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Epidemiological Characteristics and Future Projections of Atrial Fibrillation/Flutter in China: An Analysis Based on Global Burden of Disease Data
中国心房颤动/扑动的流行病学特征及未来预测：基于全球疾病负担数据的分析

(2)

Guang Li^1,2 M.D
李光 ¹ 2 医学博士

Sijin Li³ M.D
李思瑾 ³ 医学博士

Shuang Chen² M.D
陈爽 ² 医学博士
Xiancheng Xu^1,2 M.D
徐贤成 ^1,2 医学博士

Weijie Wu¹ M.D
吴伟杰 ¹M.D

Chanlin Li⁴ M.D
李灿琳 ⁴ 医学博士

Yuntao Tian^1,5 M.D
田云涛 ^1,5 医学博士

Weijie Chen^1,5 M.D, Ph.D
陈伟杰 ^1,5 医学博士，博士

Hongsheng Liang^2,6 M.D
梁宏生 ^2,6 医学博士

Heng Li^1,2,5 M.D, Ph.D
恒力 1,2,5M.博士、博士

Guang Li, Sijin Li and Shuang Chen and contributes equally to the development of this research study
Li 光、Li Sijin 和 Shuang Chen，并为这项研究的发展做出了同样的贡献.

(3)

Department of Cardiology, Dongguan Songshan Lake TungWah Hospital, Dongguan, PR China.
东莞松山湖东华医院心脏内科 ，中国东莞。

Guangdong Medical University, Dongguan, PR China.
广东医科大学，中国东莞。

Department of Cardiovascular Surgery, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, PR China
中山大学附属第八医院心血管外科，中国深圳.

Department of Cardiology, Dongguan TungWah Hospital, Dongguan, PR China.
东莞市东华医院心脏内科 ，东莞。

Key Laboratory of Coronary Intraluminal Imaging and Functional Analysis of Dongguan City, Dongguan, PR China
东莞市冠状动脉腔内成像与功能分析重点实验室，中国东莞市.

Department of Cardiovascular, The Eighth Affiliated Hospital of Dongguan City, Dongguan, PR China.
中国东莞市第八附属医院心血管科 。

Send correspondence to:
将信件发送至：

Heng Li, M.D. Ph.D.
李恒， 医学博士

Department of Cardiology, Dongguan Songshan Lake Tungwah Hospital, Dongguan, China
东莞松山湖东华医院心内科，东莞.

Key Laboratory of Coronary Intraluminal Imaging and Functional Analysis of Dongguan City, Dongguan, China
东莞市冠状动脉腔内成像与功能分析重点实验室，东莞.

Guangdong Medical University, Dongguan, PR China.
广东医科大学，中国东莞。

Email: lh12818@163.com
电子邮件：lh12818@163.com

Hongsheng Liang, M.D
梁宏生，医学博士

Department of Cardiovascular, The Eighth Affiliated Hospital of Dongguan City, Dongguan, PR China
东莞市附属第八医院心血管科，中国东莞.

Guangdong Medical University, Dongguan, PR China.
广东医科大学，中国东莞。

Email: 15019991868@163.com
电子邮件：15019991868@163.com

Epidemiological Characteristics and Future Projections of Atrial Fibrillation/Flutter in China: An Analysis Based on Global Burden of Disease Data
中国心房颤动/扑动的流行病学特征及未来预测：基于全球疾病负担数据的分析

Guang Li^#, Sijin Li^#, Shuang Chen^#, Xiancheng Xu, Weijie Wu, Canlin Li, Yuntao Tian, Weijie Chen, Hongsheng Liang^*, Heng Li^*
李光 ^#， 李思瑾 ^#， 陈爽 ^#， 徐贤成， 吴伟杰， 李灿林， 田云涛， 陈伟杰， 梁宏生 ^*， 李恒 ^*

^# These authors contribute equally to the development of this research study
^# 这些作者对这项研究的开展做出了同等贡献

