Archives of Cardiovascular Disease (2011) 104, 115124

REVIEW

Epidemiology of atrial brillation in France:

Extrapolation of international epidemiological data
to France and analysis of French hospitalization data
pidmiologie de la brillation atriale en France : extrapolation partir des
donnes internationales et point sur les hospitalisations
Agns Charlemagne a,, Jacques Blacher b,
Ariel Cohen c, Jean-Philippe Collet d,
Franc
ois Divart e, Pascal de Groote f, Olivier Hanon g,
ois Pinel i,
Antoine Leenhardt h, Jean-Franc
George Pisica-Donose j, Jean-Yves Le Heuzey k
a

Cemka-Eval, 43, boulevard du Marchal-Joffre, 92340 Bourg-la-Reine, France

Diagnosis and Therapeutic Center, Htel-Dieu, APHP, universit Paris Descartes, 75004
Paris, France
c
Department of Cardiology, hpital Saint-Antoine, 75012 Paris, France
d
Institute of Cardiology, hpital de la Salptrire, 75013 Paris, France
e
Department of Cardiology, clinique Villette, 59240 Dunkerque, France
f
Department of Cardiology C and prevention of cardiovascular diseases, hpital
cardiologique, 59000 Lille, France
g
Department of Geriatrics, universit Paris Descartes, hpital Broca, 75013 Paris, France
h
Department of Cardiology, hpital Lariboisire, 75010 Paris, France
i
Department of Neurology, hpital Pontchaillou, 35000 Rennes, France
j
Bristol-Myers-Squibb France, Medical Department, 92500 Rueil-Malmaison, France
k
Department of Cardiology, hpital europen Georges-Pompidou, APHP, Paris V University,
75015 Paris, France
b

Received 29 June 2010; received in revised form 15 November 2010; accepted 16 November
2010

KEYWORDS
Atrial brillation;

Summary The prevalence of atrial brillation is steadily increasing throughout the world
because of ageing populations and better management of coronary heart disease. An international literature review was conducted to estimate the prevalence and incidence of atrial

Corresponding author. Fax: +33 1 40 91 30 21.

E-mail address: agnes.charlemagne@cemka.fr (A. Charlemagne).

1875-2136/$ see front matter 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.acvd.2010.11.012

116

A. Charlemagne et al.

Epidemiology;
Prevalence;
Incidence;
Comorbidity;
Hospitalization

MOTS CLS
Fibrillation atriale ;
pidmiologie ;
Prvalence ;
Incidence ;
Comorbidits ;
Hospitalisation

brillation in France. A review of the literature on comorbidities was also performed. Finally,
French mortality and hospitalization data were analysed using the PMSI database. The prevalence of atrial brillation is estimated to be between 600,000 and 1 million people; of these,
two-thirds are aged > 75 years. The incidence is estimated at between 110,000 and 230,000
new cases per year. In 2008, 412,000 hospitalized patients had a diagnosis of atrial brillation;
this gure increased by 26% in the 3-year period between 2005 and 2008. These ndings highlight the importance of targeting therapy, of upstream therapy, and of therapy that provides
clear clinical and economic advantages over the well-established reductions already achieved
in atrial brillation morbidity, mortality and cost. In addition, new prevention strategies should
be developed, particularly secondary prevention strategies in patients with cardiovascular
diseases.
2011 Elsevier Masson SAS. All rights reserved.

Rsum La brillation atriale (FA) est en augmentation constante dans le monde, du fait du
vieillissement des populations et de la meilleure prise en charge de la pathologie coronaire.
Une revue de littrature internationale a t ralise pour estimer la prvalence et lincidence
de la FA en France. Une analyse des publications sur les comorbidits a galement t ralise, ainsi quune analyse des donnes franc
aises de mortalit et dhospitalisations (PMSI). La
prvalence de la FA est estime entre 600 000 et un million de personnes, dont deux tiers de
plus de 75 ans et lincidence est estime entre 110 000 et 230 000 nouveaux cas par an. En 2008,
412 000 patients hospitaliss ont eu un diagnostic de FA. Ce chiffre a augment de 26 % sur
les trois annes 20052008. Ces donnes soulignent limportance de la prvention des maladies cardiovasculaires et du dveloppement de thrapies ciblant la FA, avec des avantages
clairement tablis en termes defcacit clinique et de rapport bnce/risque, ainsi que le
dveloppement de stratgies de prvention secondaire chez les patients porteurs de maladie
cardiovasculaire.
2011 Elsevier Masson SAS. Tous droits rservs.

