Obesity as a risk factor for atrial fibrillation

Authors: Bogdanov A.R., Romanova T.A.

Company: 1 Pirogov Russian National Research Medical University, Moscow, Russian Federation
2 Russian State Social University, Moscow, Russian Federation
3 City Clinical Hospital #13, Moscow, Russian Federation

For correspondence:  Sign in or register.

Type:  Reviews

DOI: https://doi.org/10.24022/1997-3187-2022-16-3-278-288

For citation: Bogdanov A.R., Romanova T.A. Obesity as a risk factor for atrial fibrillation. Creative Cardiology. 2022; 16 (3): 278–88 (in Russ.). DOI: 10.24022/1997-3187-2022-16-3-278-288

Received / Accepted:  25.07.2022 / 02.09.2022

Keywords: atrial fibrillation overweight obesity diet therapy myocardial fibrosis myocardial apoptosis heart remodeling lipotoxicity insulin resistance obstructive sleep apnea

Full text:  



The purpose of writing this literature review is to summarize current scientific data on the relationship, mechanisms of initiation, development and progression of atrial fibrillation (AF) in patients with obesity. The article provides a scientific literature review of the relationship between obesity and AF. In particular, it has been shown that obesity is an independent factor in the development and progression of AF, being both a trigger and a substrate for atrial electrical instability. The pathogenetic factors of the complex effect of obesity on the electrical function of the atria are considered in detail, which are divided into direct factors associated with the direct influence of adipose tissue, and indirect factors developing as a result of the influence of diseases comorbid with obesity. The role of neurohumoral and hemodynamic factors, ventricular and atrial remodeling, apoptosis and myocardial fibrosis, local and systemic lipotoxicity, inflammation, and tissue hypoxia are discussed. The contribution of comorbid diseases and conditions – arterial hypertension, diabetes mellitus, coronary atherosclerosis and obstructive sleep apnea is described. The authors conclude that obesity prevention is a powerful tool for the prevention of supraventricular arrhythmias, including AF, and diet therapy aimed at reducing body weight may have the potential of an independent therapeutic approach to reduce the incidence of AF recurrence, reduce drug load and optimize conditions for electrophysiological procedures. In preparing the article, the following electronic resources were used: PubMed/MEDLINE portal, “Scientific Electronic Library eLIBRARY.RU”