^* Corresponding authors
^* 通讯作者

ABSTRACTS
文摘

Atrial fibrillation/flutter (AF/AFL) is a prevalent cardiac arrhythmia that markedly elevates the risk of stroke and heart failure, imposing substantial morbidity and mortality, as well as significant economic burdens on healthcare systems. This study aimed to comprehensively assess the burden of AF/AFL across different regions, including China, Southeast Asia, and Europe, focusing on epidemiological indicators such as incidence, prevalence, mortality, and disability-adjusted life years (DALYs). Utilizing statistical modeling techniques, including Joinpoint regression and age-period-cohort (APC) models, we analyzed a robust dataset spanning multiple countries and years. Our findings revealed a notable increase in AF/AFL incidence and prevalence rates, particularly in China where the age-standardized incidence rate rose from 42.628 per 100,000 in 1990 to 44.923 in 2021. Conversely, Europe exhibited a slight decline, with an annual percentage change of -0.035. Risk factor decomposition analysis indicated that population aging and growth predominantly contributed to the rise in AF/AFL burden in China, while effective management strategies have led to a decrease in mortality rates. Our prognostic assessments suggest that the age-standardized incidence rate (ASIR) and age-standardized prevalence rate (ASPR) in China may continue to rise, albeit with a decline in mortality rates. In conclusion, this study emphasizes the urgent need for targeted interventions and continuous monitoring of AF/AFL to enhance patient care and inform public health strategies. Future research should delve into the underlying mechanisms and additional risk factors associated with AF/AFL to further mitigate its burden.
心房颤动/扑动 （AF/AFL） 是一种普遍的心律失常，可显着增加中风和心力衰竭的风险，带来巨大的发病率和死亡率，并给医疗保健系统带来重大的经济负担。本研究旨在全面评估中国、东南亚和欧洲等不同地区的房颤/房颤负担，重点关注发病率、患病率、死亡率和残疾调整生命年（DALYs）等流行病学指标。利用统计建模技术，包括 Joinpoint 回归和 ge-p eriod-c ohort （APC） 模型，我们分析了跨越多个国家和年份的稳健数据集。我们的研究结果显示，AF/AFL 的发病率和患病率显着增加，特别是在中国，年龄标准化发病率从 1990 年的每 100,000 人 42.628 人上升到 2021 年的 44.923 人。相反，欧洲则略有下降，年百分比变化为 -0.035。危险因素分解分析表明，人口老龄化和增长主要导致中国房颤/房颤负担增加，而有效的管理策略导致死亡率下降。我们的预后评估表明， 尽管死亡率有所下降，但中国的 ge-s 标准化 p 显示 rate （ASIR） 和 ge-s dandardized prevalence rate （ASPR） 可能会继续上升。 总之，本研究强调迫切需要对 AF/AFL 进行有针对性的干预和持续监测，以加强患者护理并为公共卫生策略提供信息。未来的研究应深入研究与 AF/AFL 相关的潜在机制和其他风险因素，以进一步减轻其负担。

Keywords: Atrial fibrillation/atrial flutter, Global Burden of Disease study, multidimensional comparison, trend analysis, age-period-cohort analysis, future projection
关键词： 试用颤动/心房扑动 、Global 疾病负担研究 、 多维比较 、 趋势分析 、ge-p eriod-c ohort 分析 、 未来预测

1 Introduction
1 介绍

Atrial fibrillation/flutter (AF/AFL) is recognized as a prevalent cardiac arrhythmia that poses a significant risk for various complications, including stroke and heart failure, leading to substantial morbidity and mortality rates among affected individuals^1-3. The economic implications of AF/AFL are considerable, as it is associated with increased hospitalization rates and ongoing medical management expenses^4,5. Despite the availability of treatment options such as anticoagulation therapy, rate and rhythm control strategies, and catheter ablation, barriers including treatment adherence and access to specialized care continue to hinder optimal management of the condition. Consequently, there is a pressing need for research aimed at elucidating the burden of AF/AFL and informing public health initiatives to improve patient outcomes⁶
心房颤动/扑动 （AF/AFL） 被认为是一种普遍的心律失常，对各种并发症（包括中风和心力衰竭）构成重大风险，导致受影响个体的发病率和死亡率很高 ^1-3。AF/AFL 的经济影响是相当大的，因为它与住院率和持续医疗管理费用的增加有关 ^4,5。尽管有抗凝治疗、心率和节律控制策略以及导管消融等治疗方案，但包括治疗依从性和获得专业护理在内的障碍继续阻碍病情的最佳管理。因此，迫切需要进行旨在阐明 AF/AFL 负担并为改善患者预后的公共卫生举措提供信息的研究 ⁶.