Abbreviations
AF
CHF
CI
NYHA
PMSI

atrial brillation
congestive heart failure
condence interval
New York Heart Association
Programme for the Medicalization of Information
Systems

In this report, we carried out a systematic review of

the literature to gather data on the prevalence and consequences of AF. Extrapolation of these data to French
population statistics should enable us to better dene the
public health repercussions of AF in France and to identify
specic target populations for monitoring and treatment.
The incidence and prevalence of AF are not well known in
France. A study by Guize et al. was published in 2007, but
the study population was not representative of the general
population [12].

Background
AF is the most common arrhythmia and is characterized by
uncontrolled atrial activation and a subsequent deterioration of atrial mechanical function. Stroke and CHF are the
most common complications in subjects with AF [1], and
associated mortality rates are higher than in patients without AF [13].
Epidemiological surveys show that the risk of AF increases
with age, particularly during the sixth and seventh decades
of life [1,46]. The increase in prevalence of AF over the
past 50 years, due to the growing elderly population in industrialized countries, reects this trend [68]. The projected
continued increase in the prevalence of AF is a cause of great
concern, as this disease presents a major public health and
socioeconomic burden [911]. Targeting preventive healthcare and treatment for patients who are at risk is becoming
an increasingly attractive option in order to reduce morbidity and control medical costs.

Methods
Literature review
A literature review of published epidemiological studies
in the eld of AF was conducted using PubMed, with the
following terms: atrial brillation and epidemiology or
prevalence or incidence or mortality or comorbidity.
This literature review took into account only general population or community-based studies, which relate to the
sampling of a geographical territory or of an administrative
database, such as the Health Maintenance Organization in
the USA or the General Practitioner database in the UK or
other European countries. These studies cover all types of
AF and the distinction between different types of AF is generally not detailed in the published articles or in the data
sources.

Epidemiology of atrial brillation in France

Statistics
Data from international studies were used to extrapolate
incidence and prevalence rates in the French population:
the prevalence or incidence rates by age observed in the
different studies were applied to the French population
structure.

Analysis of French hospitalization data

Since 1991, public and private hospitals have been required
to evaluate and analyse their activities. This analysis
is based on the systematic collecting and computerized
processing of minimal standardized medicoadministrative
information contained in the standardized discharge case
records, in a medicoeconomic database called PMSI.
The standardized discharge case record contains a limited amount of mandatory information: diagnoses (principal
diagnosis and associated diagnosis) according to the International Classication of Diseases (ICD-10), procedures,
related complications and/or morbidities and other information such as length of stay, patients age, etc.
An analysis of the PMSI database records for 20052008
was conducted for patients hospitalized for AF (as the principal or associated diagnosis).

Classication of atrial brillation

Several different classications of AF can be found in the literature, complicating interstudy group comparisons [10,13].
The following classication, dividing AF into one of four
types based on the number and duration of episodes, is
recommended by the current guidelines of the American
College of Cardiology, the American Heart Association and
the European Society of Cardiology [10]: rst detected
episode of AF (symptomatic or asymptomatic); paroxysmal
(self-terminating) AF, when an episode lasts 7 days and
usually < 24 hours; persistent AF, when an episode lasts > 7
days, usually requiring termination by electrical or pharmacological cardioversion; permanent AF (previously referred
to as chronic AF [13]), when AF fails to stop after cardioversion, or cardioversion is not attempted [10]. Paroxysmal and
persistent AF may both be recurrent (two or more episodes)
and are often progressive. Approximately 89% of patients
with paroxysmal AF progress to permanent AF within 1 year
and 25% within 5 years [14]. Higher rates of progression
are observed in patients with persistent AF, with approximately 40% developing permanent AF by the end of the
1-year period [15].
The classications have been dened for clinical
research; they are very detailed and based on clinical features, so they are difcult to use in epidemiological studies.