  1. Daugherty S.E., Guo Y., Heath K., Dasmariñas M.C., Jubilo K.G., Samranvedhya J. et al. Risk of clinical sequelae after the acute phase of SARS-CoV-2 infection: retrospective cohort study. B. M. J. 2021; 373: n1098. DOI: 10.1136/bmj.n1098
  2. Benjamin E.J., Muntner P., Alonso A., Bittencourt M.S., Callaway C.W., Carson A.P. et al. American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics – 2019 update: a report from the American Heart Association. Circulation. 2019; 139: 56–528. DOI: 10.1161/CIR.0000000000000659
  3. Schnabel R.B., Yin X., Gona P., Larson M.G., Beiser A.S., McManus D.D. et al. 50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: a cohort study. Lancet. 2015; 386: 154–62. DOI: 10.1016/S0140-6736(14)61774-8
  4. Kornej J., Börschel C.S., Benjamin E.J., Schnabel R.B. Epidemiology of atrial fibrillation in the 21st century: novel methods and new insights. Circ. Res. 2020; 127 (1): 4–20. DOI: 10.1161/circresaha.120.316340
  5. Di Carlo A., Bellino L., Consoli D., Mori F., Zaninelli A., Baldereschi M. et al. National research program: progetto FAILFAiI. Prevalence of atrial fibrillation in the Italian elderly population and projections from 2020 to 2060 for Italy and the European Union: the FAI Project. Europace. 2019; 21: 1468–75. DOI: 10.1093/europace/euz141
  6. Hindricks G., Potpara T., Dagres N., Arbelo Е., Bax J.J., Blomström-Lundqvist С. et al. Рекомендации ESC 2020 по диагностике и лечению пациентов с фибрилляцией предсердий, разработанные совместно с Европейской ассоциацией кардиоторакальной хирургии (EACTS). Российский кардиологический журнал. 2021; 26 (9): 4701. DOI: 10.15829/1560-4071-2021-4701 Hindricks G., Potpara T., Dagres N., Arbelo Е., Bax J.J., Blomström-Lundqvist С. et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Russian Journal of Cardiology. 2021; 26 (9): 4701 (in Russ.).
  7. Atrial fibrillation and flutter. Clinical guidelines. Available at: http://rkdb.ru/wpcontent/uploads/2020/12/Фибрилляция-и-трепетание-предсердий-2020-г.pdf (accessed June 11, 2022) (in Russ.).
  8. Aune D., Feng T., Schlesinger S., Janszky I., Norat T., Riboli E. Diabetes mellitus, blood glucose and the risk of atrial fibrillation: a systematic review and meta-analysis of cohort studies. J. Diabetes Complications. 2018; 32 (5): 501–11. DOI: 10.1016/j.jdiacomp.2018.02.004
  9. Hobbelt A.H., Siland J.E., Geelhoed B., Van Der Harst P., Hillege H.L., Van Gelder I.C., Rienstra M. Clinical, biomarker, and genetic predictors of specific types of atrial fibrillation in a community-based cohort: data of the PREVEND study. Europace. 2017; 19: 226–32. DOI: 10.1093/europace/euw016
  10. Boriani G., Savelieva I., Dan G.A., Deharo J.C., Ferro C., Israel C.W. et al. Chronic kidney disease in patients with cardiac rhythm disturbances or implantable electrical devices: clinical significance and implications for decision making – a position paper of the European Heart Rhythm Association endorsed by the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society. EP Europace. 2015; 17 (8): 1169–96. DOI: 10.1093/europace/euv202
  11. Golukhova E.Z., Gromova O.I., Bulaeva N.I., Arakelyan M.G., Lifanova L.S., Shlyappo M.A. et al. Epicardial fat and atrial fibrillation: the role of profibrinogenic mediators. Kardiologiia. 2018; 58 (7): 59–65 (in Russ.).
  12. Golukhova E.Z., Maliovanova I.M., Kakuchaya T.T. Cardiac arrhythmias in patients with obstructive sleep apnoea: clinical features, diagnosis and treatment. Annaly Aritmologii. 2006; 3 (2): 66–71 (in Russ.).
  13. Wanahita N., Messerli F.H., Bangalore S., Gami A.S., Somers V.K., Steinberg J.S. Atrial fibrillation and obesity–results of a meta-analysis. Am. Heart J. 2008; 155 (2): 310–5. DOI: 10.1016/j.ahj.2007.10.004