Current literature highlights considerable variability in the epidemiological indicators of AF/AFL across different populations^7-9. Previous studies have documented trends in AF/AFL prevalence^8,10,11. Understanding these trends is crucial for recognizing the broader impact of AF/AFL and for developing informed healthcare policies and resource allocation strategies. China, the most populous nation worldwide, exemplifies this conundrum: its rapid economic growth has been coupled with vigorous health-system reforms and noticeable improvements in the identification and management of AF/AFL. However, the country is concurrently facing a rising tide of metabolic risk factors and a significant aging population^12,13. At present, there exists a dearth of comparative data that positions China alongside Southeast Asia, the relatively advanced health systems of Europe, and the global average over the past three decades¹⁴
目前的文献强调了不同人群 ^7-9 中 AF/AFL 流行病学指标的相当大的差异 。先前的研究记录了 AF/AFL 患病率的趋势 ^8,10,11。了解这些趋势对于认识 AF/AFL 的更广泛影响以及制定明智的医疗保健政策和资源分配策略至关重要。中国是世界上人口最多的国家，它体现了这一难题：其快速的经济增长伴随着大力的卫生系统改革以及 AF/AFL 识别和管理的显着改善。然而，该国同时面临着代谢风险因素的上升和人口的严重老龄化 ^12,13。目前，缺乏将中国与东南亚、欧洲相对先进的卫生系统以及过去三十年的全球平均水平并列的比较数据 ¹⁴.

To address these gaps, this research employs advanced statistical methodologies, including age-standardized rates and temporal trend analysis, utilizing techniques such as Joinpoint regression and Age-Period-Cohort (APC) models. These methodologies are designed to enhance the accuracy of trend identification and to facilitate a nuanced understanding of the disease burden across different demographics. By integrating diverse data sources and employing robust analytical frameworks, the study aims to quantify the variations in AF/AFL burden across distinct geographical regions and to identify the underlying factors contributing to these differences.
为了解决这些差距，本研究采用了先进的统计方法，包括年龄标准化率和时间趋势分析，利用 Joinpoint 回归和年龄期队列 （APC） 模型等技术。这些方法旨在提高趋势识别的准确性，并促进对不同人群的疾病负担的细致入微的了解。通过整合不同的数据源并采用强大的分析框架，该研究旨在量化不同地理区域之间 AF/AFL 负担的变化，并确定导致这些差异的潜在因素。

The primary objective of this study is to provide a comprehensive assessment of the burden of AF/AFL, focusing on key epidemiological indicators such as incidence, prevalence, mortality rates, and disability-adjusted life years (DALYs). By dissecting these indicators, the research aspires to illuminate the multifaceted nature of AF/AFL and its implications for public health. Furthermore, the findings are expected to serve as an invaluable resource for policymakers and healthcare providers, facilitating tailored interventions and strategic planning that address the growing burden of AF/AFL.
本研究的主要目的是对 AF/AFL 的负担进行全面评估，重点关注发病率、患病率、死亡率和残疾调整生命年 （DALY） 等关键流行病学指标。通过剖析这些指标，该研究旨在阐明 AF/AFL 的多方面性质及其对公共卫生的影响。此外，这些发现预计将成为政策制定者和医疗保健提供者的宝贵资源，促进量身定制的干预措施和战略规划，以解决 AF/AFL 日益增长的负担。

In summary, this research endeavors to fill the existing knowledge gaps regarding the burden of AF/AFL by employing sophisticated statistical approaches to analyze a rich dataset spanning multiple countries and years. The insights garnered from this study will not only advance our understanding of AF/AFL trends but will also contribute to the development of targeted public health strategies aimed at mitigating the impact of this prevalent arrhythmia on global health outcomes. This study stands to significantly influence the discourse surrounding AF/AFL management and resource allocation in healthcare systems worldwide.
总之，本研究致力于通过采用复杂的统计方法分析跨多个国家和年份的丰富数据集，填补有关 AF/AFL 负担的现有知识空白。从这项研究中获得的见解不仅将增进我们对 AF/AFL 趋势的理解，还将有助于制定有针对性的公共卫生战略，旨在减轻这种普遍心律失常对全球健康结果的影响。这项研究将对全球医疗保健系统中围绕 AF/AFL 管理和资源分配的讨论产生重大影响。