Results
Prevalence of atrial brillation: international
data
The prevalence of AF increases with age in both men and
women (Table 1) and approximately 70% of patients with
AF are aged 6585 years [4]. In the general population

117
Table 1 Prevalence of atrial brillation in large,
population-based surveys.
Study
Meta-analysis of four USA studies [4]
Number of persons
Prevalence of atrial brillation (%)
Overall
40 years
65 years
Median age (years)
Atrial brillation in California 19961997
(ATRIA study) [5]
Number of persons
Prevalence of atrial brillation (%)
Overall ( 20 years)
2055 years
60 years
80 years
Median age (years)
ECG baseline study (Rotterdam study)
[25]
Number of persons
Prevalence of atrial brillation (%)
Overall ( 55 years)
5559 years
85 years

14,000
0.89
2.3
5.9
75

17,974
0.95
0.1
3.8
9.0
71.2

6808
5.5
0.7
17.8

ECG: electrocardiogram.

aged > 60 years, the prevalence of AF is estimated to be

below 1% [4,5,16]. However, a meta-analysis of four large
population-based surveys [1720] carried out in the USA,
western Australia and Europe revealed that the prevalence
of AF doubles with each decade of life after the age of
50 years, increasing to around 10% in individuals aged > 80
years [4]. In another long-term, follow-up study of 3983
male aircrew recruits, the probability of developing AF over
a 44-year follow-up period was 7.5% [3]. These observations are supported by surveys conducted in the UK [21] and
Scotland [22,23]. Murphy et al. recorded a prevalence of
9.4/1000 persons in men and 7.9/1000 in women, increasing
to 71/1000 in subjects aged > 85 years [22] (Fig. 1).
A higher age-adjusted prevalence of AF has been documented consistently in men compared with in women
[4,5,1719,24,25]. The age-adjusted risk of developing AF
is also signicantly higher in Caucasians than in Africans
[5,21,26].
Asymptomatic AF has been reported in 1132% of
patients in different studies [12,27,28] and seems to be more
common in white (92% vs 88%, P = 0.01), male (77% vs 59%,
P < 0.0001) patients.
The prevalence of AF has increased signicantly over the
past 50 years. Between 1968 and 1970, the prevalence of AF
in US men aged 6584 years was reported to be 3.2%, but
this increased to 9.1% in the same age group between 1987
and 1989 [1]. A similar increase in the prevalence of AF, from
0.84 to 1.49% in men, and from 0.83 to 1.29% in women, was
also observed in the UK between 1994 and 2003 [7].

118

A. Charlemagne et al.
98,961 men and 55,109 women, who had a free check-up in
the Centre dInvestigations Prventives et Cliniques, Paris
[12]. AF was identied in 0.05% of men and 0.01% of women
aged < 50 years, compared with in 6.5% of men and 5.2% of
women aged > 80 years.
By applying the prevalence gures calculated for the
different age groups and sexes in the USA, Australia and
Europe [4,5,25] to the French population, we estimated that
there are currently between 600,000 and 1 million people in France with AF, that two-thirds of these subjects
are likely to be aged > 75 years and that most of them will
be women.

Incidence of atrial brillation: international

data

Figure 1. Prevalence of atrial brillation according to age in different studies. M: men; W: women.

Prevalence of atrial brillation in France

A study carried out in the 1990s (ALFA) attempted to
characterize the different subsets of AF observed by general cardiologists in ofce practice in France. The relative
prevalences of paroxysmal, chronic and recent onset AF
among 756 patients with electrocardiogram-conrmed AF
were 22.1, 51.4 and 26.4%, respectively [13]. Patients with
chronic AF were signicantly older (P < 0.0002) than those
with paroxysmal AF but there was no association between
sex and type of AF [13]. Asymptomatic AF was present in
11.4% of patients.
The current prevalence of AF in France was recently
estimated by Guize et al. in a study population comprising

Table 2
years).