  14. Tedrow U.B., Conen D., Ridker P.M., Cook N.R., Koplan B.A., Manson J.E. et al. The long- and short-term impact of elevated body mass index on the risk of new atrial fibrillation the WHS (women’s health study). J. Am. Coll. Cardiol. 2010; 55 (21): 2319–27. DOI: 10.1016/j.jacc.2010.02.029
  15. Aronis K.N., Wang N., Phillips C.L., Benjamin E.J., Marcus G.M., Newman A.B. et al. Associations of obesity and body fat distribution with incident atrial fibrillation in the biracial health aging and body composition cohort of older adults. Am. Heart J. 2015; 170 (3): 498–505 e2. DOI: 10.1016/j.ahj. 2015.06.007
  16. Obesity and overweight. https://www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight (accessed June 15, 2022).
  17. Drapkina O.M., Samorodskaya I.V., Starinskaya M.A., Kim O.T., Neimark A.E. Obesity: evaluation and management of patients. Collective monograph. Moscow; 2021 (in Russ.).
  18. National guidelines of obesity. 2020 (in Russ.).
  19. Kruszewska J., Cudnoch-Jedrzejewska A., Czarzasta K. Remodeling and fibrosis of the cardiac muscle in the course of obesity – pathogenesis and involvement of the extracellular matrix. Int. J. Mol. Sci. 2022; 23(8): 4195. DOI: 10.3390/ijms23084195
  20. Tadic M., Cuspidi C. Obesity and heart failure with preserved ejection fraction: a paradox or something else? Heart Fail. Rev. 2019; 24 (3): 379–85. DOI: 10.1007/s10741-018-09766-x
  21. Alpert M.A., Karthikeyan K., Abdullah O., Ghadban R. Obesity and cardiac remodeling in adults: mechanisms and clinical implications. Prog. Cardiovasc. Dis. 2018; 61 (2): 114–23. DOI: 10.1016/j.pcad.2018.07.012
  22. Opie L.H., Commerford P.J., Gersh B.J., Pfeffer M.A. Controversies in ventricular remodelling. Lancet. 2006; 367 (9507): 356–67. DOI: 10.1016/S0140-6736(06)68074-4
  23. Lauer M.S., Anderson K.M., Kannel W.B., Levy D. The impact of obesity on left ventricular mass and geometry. The Framingham Heart Study. Jama. 1991; 266 (2): 231–6. DOI: 10.1001/jama.1991.03470020057032
  24. Bombelli M., Facchetti R., Sega R., Carugo S., Fodri D., Brambilla G. et al. Impact of body mass index and waist circumference on the long-term risk of diabetes mellitus, hypertension, and cardiac organ damage. Hypertension. 2011; 58 (6): 1029–35. DOI: 10.1161/HYPERTENSIONAHA.111.175125
  25. Woodiwiss A.J., Libhaber C.D., Majane O.H.I., Libhaber E., Maseko M., Norton G.R. Obesity promotes left ventricular concentric rather than eccentric geometric remodeling and hypertrophy independent of blood pressure. Am. J. Hypertens. 2008; 21 (10): 1144–51. DOI: 10.1038/ajh.2008.252
  26. Cuspidi C., Rescaldani M., Sala C., Grassi G. Left-ventricular hypertrophy and obesity: a systematic review and meta-analysis of echocardiographic studies. J. Hypertens. 2014; 32 (1): 16–25. DOI: 10.1097/HJH.0b013e328364fb58
  27. Nelson R., Antonetti I., Bisognano J.D., Sloand J. Obesity-related cardiorenal syndrome. J. Clin. Hypertens. 2010; 12 (1): 59–63. DOI: 10.1111/j.1751-7176.2009.00205
  28. Gami A.S., Hodge D.O., Herges R.M., Olson E.J., Nykodym J., Kara T., Somers V.K. Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation. J. Am. Coll. Cardiol. 2007; 49 (5): 565–71. DOI: 10.1016/j.jacc.2006.08.060
  29. Neeland I.J., Gupta S., Ayers C.R., Turer A.T., Rame J.E., Das, S.R. et al. Relation of regional fat distribution to left ventricular structure and function. Circ. Cardiovasc. Imaging. 2013; 6 (5): 800–7. DOI: 10.1161/CIRCIMAGING.113.000532
  30. Stritzke J., Markus M.R.P., Duderstadt S., Lieb W., Luchner A., Döring A. et al. The aging process of the heart: obesity is the main risk factor for left atrial enlargement during aging. The MONICA/KORA (Monitoring of Trends and Determinations in Cardiovascular Disease/Cooperative Research in the Region of Augsburg) Study. J. Am. Coll. Cardiol. 2009; 54 (21): 1982–9. DOI: 10.1016/j.jacc.2009.07.034