2 Materials and Methods
2 材料与方法

2.1 Data source
2.1 数据来源

We obtained data from the Global Burden of Disease Study (GBD 2021) database, which is an updated version of the GBD 2019 project, providing extensive epidemiological information for 204 countries and regions from 1990 to 2021¹⁵. The GBD system collects data from various sources, including national population censuses, household surveys, civil registration systems, vital statistics, disease registration, health service records, and other relevant notifications¹⁶. For our purposes, we accessed the data through the query tool provided at https://vizhub.healthdata.org/gbd-results, from which we extracted specific causes of death, various observation indicators, stratified by age, gender, year, and region. All procedures were in accordance with the principles outlined in the Declaration of Helsinki. Given that the GBD database is publicly accessible and contains anonymized data, ethical approval and informed consent were not required. It is worth noting that the data analyzed in this study pertains to individuals aged 30 and above, consistent with the scope of the GBD 2021 report, including information from China, Southeast Asia, Europe, and global populations.
我们从全球疾病负担研究（GBD 2021）数据库中获取数据，该数据库是 GBD 2019 项目的更新版本，为 1990 年至 2021 年期间的 204 个国家和地区提供了广泛的流行病学信息 ¹⁵。GBD 系统从各种来源收集数据，包括全国人口普查、家庭调查、民事登记系统、生命统计、疾病登记、卫生服务记录和其他相关通知 ¹⁶。出于我们的目的，我们通过 https://vizhub.healthdata.org/gbd-results 提供的查询工具访问数据 ，从中提取了具体的死因、各种观察指标，并按年龄、性别、年份和地区分层。所有程序均符合《赫尔辛基宣言》中概述的原则。鉴于 GBD 数据库可公开访问并包含匿名数据，因此不需要伦理批准和知情同意。值得注意的是，本研究分析的数据涉及 30 岁及以上的人群，与 GBD 2021 报告的范围一致，包括来自中国、东南亚、欧洲和全球人群的信息。

2.2 Disease burden description
2.2 疾病负担描述

In this investigation, we quantified the burden of atrial fibrillation/flutter by examining several epidemiological indicators, including the annual incidence, prevalence, mortality, and DALYs, along with their respective age-standardized rates (ASRs) per 100,000 people. To facilitate meaningful comparison across different populations, we calculated the ASRs based on the World Health Organization’s (WHO) standard population. All estimates are presented alongside 95% UI, corresponding to the 2.5th and 97.5th percentiles derived from 100 uncertainty distributions. Utilizing age-standardized measures such as the ASIR, ASPR and mortality rate (ASMR) enables accurate comparisons between populations with varying age structures and sizes, thereby enhancing analytical precision. The scope of our analysis encompasses the burden of AF/AFL in China, Europe, Southeast Asia, and globally. Additionally, we examined how these metrics distribute across different age groups and genders, analyzing the multifaceted impact of the disease burden from multiple perspectives.
在这项调查中，我们通过检查几个流行病学指标来量化心房颤动/扑动的负担，包括年发病率、患病率、死亡率和 DALY，以及它们各自的每 100,000 人的年龄标准化率 （ASR）。为了促进不同人群之间的有意义的比较，我们根据世界卫生组织 （WHO） 的标准人群计算了 ASR。所有估计值都与 95% 的 UI 一起呈现 ，对应于 2.5 个不确定性分布得出的第 97.5 个百分位数和第 100 个百分位数。利用 ASIR、ASPR 和死亡率 （ASM R） 等年龄标准化指标， 可以在不同年龄结构和规模的人群之间进行准确比较，从而提高分析精度。我们的分析范围包括中国、欧洲、东南亚和全球的 AF/AFL 负担。此外，我们还研究了这些指标在不同年龄组和性别之间的分布情况，从多个角度分析了疾病负担的多方面影响。