The incidence of AF is also higher in older subjects

(Table 2) [3,2426]. The incidence of AF has been reported
to double for every 10-year increment in age, with an
annual incidence of 3.1 cases per 1000 patient-examinations
in men and 1.9 cases in women aged 5564 years,
increasing to 38.0 and 31.4 cases, respectively, in elderly
patients aged 8594 years [24]. Mabo et al. also reported
a higher annual incidence in older subjects, increasing
from 0.1% in those aged < 40 years to more than 1.5%
in women and more than 2% in men aged > 80 years
[16].
The incidence of AF has also increased over the past 30
years [16]. Miyasaka et al., in the Minnesota study, showed
an age- and sex-adjusted incidence of AF per 1000 personyears of 3.04 (95% CI 2.783.31) in 1980, which increased
to 3.68 (95% CI 3.423.95) in 2000 [29]. Poisson regression
with adjustment for age and sex conrmed an increase in the
incidence over the 21-year period of 12.6% (95%CI 2.123.1)
(P = 0.014). The incidence ratio for men/women was 1.86
(P < 0.01) [29].

Age-related incidence of atrial brillation in different studies (calculated as number of cases per 1000 patient-

Framingham study [24]

Cardiovascular Health
study [26]

Manitoba follow-up study

[3]

Rotterdam study [25]

Age
(years)

Age
(years)

Age
(years)

Age
(years)

Incidence of
AF
Men

Women

5564

3.1

1.9

6575

9.0

5.5

7584

17.5

15.0

8594
Total

38.0

31.4

AF: atrial brillation.

Incidence of
AF
Men

6569
7074
7579
80

Women

12.3
22.8
34.8
58.7

10.9
9.1
23.1
25.1

Total
26.4
Combined 19.2
total

14.1

Incidence of
AF
Men & women

< 50
5054
5559
6064
6569
70
85
Total

0.5
0.8
2.2
3.6
5.0
9.7

16.9
2.0

5559
6064
6569
7074
7579
8084
85
Total

Incidence of
AF
Men

Women

2.6
4.9
6.6
12.4
19.9
25.5
25.4
11.5

2.1
4.7
10.1
11.5
18.2
15.2
8.9

Epidemiology of atrial brillation in France

Estimated incidence of atrial brillation in

France
The current incidence of AF in France is unknown, but by
applying the above incidence rates to French population gures, it is estimated that there are between 110,000 and
230,000 new cases of AF per year in France. This represents
a signicant burden for the healthcare service.

Comorbidities and risk factors for atrial

brillation
Underlying heart disease is present in 70% of patients with
AF, and a number of specic predictors have been identied,
including ischaemic heart disease, valvular (mitral) disease,
CHF, hypertension, cardiomyopathy, supraventricular and
ventricular rhythm disturbances [1,3,10]. The prevalence of
AF increases in line with the severity of heart disease (NYHA
I prevalence 4% vs NYHA IV prevalence 50%) [10].
In the Framingham 38-year study, 20.6% of men who
developed AF had CHF at inclusion, compared with only
3.2% without AF (26% vs 2.9% of women) [24]. In this study,
patients with CHF (odds ratio 4.5 [95% CI 3.16.6] in men
and 5.9 [4.28.4] in women) and valvular heart disease
(odds ratio 1.8 [95% CI 1.22.5] in men and 3.4 [2.54.5]
in women) had a particularly high risk of developing AF. The
23 year incidence of AF in heart failure patients has been
reported to be 510% [30].
Patients with asymptomatic AF are more likely to have
less severe heart disease and a lower incidence of coronary artery disease (28% vs 40%, P < 0.0001), CHF (13% vs
24%, P < 0.0001) and peripheral vascular disease (4% vs 7%,
p = 0.018) [27]. Conversely, the prevalence of symptomatic
AF increases with the severity of these conditions.
Hypertension (odds ratio 1.5 [95% CI 1.22.0] in men
and 1.4 [1.11.8] in women) and myocardial infarction in
men (odds ratio 1.4 [95% CI 1.02.0]) also increase the
risk of AF (Table 3) [24]. According to the different studies related to AF comorbidities, 921% of AF patients also
present diabetes mellitus [5,11,13,21,27,31,32]. Diabetes
mellitus was an independent risk factor for AF (odds ratio
1.4 [95% CI 1.02.0] in men and 1.6 [1.12.2] in women)
[1,2]. Obesity is also reported to carry a 50% higher risk
of AF in both men and women, mediated by left atrial
dilation [33].
Cigarette smoking has been identied as a signicant
age-adjusted risk factor in women [1,2]. A number of
non-cardiovascular factors have also been reported to trigger acute, temporary AF, including alcohol intoxication
(so-called holiday heart syndrome), cardiac or thoracic
surgery, electrocution, myocardial infarction, pericarditis,
myocarditis, pulmonary embolism and other pulmonary disorders, hyperthyroidism or other metabolic disorders and
severe infections [10].