  31. Mahajan R., Lau D.H., Sanders P. Impact of obesity on cardiac metabolism, fibrosis, and function. Trends Cardiovasc. Med. 2015; 25 (2): 119–26. DOI: 10.1016/j.tcm.2014.09.005 31. Khan M.F., Movahed M.R. Obesity cardiomyopathy and systolic function: obesity is not independently associated with dilated cardiomyopathy. Heart Fail. Rev. 2013; 18 (2): 207–7. DOI: 10.1007/s10741-012-9320-4
  32. Wong C.Y., O’Moore-Sullivan T., Leano R., Hukins C., Jenkins C., Marwick T.H. Association of subclinical right ventricular dysfunction with obesity. J. Am. Coll. Cardiol. 2006; 47 (3): 611–6. DOI: 10.1016/j.jacc.2005.11.015
  33. Mouton A.J., Li X., Hall M.E., Hall J.E. Obesity, hypertension, and cardiac dysfunction novel roles of immunometabolism in macrophage activation and inflammation. Circ. Res. 2020; 126 (6): 789–806. DOI: 10.1161/CIRCRESAHA.119.312321
  34. Heeneman S., Cleutjens J.P., Faber B.C., Creemers E.E., van Suylen R.J., Lutgens E. et al. The dynamic extracellular matrix: intervention strategies during heart failure and atherosclerosis. J. Pathol. 2003; 200 (4): 516–25. DOI: 10.1002/path.1395
  35. Frangogiannis N.G. The extracellular matrix in ischemic and nonischemic heart failure. Circ. Res. 2019; 125 (1): 117–46. DOI: 10.1161/CIRCRESAHA.119.311148
  36. Moore L., Fan D., Basu R., Kandalam V., Kassiri Z. Tissue inhibitor of metalloproteinases (TIMPs) in heart failure. Heart Fail. Rev. 2012; 17 (4–5): 693–706. DOI: 10.1007/s10741-011-9266-y
  37. Fedak P.W.M., Altamentova S.M., Weisel R.D., Nili N., Ohno N., Verma S. et al. Matrix remodeling in experimental and human heart failure: a possible regulatory role for TIMP-3. Am. J. Physiol. Heart Circ. Physiol. 2003; 284 (2): H626–34. DOI: 10.1152/ajpheart.00684.2002
  38. Timms P.M.L., Wright A., Maxwell P., Campbell S., Dawnay A.B., Srikanthan V. Plasma tissue inhibitor of metalloproteinase-1 levels are elevated in essential hypertension and related to left ventricular hypertrophy. Am. J. Hypertens. 2002; 15 (3): 269–72. DOI: 10.1016/s0895-7061(01)02316-0
  39. Li D., Fareh S., Leung T.K., Nattel S. Promotion of atrial fibrillation by heart failure in dogs: atrial remodeling of a different sort. Circulation. 1999; 100: 87–95. DOI: 10.1161/01.cir.100.1.87
  40. Lavrenova E.A., Drapkina O.M. Insulin resistance in obesity: pathogenesis and effects. Obesity and Metabolism. 2020; 17 (1): 48–55 (in Russ.). DOI: 10.14341/omet9759
  41. Korneeva O.N., Drapkina O.M. Pathogenetic interaction of arterial hypertension and insulin resistance. Russian Journal of Cardiology. 2006; 11 (5): 100–3 (in Russ.).
  42. Gruzdeva O.V., Karetnikova V.N., Uchasova E.G., Kuz’mina A.A., Kashtalap V.V., Barbarash O.L. Insulin resistance and a risk for poor outcome one year after myocardial infarction. Vrach (The Doctor). 2015; 12: 30–4 (in Russ.).
  43. Dublin S., Glazer N.L., Smith N.L., Psaty B.M., Lumley T., Wiggins K.L. et al. Diabetes mellitus, glycemic control, and risk of atrial fibrillation. J. Gen. Intern. Med. 2010; 25 (8): 853–8. DOI: 10.1007/s11606-010-1340-y
  44. Garbarino J., Sturley S.L. Saturated with fat: New perspectives on lipotoxicity. Curr. Opin. Clin. Nutr. Metab. Care. 2009; 12 (2): 110–6. DOI: 10.1097/MCO.0b013e32832182ee
  45. Krishnan A., Chilton E., Raman J., Saxena P., McFarlane C., Trollope A.F. et al. Are interactions between epicardial adipose tissue, cardiac fibroblasts and cardiac myocytes instrumental in atrial fibrosis and atrial fibrillation? Cells. 2021; 10 (9): 2501. DOI: 10.3390/cells10092501
  46. Csonka C., Sárközy M., Pipicz M., Dux L., Csont T. Modulation of hypercholesterolemia-induced oxidative/nitrative stress in the heart. Oxid. Med. Cell. Longev. 2016; 2016: 3863726. DOI: 10.1155/2016/3863726
  47. Kazantseva V.D., Khidirova L.D., Yakhontov D.A., Maksimov V.N. Phenotypic and genetic features of the course of atrial fibrillation in the presence of arterial hypertension and abdominal obesity. Siberian Medical Bulletin. 2019; 4: 3–8 (in Russ.).
