limited local language proficiency in patients with AF have been associated with less knowledge of the condition, less understanding of the importance of oral anticoagulation for stroke risk reduction, and inability to describe signs or symptoms of stroke.²² Additionally, limited local language proficiency has been associated with worse maintenance of a therapeutic INR on warfarin.²² Other potential drivers of racial and ethnic disparities in AF management include provider implicit bias, cultural factors, and medical mistrust, which can all affect access and adequacy of care. 

With respect to emerging therapeutics for AF, the lack of diversity in pivotal clinical trials likely exacerbates racial and ethnic gaps in real-world utilization by creating a lag in patient access to treatments, in addition to the impact of other barriers such as cost. Underrepresented racial and ethnic groups with AF have been underrepresented in major AF clinical trials including those for DOACs, catheter ablation, and LAAO.²⁴ Furthermore, inadequate racial and ethnic representation leads to knowledge gaps and poor generalizability due to failure to appreciate differences in response to treatment. As an example, a prespecified subgroup analysis of the Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial showed a benefit from catheter ablation among UREG participants that was not seen in the overall trial population.²⁵ The reason for this is not entirely clear, but the benefit appeared to be driven by higher event rates in the medical therapy arm among UREG participants, creating uncertainty about the optimal rhythm control strategies for UREG patients with AF.

Future Directions and Recommendations

Due to the complexity of the epidemiology of AF and racial and ethnic disparities in AF management, a multifaceted approach is needed in achieving more equitable AF care. Continued efforts are needed to identify potential genetic drivers of the AF paradox using more diverse populations. In addition, further investigation is needed on the role of lifestyle and environmental factors that may mediate racial and ethnic differences in AF risk. Addressing disparities in AF management should begin with ensuring adequate racial and ethnic representation in clinical trials of AF. Efforts to better understand potential drivers of real-world disparities should include qualitative or mixed-methods studies on factors and determinants that are not easily captured in large-scale clinical trials or registries, such as shared decision-making in clinical encounters. Implementation of complementary strategies focused on poorly studied aspects of patient care, such as improving patient education and addressing clinical implicit bias, may assist in remediating disparities in care. Finally, changes in health policy, such as implementing policies that eliminate cost-related barriers to medication access, may have a role in reducing racial and ethnic disparities in AF care. 

In terms of practical recommendations for providers, the clinical encounter presents opportunities to address some of these disparities. First, when caring for patients with AF who have limited English proficiency, using interpreter services may lead to more equitable care. Studies have shown that use of professional interpreters in various settings reduces miscommunication, increases patient comprehension, equalizes health care utilization, and improves clinical outcomes.²⁶ Second, providing educational materials about AF and its associated risks and management may aid with patient understanding of AF and the severity of its downstream consequences. Consideration should be given to providing these materials in various forms, to reach patients with limited literacy more effectively. Collectively, these interventions may improve receptivity to recommended therapies and improve adherence to anticoagulation in UREG patients with AF. To address bias from clinicians, one potential approach is implementing AF-specific prompts in the electronic medical record to lead more clinicians to consider anticoagulation and/or referrals to an electrophysiologist after a diagnosis of AF is made. The latter may especially help equalize access to indicated procedures, such as catheter ablation or LAAO, across various racial and ethnic groups.

Conclusions

Notable racial and ethnic differences exist in the epidemiology, management, and outcomes associated with AF. This is the result of a complex combination of factors that must be addressed from social, structural, environmental, and scientific perspectives. Disparities in the management of AF between different racial and ethnic groups must be given continued attention to ensure improved health outcomes for all individuals with AF. 

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Jackson reports consulting fees from Sanofi and Johnson & Johnson MedTech, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from the Association of Black Cardiologists, PRIME Education, Bristol Myers Squibb, American College of Cardiology, Barclays EP Podcast, and East Carolina University, and support for attending meetings and/or travel from PRIME Education. 
  
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