Complications and prognosis of atrial

brillation
Morbidity and atrial brillation
The major complication associated with AF is stroke. It is
estimated that one of every six strokes occurs in AF patients

119
[3] and that approximately 5% of patients with persistent or
permanent AF each year will have a stroke [10].
The CHADS2 index is now used to determine the yearly
thromboembolic risk of AF patients, according to presence
or absence of the following risk factors: CHF (1 point),
hypertension (1 point), age > 75 years (1 point), diabetes (1
point), history of stroke or transitory ischaemic attack (2
points) [34]. The predictive value of this scoring system was
evaluated in 1733 elderly patients with nonvalvular atrial
brillation, aged 6595 years, who were not given warfarin
at hospital discharge. The risk of stroke increased from 1.9
in AF patient with a CHADS2 score of 0 to 18.2 in AF patients
with CHADS2 score of 6 [35]. These gures have been validated by Rietbrock et al. in more than 50,000 AF patients
from the General Practice Research Database in the UK [36].
The risk of ischaemic stroke has been reported to be
27-fold higher in patients with non-rheumatic AF than in
patients without AF after adjustment for other factors and in
the absence of anticoagulant treatment [3,10]. Patients with
asymptomatic AF have less severe heart disease, but seem
to have more frequent strokes or transient ischaemic attacks
than symptomatic patients (17% vs 13%, P = 0.005) [27].
The proportion of strokes attributable to AF increases
with age [20]. In the Framingham Heart study, the annual
incidence of stroke due to AF was 23.5% in patients aged
8089 years, compared with only 1.5% in patients aged < 59
years [20]. In patients with rheumatic heart disease and
AF, the stroke risk increased 17-fold compared with agematched controls. The attributable risk was ve-fold greater
than in those with non-rheumatic AF [37]. The risk of stroke
is higher in AF patients with predisposing factors such as a
previous history of stroke, arterial hypertension, coronary
artery disease, myocardial infarction, diabetes and recent
heart failure. Combining the results of several studies, Hart
et al. highlighted four consistent risk factors for stroke in
patients with nonvalvular AF: increasing age, hypertension,
diabetes, and previous stroke or transient ischaemic accident, which is the most powerful risk factor, associated with
high rates of stroke (10% per year on average) [38].
The risk of distal embolic events is also higher in patients
with AF [39]. Authors of the ALFA study reported a 2.4%
increase in the incidence of emboli in subjects with AF, over
a mean follow-up period of 8.6 months [13]. AF has also
been reported to increase the risk of evolution towards CHF
(relative risk 2.98) [3].

Heart failure
A study in a community-based cohort in Minnesota showed an
incidence of CHF of 7.8% within the rst 12 months after AF
diagnosis and of around 3% per year in the following years,
with a cumulative CHF rate of 20% at 5 years [40]. In this
study, CHF in AF patients was associated with an increased
mortality risk of 3.4 [95% CI 3.13.8]. A higher risk of mortality has also been observed by Nieuwlaat et al. in AF patients
with heart failure: 9.5% vs 3.3% after a 1-year follow-up
period [41]. Wang et al. studied the relationship between
AF and heart failure, particularly the temporal relationship
between the two conditions, in the Framingham cohort [42].
During the study period, 1470 participants developed AF,
CHF or both. Among patients with both conditions, 38% had
AF rst, 41% had CHF rst and 21% had both diagnosed on
the same day. The incidence of CHF among AF subjects was

120

Table 3

Common comorbidities in patients with atrial brillation.

