Background
Pulmonary hypertension (PH) is characterized by progressive right ventricular pressure overload, right atrial remodeling, and hemodynamic vulnerability. Atrial fibrillation (AF) may further impair cardiac function through loss of atrioventricular synchrony and reduced right ventricular filling. Although atrial arrhythmias are common in pulmonary arterial hypertension and chronic thromboembolic PH, large real-world data quantifying the long-term risk of incident AF after PH diagnosis remain limited. We therefore investigated the association between PH and subsequent AF in a large nationwide outpatient cohort.
Methods
This retrospective cohort study used the German IQVIA Disease Analyzer database, which contains anonymized longitudinal data from approximately 3,000 office-based practices. Adults aged ≥40 years with a first diagnosis of PH (ICD-10: I27.0, I27.2) between January 2005 and December 2023 were included. Patients with a history of AF were excluded. Individuals with PH were matched in a 1:5 ratio to individuals without PH using propensity scores based on age, sex, index year, consultation frequency, and major cardiovascular, metabolic, renal, pulmonary, and oncological comorbidities. The primary endpoint was incident AF during a follow-up period of up to 10 years. Cox regression analyses were performed to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).
Results
A total of 5,883 patients with PH and 29,415 matched individuals without PH were included. Baseline characteristics were well balanced after matching, with all standardized mean differences below 0.1. Mean age was 72.1 years in the PH cohort, and 58.4% of patients were women. During follow-up, the cumulative incidence of AF was substantially higher in patients with PH than in matched controls. At 10 years, AF occurred in 33.5% of patients with PH compared with 22.3% of individuals without PH (p< 0.001). Kaplan–Meier curves separated early after the index date and continued to diverge throughout follow-up.
PH was associated with a significantly increased risk of incident AF (HR 1.60, 95% CI 1.50–1.72). Similar findings were observed across PH subtypes. Patients with primary PH showed the highest relative risk (HR 1.72, 95% CI 1.39–2.12), whereas secondary PH was associated with an HR of 1.59 (95% CI 1.48–1.71). The strongest association was observed in patients aged 65–75 years (HR 2.20, 95% CI 1.85–2.62). Risk elevations were consistent in women (HR 1.66, 95% CI 1.51–1.82) and men (HR 1.54, 95% CI 1.38–1.71).
Conclusion
In this large nationwide real-world cohort, pulmonary hypertension was associated with a markedly increased long-term risk of incident atrial fibrillation. Approximately one in three patients with PH developed AF within 10 years, and the association remained robust across age groups, sexes, and PH subtypes. These findings identify AF as a major long-term complication of PH and support increased rhythm surveillance and prospective studies evaluating PH-specific AF management strategies.