  48. Schütten M.T.J., Houben A.J.H.M., de Leeuw P.W., Stehouwer C.D.A. The link between adipose tissue renin-angiotensin-aldosterone system signaling and obesity-associated hypertension. Physiology (Bethesda). 2017; 32 (3): 197–209. DOI: 10.1152/physiol.00037.2016
  49. Vatutin N.T., Shevelyok A.M., Degtiarova G.E. Aldosterone and obesity: where to look for the key to therapy? The Russian Archives of Internal Medicine. 2016; 6 (4): 21–9 (in Russ.). DOI: 10.20514/2226-6704-2016-6-4-21-29
  50. Huang L., Gao X. The interaction of obesity and craniofacial deformity in obstructive sleep apnea. Dentomaxillofac Radiol. 2021; 50 (4): 20200425. DOI: 10.1259/dmfr.20200425
  51. Shamsuzzaman A.S., Gersh B.J., Somers V.K. Obstructive sleep apnea: implications for cardiac and vascular disease. Jama. 2003; 290 (14): 1906–14. DOI: 10.1001/jama.290.14.1906
  52. Mehra R., Benjamin E.J., Shahar E., Gottlieb D.J., Nawabit R., Kirchner H.L. et al. Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep Heart Health Study. Am. J. Respir. Crit. Care. Med. 2006; 173 (8): 910–6. DOI: 10.1164/rccm.200509-1442OC
  53. Qaddoura A., Kabali C., Drew D., van Oosten E.M., Michael K.A., Redfearn D.P. et al. Obstructive sleep apnea as a predictor of atrial fibrillation after coronary artery bypass grafting: a systematic review and meta-analysis. Can. J. Cardiol. 2014; 30 (12): 1516–22. DOI: 10.1016/j.cjca.2014.10.014
  54. Ng C.Y., Liu T., Shehata M., Stevens S., Chugh S.S., Wang X. Meta-analysis of obstructive sleep apnea as predictor of atrial fibrillation recurrence after catheter ablation. Am. J. Cardiol. 2011; 108 (1): 47–51. DOI: 10.1016/j.amjcard.2011.02.343
  55. Holmqvist F., Guan N., Zhu Z., Kowey P.R., Allen L.A., Fonarow G.C. et al. Impact of obstructive sleep apnea and continuous positive airway pressure therapy on outcomes in patients with atrial fibrillation-Results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Am. Heart. J. 2015; 169 (5): 647–54.e2. DOI: 10.1016/j.ahj.2014.12.024
  56. Dimitri H., Ng M., Brooks A.G., Kuklik P., Stiles M.K., Lau D.H. et al. Atrial remodeling in obstructive sleep apnea: implications for atrial fibrillation. Heart Rhythm. 2012; 9 (3): 321–7. DOI: 10.1016/j.hrthm.2011.10.017
  57. Orban M., Bruce C.J., Pressman G.S., Leinveber P., Romero-Corral A., Korinek J. et al. Dynamic changes of left ventricular performance and left atrial volume induced by the mueller maneuver in healthy young adults and implications for obstructive sleep apnea, atrial fibrillation, and heart failure. Am. J. Cardiol. 2008; 102 (11): 1557–61. DOI: 10.1016/j.amjcard.2008.07.050
  58. Ntalapascha M., Makris D., Kyparos A., Tsilioni I., Kostikas K., Gourgoulianis K. et al. Oxidative stress in patients with obstructive sleep apnea syndrome. Sleep Breath. 2013; 17 (2): 549–55. DOI: 10.1007/s11325-012-0718-y
  59. Shamsuzzaman A.S., Winnicki M., Lanfranchi P., Wolk R., Kara T., Accurso V., Somers V.K. Elevated C-reactive protein in patients with obstructive sleep apnea. Circulation. 2002; 105 (21): 2462–4. DOI: 10.1161/01.cir.0000018948.95175.03
  60. Linz D., Schotten U., Neuberger H.R., Bohm M., Wirth K. Negative tracheal pressure during obstructive respiratory events promotes atrial fibrillation by vagal activation. Heart Rhythm. 2011; 8 (9): 1436–43. DOI: 10.1016/j.hrthm.2011.03.053

About Authors

  • Alfred R. Bogdanov, Dr. Med. Sci., Professor, Head of Department, Professor of the Department of Faculty Therapy, Faculty of Pediatrics, Pirogov RNRMU, Advisor to the Rector of the RSSU, Head of Department of Cardiology for Patients with Acute Myocardial Infarction, CCH # 13; ORCID
  • Tat’yana A. Romanova, Cardiologist; ORCID

Chief Editor

Leo A. Bockeria, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, President of Bakoulev National Medical Research Center for Cardiovascular Surgery