Study [reference]
ATRIA [5]
AFFIRM [27]
USA
Asympt.

AFFIRM [31]

WBAFP [21]

Sudlow [32]

ALFA [13]

COCAF [11]

USA

UK

UK

France

France

75
ECG AF in
patients
aged > 65
years

6574

68.6
AF patients
of 206
cardiologists

69.0
AF patients
of 82
cardiologists

160
55.6

47
57.4

756
39.4
16.6
15.3

671
43
13

Country
Category

USA

Canada

Mean age (years)

Eligibility

71.2

70
69.7
69.7
70
> 65 years of age or at least one
risk factor

Sample size
Hypertension (%)
CAD (%)
Cardiomyopathy
(%)
Heart failure (%)
Valvular disease
(%)
Diabetes mellitus
(%)
Ischaemic
stroke/TIA (%)

17,974
49.3
34.6

481
68
28
6.0

3576
71
40
9.0

3400
51
26
5

660
48
25
3

76.6
Paroxystic
or
persistent
AF, > 50
years
111
36.9
28.8
5.4

29.2
4.9

13
12

24
12

24
5

18
6

26.1

8.8
22.5

6.4
10.6

14.3
18.5

16
13

17.1

21

20

20

18

9.4

12.8

10.7

8.9

17

13

8.4

Sympt.

Asympt: asymptomatic; CAD: coronary artery disease; ECG: electrocardiogram; Sympt.: symptomatic; TIA: transient ischaemic attack; WBAFP: West Birmingham Atrial Fibrillation Project.

A. Charlemagne et al.

Epidemiology of atrial brillation in France

121

33 per 1000 person-years, and the incidence of AF among

CHF subjects was 54 per 1000 person-years. Development of
the other condition in patients with AF or CHF is associated
with a poor prognosis.

Atrial brillation and quality of life

AF leading to reduced functional capacity, dyspnoea, palpitations, fatigue, tachycardia-induced cardiomyopathy,
heart failure or angina signicantly affects quality of life
[43]. Even subjects with paroxysmal AF reported a substantially worse quality of life than healthy control subjects,
using validated quality of life questionnaires [44].

Mortality and atrial brillation: international data

Data on the contribution of AF to mortality are conicting,
particularly in patients with mild-to-moderate heart failure. One study showed no increase in mortality in patients
with concomitant AF [45], whereas in another study, mortality was signicantly higher in patients with AF than in
those with normal sinus rhythm (34% vs 23% respectively,
P < 0.001) [46]. In most studies, the increased mortality seen
in patients with AF has been linked to the severity of the
underlying heart disease rather than to the presence of AF
itself [1,3,27,45,46]. In some studies, AF does nevertheless
appear to contribute directly to increased mortality. In the
Manitoba follow-up study, AF increased the total mortality
risk 1.31-fold (P < 0.05) and increased the risk of cardiovascular mortality 1.41-fold. AF also increased the risk of
fatal stroke 2.48-fold [95% CI 1.354.57] [3]. After adjustment for age, AF was associated with an overmortality of
2.4 in men and 3.5 in women. After adjustment for other
coexisting cardiovascular conditions and risk factors, AF was
associated with a 1.5-fold [1.21.8] higher risk of death in
men and 1.9-fold [1.52.2] increased risk in women, over all
age ranges [2].
In Sweden, a recent study of 888 patients treated for
paroxysmal AF at the hospital in Stockholm showed a mean
annual mortality rate of 7%, which corresponds to a standardized mortality ratio of 1.6 for all-cause mortality,
compared with the general population [47].
No association has been found between AF and noncardiovascular mortality in either men or women [29].