2.3 Trends analysis
2.3 趋势分析

In order to examine the temporal trends associated with the disease burden of AF/AFL from 1990 to 2021, we utilized the Joinpoint regression model. This statistical method is well-regarded in epidemiology for its effectiveness in analyzing time-series data and identifying significant trend changes. The model determines residuals through least squares, aiming to reduce discrepancies between actual and projected values, effectively pinpointing inflection points without depending on subjective criteria¹⁷.Furthermore, to assess the evolving trends, we calculated both the Average Annual Percentage Change (AAPC) and the Annual Percentage Change (APC) for each identified segment. An AAPC or APC value exceeding zero indicated a rising trend, while values below zero implied a declining trend; a value of zero was interpreted as a stable trend. We established a threshold of P < 0.05 to denote statistical significance.
为了检查 1990 年至 2021 年与 AF/AFL 疾病负担相关的时间趋势，我们利用了 Joinpoint 回归模型。这种统计方法因其在分析时间序列数据和识别显着趋势变化方面的有效性而在流行病学中广受好评。该模型通过最小二乘法确定残差，旨在减少实际值和预测值之间的差异，有效地查明拐点，而无需依赖主观标准 ¹⁷。此外，为了评估不断变化的趋势，我们计算了每个已确定细分市场的平均年百分比变化 （AAPC） 和年百分比变化 （APC）。AAPC 或 APC 值超过零表示上升趋势，而低于零的值表示下降趋势;值为零被解释为稳定趋势。我们建立了 P < 0.05 的阈值来表示统计显着性。

2.4 Age-Period-Cohort (APC) model
2.4 年龄-时期-队列 （APC） 模型

For comprehensive evaluation, we applied the APC model, a robust statistical framework that enables researchers to analyze the independent and combined effects of age, period, and birth cohort on health outcomes and population trends. Period effects are caused by changes in social, economic, cultural, or physical environments, affecting all age groups equally, and differences within the same birth year group can also be attributed to cohort effects. Period and cohort relative risk (RR) refers to the age-specific ratio of each period and cohort relative to the control group. Specifically, we used this model to analyze the prevalence, incidence rate, mortality rate, and DALYs of AF/AFL patients in the observation area of our article. We obtained estimated parameters from the APC Network Utility Program of the National Cancer Institute. This approach allows us to better understand the trends of atrial fibrillation/atrial fibrillation-like episodes, providing valuable insights into this critical public health issue^18,19
为了进行综合评估，我们应用了 APC 模型，这是一个强大的统计框架，使研究人员能够分析年龄、时期和出生队列对健康结果和人口趋势的独立和综合影响。经期效应是由社会、经济、文化或物理环境的变化引起的，对所有年龄组的影响相同，同一出生年份组内的差异也可以归因于队列效应。时期和队列相对风险 （RR） 是指每个时期和队列相对于对照组的年龄特定比率。具体来说，我们利用该模型分析了本文观察区域内 AF/AFL 患者的患病率、发生率、死亡率和 DALY。我们从美国国家癌症研究所的 APC 网络公用事业计划中获得了估计的参数。这种方法使我们能够更好地了解心房颤动/心房颤动样发作的趋势，为这一关键的公共卫生问题提供有价值的见解 ^18,19.

2.5.Bayesian Age-Period-Cohort (BAPC) model
2.5.贝叶斯年龄-期-队列 （BAPC） 模型

We use the BAPC model to predict the disease burden of AF/AFL in the future. The model is selected because it can effectively clarify the age, period and cohort effects, and can capture nonlinear trends and group specific risk profiles²⁰. The integrated nested Laplacian approximation (INLA) is applied to improve the accuracy, which surpasses the traditional linear method. Positive BAPC values above zero indicate an increasing trend, while negative values indicate a decreasing trend. Therefore, based on GBD 2021 research data, this study uses this model to predict the trend of ASPR, ASIR, ASMR and ASDR of patients in the observed region from 2022 to 2050.
我们使用 BAPC 模型来预测未来 AF/AFL 的疾病负担 。选择该模型是因为它可以有效地阐明年龄、时期和队列效应，并且可以捕获非线性趋势和分组特定风险概况 ²⁰。采用积分嵌套拉普拉斯近似（INLA）来提高精度，超越了传统的线性方法。高于零的正 BAPC 值表示上升趋势，而负值表示下降趋势。因此，本研究基于 GBD 2021 研究数据，利用该模型预测 2022—205 0 年观测区患者 ASPR、ASIR、ASMR 和 ASDR 的趋势 。