Atrial brillation mortality in France

Although the hazard risk of stroke-related mortality was 2.0
[0.74.3] in men and 4.5 [1.316] in women in a French
population study, the risk of death among men without cardiopathy or hypertension, after adjustment for other risk
factors, was not signicantly increased (overall mortality
1.1 [0.52.0], cardiovascular mortality 1.4 [0.62.9]) [12].
Furthermore, in the ALFA study, two-thirds of the 3.7% mortality over 8.6 months was due to underlying cardiovascular
causes [13].
Data from CepiDC-IFR 69-INSERM on the medical causes
of death in French subjects [48] indicate that the annual
number of deaths from AF increased between 2000 and 2007,
particularly in older subjects (Fig. 2). A total of 3440 French
subjects (1183 men and 2257 women) died from AF in 2000
and 4747 (1678 men, 3069 women) died in 2007, but these
data are probably underestimated because they depend on
the details listed on death certicates. The age- and sex-

Figure 2. Mortality (per 100,000 persons) from atrial brillation

between 2000 and 2007 in France, according to age group, in (A)
men and (B) women.

standardized mortality rate increased from 6.1 to 9.5 per

100,000 between 2000 and 2007.

Hospitalizations
Approximately one-third of hospital admissions for cardiac
rhythm disturbances are due to AF. In patients in the west of
Scotland, Stewart et al. reported a rate of incident hospitalization of 1.9 cases/1000 person-years in the 20 years after
initial screening for their study [23]. The number of hospital
admissions for AF has increased by 66% over the last 20 years
due to the ageing population, the increasing prevalence of
chronic heart disease and more frequent diagnosis [10]. In
the USA, the number of hospitalizations with AF as the primary diagnosis increased by 34% over the 6 years between
1996 and 2001 [49].
In France, the 2008 PMSI database showed that around
84,000 patients were hospitalized with a principal diagnosis of AF and 349,000 with an associated diagnosis of AF
(total of 412,000 patients corresponding to 610,198 hospital
stays, 53.3% male). The number of cases increased regularly
over the 3 years (+ 26% for the number of patients, + 32%
for the number of hospitalizations) (Fig. 3). Most of these
patients (92%) were aged 60 years. Major comorbidities
were hypertension, heart disease, heart failure, stroke, syncope and collapse, and dialysis (Table 4). In patients with
AF as the principal diagnosis, the attributable mortality was
0.6%; however, in patients who were hospitalized with AF
associated with another pathology, the mortality rate was
6.6%, giving an overall hospital mortality of 5.6%.
In the Cost of Care in AF (COCAF) study, 31.3% of 671
patients with AF recruited by cardiologists across France

122

Figure 3.

A. Charlemagne et al.

Number of AF patients hospitalized and total number of hospitalization stays for AF patients in France, 20052008.

were hospitalized because of their disease [11]. Subjects

with persistent or permanent AF were signicantly more
likely to be hospitalized or to die compared with those
with paroxysmal AF (P < 0.05, P < 0.001, respectively). In
this study, the nancial burden of AF was related to hospitalization (52%), drugs (23%), consultations (9%), further
investigations (8%), loss of work (6%) and paramedic procedures (2%).

Perspectives
The prevalence of AF in France is estimated at between
600,000 and 1 million patients, of which 400,000660,000

Table 4

are aged > 75 years. The number of new cases is

110,000230,000 per year.
The number of patients with AF is increasing every year
and the socioeconomic burden of AF is expected to continue
to increase in the foreseeable future.
An estimate of the projected number of AF patients
in France in 2050, based on central projected population
trends (70 million inhabitants; life expectancy 86.4 years;
reproduction rate 1.9; migration + 100,000 per year) and
former AF rates, has been calculated. With all reserves,
particularly due to the evolution of cardiovascular diseases
and other risk factors in the population, it is estimated that
between 1.1 and 2 million French people will present AF by
2050.

Characteristics of patients hospitalized with atrial brillation in France in 2008.