2.6 Decomposition analysis
2.6 分解分析

In the research of GBD, decomposition analysis is often used to quantify the impact of population and risk factors. The change of disease burden is attributed to population aging, population growth and epidemiological changes, so as to reveal the potential factors leading to the observed changes²¹. The purpose of this study is to explore the driving force behind the change of disease burden by using decomposition analysis method. All the analysis and visualization in this study were performed in R language (version 4.3.1). When the bilateral P<0.05, the difference was considered statistically significant.
在 GBD 的研究中，常采用分解分析来量化人群和风险因素的影响。疾病负担的变化归因于人口老龄化、人口增长和流行病学变化，从而揭示导致观察到的变化的潜在因素 ²¹.本研究的目的是利用分解分析方法探讨疾病负担变化的驱动力。本研究中的所有分析和可视化均以 R 语言（4.3.1 版）进行。当双侧 P<0.05 时，差异有统计学意义。

2.7 Frontier analysis
2.7 前沿分析

In order to explore and horizontally compare the prevention and treatment of disease burden in more dimensions, we also use the data envelopment analysis (DEA) method based on linear programming for frontier analysis. DEA determines the best performance by constructing a "boundary" containing all decision-making units, and the units below the boundary are considered invalid. In order to evaluate the robustness of DEA, we use a bootstrap process with 100 iterations to generate multiple resampled datasets to evaluate the stability. Local weighted regression (LOESS) was used to visualize the final results to illustrate the trends and performance of ASMR and ASDR attributed to AF/AFL in the observed region from 1990 to 2021²²
为了在更多维度上探索和横向比较疾病负担的防治，我们还采用基于线性规划的数据包络分析（DEA）方法进行前沿分析。DEA 通过构建包含所有决策单位的“边界”来确定最佳性能，边界以下的单位被视为无效。为了评估 DEA 的鲁棒性，我们使用具有 100 次迭代的引导过程来生成多个重采样数据集来评估稳定性。局部加权回归（LOESS） 用于可视化最终结果，以说明 1990 年至 2021 年观测区域中 AF/AFL 归因于 ASMR 和 ASDR 的趋势和表现 ²².

3 Results
3 结果

3.1 Overall burden of AF/AFL from 1990 to 2021.
3.1 1990 年至 2021 年 AF/AFL 的总体负担 。

3.1.1 Incidence
3.1.1 发生率

Between 1990 and 2021 the absolute number of incident AF/AFL cases in China rose from 306 585 (95% UI: 234 243-404 868) to 916 180 (95% UI: 707 384-1 201 381). ASIR increased modestly, from 42.63 to 44.92 per 100 000 (AAPC 0.155 %, 0.051-0.260), the steepest rise among the four macro-regions examined. Southeast Asia followed a similar upward trajectory (1990: 318 971 cases, ASIR 52.28; 2021: 900 234 cases, ASIR 53.02), whereas Europe (1990: 645 411, 59.47; 2021: 957 812, 58.93) and the globe (1990: 2.01 million, 52.51; 2021: 4.33 million, 52.12) experienced slight net declines in ASIR (Europe AAPC －0.035 %, global AAPC －0.027 %). These divergent slopes highlight China’s unique epidemiological transition and the heterogeneous pace of preventive cardiology across regions.
1990—2021 年，中国房颤/房颤病例的绝对数量从 306585 例（95% UI：234 243-404 868）上升到 916 180 例（95% UI：707 384-1 201 381）。ASIR 温和上升，从每 100 000 人 42.63 增加到 44.92 人（AAPC 0.155%，0.051-0.260），是所研究的四个宏观区域中增幅最大的。东南亚也遵循类似的上升轨迹（1990 年：318 971 例，ASIR 52.28;2021 年：900 234 例，ASIR 53.02），而欧洲（1990 年：645 411 例，59.47;2021 年：957 812 例，58.93）和全球（1990 年：201 万例，52.51 例;2021 年：433 万例，52.12 例）的 ASIR 略有净下降（欧洲 AAPC -0.035%，全球 AAPC -0.027 %).这些不同的斜率凸显了中国独特的流行病学转型和跨地区预防心脏病学步伐的异质性。

3.1.2 Prevalence
3.1.2 患病率

Prevalent cases in China expanded almost 3.4-fold, from 3.20 million (2.52-4.17) to 10.78 million (8.53-14.01). ASPR climbed from 457.7 to 524.0 per 100 000 (AAPC 0.324 %), again the largest increment worldwide. Southeast Asia’s ASPR edged upward from 549.4 to 562.4, Europe’s fell from 713.0 to 562.4, and the global rate inched from 616.6 to 620.5. The sustained growth in China reflects both demographic momentum and an apparent epidemiological shift-possibly driven by hypertension control gaps, dietary sodium excess and rising obesity-that outweighs improvements in secondary prevention.
中国的流行病例增加了近 3.4 倍，从 320 万例（2.52-4.17）增加到 1078 万例（8.53-14.01）。ASPR 从每 100 000 人 457.7 攀升至 524.0 人（AAPC 0.324%），再次成为全球最大增幅。东南亚的 ASPR 从 549.4 小幅上升至 562.4，欧洲的 ASPR 从 713.0 下降至 562.4，全球 ASPR 从 616.6 小幅上升至 620.5。中国的持续增长既反映了人口势头，也反映了明显的流行病学转变 —— 可能是由高血压控制差距、膳食钠过量和肥胖率上升推动的——这超过了二级预防的改善。

3.1.3 Mortality
3.1.3 死亡率

Deaths attributable to AF/AFL in China quadrupled from 16 449 (13 240-20 521) to 64 728 (51 765-77 729), yet age-standardized mortality rate (ASMR) fell from 4.93 to 4.33 per 100 000 (AAPC －0.78 %), the sharpest decline among all studied regions. Southeast Asia conversely saw ASMR rise from 2.94 to 4.06 (AAPC 0.76 %), Europe from 4.92 to 5.10, and the globe from 4.24 to 4.36. These patterns suggest that China’s health system has been comparatively effective at averting premature deaths once AF/AFL is manifest, whereas other regions - especially Southeast Asia - struggle to deliver guideline-concordant stroke prophylaxis or rate/rhythm control.
中国房颤/全身性肺病死亡率从 16 449 例（13 240-20 521 例）增至 64 728 例（51 765-77 729 例）翻了两番，但年龄标准化死亡率（ASMR）从每 10 万人 4.93 例下降至 4.33 例（AAPC -0.78%），是所有研究地区中下降幅度最大的。相反，东南亚的 ASMR 从 2.94 上升到 4.06 （AAPC 0.76%），欧洲从 4.92 上升到 5.10，全球从 4.24 上升到 4.36。这些模式表明，一旦出现房颤/心房颤动，中国的卫生系统在避免过早死亡方面相对有效，而其他地区 （ 尤其是东南亚 ） 则难以提供符合指南的中风预防或心率/节律控制。

3.1.4 Disability-adjusted life-years (DALYs)
3.1.4 伤残调整生命年 （DALYs）

DALYs in China surged from 508 610 (395 853-638 618) to 1.65 million (1.30-2.06), but age-standardized DALY rate (ASDR) slipped slightly from 93.29 to 89.76 per 100 000 (AAPC －0.32 %). Southeast Asia, Europe and the global average all recorded net increases in ASDR. The combination of rising absolute DALYs but falling rates in China underscores rapid population ageing: years lived with disability accumulate, yet the average individual loses fewer life-years than three decades ago (Table 1, 2).
中国的 DALY 从 508 610 （395 853-638 618） 飙升至 165 万 （1.30-2.06），但年龄标准化 DALY 率 （ASDR） 从 93.29 略有下滑至 89.76/100 000 （AAPC -0.32%）。东南亚、欧洲和全球平均水平的 ASDR 均录得净增长。中国绝对 DALY 上升但死亡率下降，凸显了人口快速老龄化：残疾年限不断累积，但平均个人损失的生命年数比三十年前少 （表 1、2）。