Number of patients (n)

Men/women (%)

Principal diagnosis

Associated diagnosis

Total

84,603
57.7/42.3

348,683
52.4/47.6

412,047
53.3/46.7

Age group (%)

< 40 years
4044 years
4549 years
5059 years
6069 years
7079 years
80 years

2.6
1.6
2.8
12.5
20.6
31.4
28.3

0.4
0.3
0.7
4.4
11.3
30.4
52.4

0.8
0.6
1.1
5.8
12.9
30.4
48.4

Comorbidities (%)
Hypertension (I10 to I15)
Heart disease (I20 to I2298)
Heart failure (I50)
Stroke (I60 to I669)
Aortic stenosis
Syncope and collapse (R55)
Dialysis (Z491)

33.9
2.2
9.1
1.2

15.0
0.8
1.0
1.1
2.9

0.6

6.6

5.6

Hospital deaths (%)

Epidemiology of atrial brillation in France

Conclusion
This study focuses on the major published studies on the
incidence and prevalence of AF, and highlights the disparity
of approaches in terms of reference population studied and
denition of AF. These studies do not yet take into account
the recent recommendations of the European Society of Cardiology with respect to the classication of AF or the use of
different risk scores, including the CHA2 DS2 -VASc score.
The prevalence of AF in France is estimated to be
between 600,000 and 1 million people and the incidence
between 110,000 and 230,000 new cases per year. In 2008,
412,000 hospitalized patients had a diagnosis of AF, which
represents an increase of 26% over the 3 years from 2005
and 2008.
These gures emphasize the importance of targeting
therapy, of upstream therapy and of therapy that provides
clinical and economic advantages over the well-established
reductions already achieved in AF morbidity, mortality and
cost.
These perspectives have great implications for primary
prevention of cardiovascular diseases in young people and
screening for cardiovascular risk factors in adults (cardiovascular history, smoking status, systolic blood pressure,
cholesterol status, diabetes). The development of a scoring system to predict an individuals risk of developing AF
may contribute to its prevention [50].
New prevention strategies should be developed, particularly secondary prevention strategies in patients with
cardiovascular diseases.

Conict of interest statement

A.C.: employee of Cemka-Eval (CRO). J.B.: advisory
activity; conference invitations as contributor for BristolMyers Squibb and Sano-Aventis. A.C.: advisory activity;
conference invitations as contributor for AstraZeneca,
Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Novartis, Sano-Aventis and Servier. J.-P.C.: advisory activity for
Bristol-Myers Squibb and Sano-Aventis. F.D.: advisory activity for Abbott, AstraZeneca, Bristol-Myers Squibb, Pzer,
Roche Diagnostics and Sano-Aventis France; conference
attendance for Abbott, AstraZeneca, Bristol-Myers Squibb,
Boehringer Ingelheim, Ipsen, Menarini, Merck Sharpe &
Dohme, Novartis, Pzer, Roche Diagnostics, Sano-Aventis
France, Servier and Takeda. P. de G.: advisory activity; conference invitations as contributor for Bristol-Myers Squibb
and Sano-Aventis; co-investigator, secondary experimenter
or collaborator in clinical trials for Bristol-Myers Squibb
and Sano-Aventis; expert/survey report for HFPEF study
(Columbia University); invitations to national meetings as
auditor for Bristol-Myers Squibb and Sano-Aventis. O.H.:
advisory activity; conference invitations as contributor for
AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, EISAI, Janssen-Cilag, Lundbeck, Menarini, Negma,
Novartis, Pzer, Sano-Aventis, Servier, Solvay and Takeda;
main investigator, co-ordinator or main experimenter for
clinical trials for Solvay; co-investigator for clinical trials
for Servier. A.L.: advisory activity; conference invitations
as contributor for Bristol-Myers Squibb, Boston France,
Meda Pharma, Medtronic, Sano-Aventis and St Jude Med-

123
ical. J.-F.P.: advisory activity for Bristol-Myers Squibb and
Sano-Aventis. G.P.-D.: employee of Bristol-Myers Squibb
France. J.-Y. le H.: consultant, advisory activity and conference attendance for Bayer, Bristol-Myers Squibb, Boehringer
Ingelheim, Daiichi Sankyo, Meda Pharma, Medtronic, Menarini, Merck Sharpe & Dohme, Sano-Aventis and Servier.
Funding: This study was conducted with the nancial support of Bristol-Myers Squibb and Sano-Aventis France.

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