Table 1 All-age cases incidence, prevalence, mortality, and DALYs rates of AF/AFL in China, South-East Asia Region, European Region and Global in 1990,2019,2020 and 2021.
表 1 1990 年、2019 年 、2020 年和 2021 年中国、东南亚地区、欧洲地区和全球 AF/AFL 各年龄段病例发病率、患病率、死亡率和 DALYs 发生率 。

Table 2 Age-standardized incidence, prevalence, mortality, DALYs rates and corresponding AAPC of AF/AFL in China, South-East Asia Region, European Region and Global in 1990,2019,2020 and 2021.
表 2 1990 年、2019 年、2020 年和 2021 年中国、东南亚地区、欧洲地区和全球房颤/肺萎缩症的年龄标准化发病率、患病率、死亡率、DALYs 发生率及相应 AAPC。

3.2 Temporal trends in AF/AFL burden from 1990 to 2021.
3.2 1990—2021 年 AF/AFL 负担时间趋势 。

3.2.1 Incidence trends
3.2.1 发病趋势

Joinpoint regression identified two distinct epochs in China: (i) 2000-2005 (APC 1.60 %) and (ii) 2015-2021 (APC 1.21 %), both statistically significant (p < 0.05) (Fig. 1A). A transient downturn (2005-2010) coincided with nationwide antihypertensive campaigns; however, the long-term slope remains upward, mirroring Southeast Asia and contrasting with Europe’s steady decline (Fig. 1B and 1C). After 2019, the COVID-19 pandemic coincided with an abrupt spike in ASIR in China, Europe and globally - plausibly through delayed diagnoses, inflammatory milieu and healthcare disruptions—whereas Southeast Asia recorded no inflection.
Joinpoint 回归确定了中国的两个不同时期：（i）2000-2005 年 （APC 1.60%）和（ii）2015-2021 年（APC 1.21%），均具有统计学意义（p < 0.05）（ 图。 1A） 的。短暂的低迷（2005-2010 年 ）恰逢全国范围内的抗高血压运动;然而，长期斜率仍然向上，反映了东南亚，与欧洲的稳步下降形成鲜明对比 （ 图 1）。 1B 和 1C）。2019 年之后，COVID-19 大流行恰逢中国、欧洲和全球 ASIR 的突然飙升 —— 可能是由于诊断延迟、炎症环境和医疗保健中断——而东南亚则没有出现拐点。

3.2.2 Prevalence trends
3.2.2 流行趋势

China’s ASPR exhibited sustained growth punctuated by a brief 2005-2010 dip (APC －0.3 %) (Fig. 1E). The most recent segment (2015-2021, APC 1.30 %) aligns with intensified secondary prevention (oral anticoagulation uptake > 40 % among high-risk patients) but is insufficient to offset demographic expansion. Parallel trajectories in Southeast Asia diverge after 2019 (Fig. 1F), when prevalence accelerated further, while Europe plateaued (Fig. 1G).
中国的 ASPR 表现出持续增长，但 2005-2010 年出现短暂下降（APC -0.3%）（ 图。 1E） 的。最近的部分（2015-2021 年，APC 1.30 %）与强化二级预防（高危患者口服抗凝摄取率 > 40%）一致，但不足以抵消人口扩张。2019 年后东南亚的平行轨迹出现分歧 （ 图。 1F）， 当患病率进一步加速时，而欧洲趋于稳定 （ 图。 1G） 的。

3.2.3 Mortality trends
3.2.3 死亡率趋势

China’s ASMR declined in two windows (2004-2007 APC －3.78 %; 2010-2013 APC －4.12 %), interrupted by a modest rebound (2007-2010 APC 0.67 %) (Fig. 2A). The net downward drift reflects cumulative gains in acute stroke care, anticoagulation and integrated AF management. Conversely, Southeast Asia, Europe and the globe experienced rising ASMR until 2019; thereafter Europe and the globe recorded sharp COVID-era declines, whereas China’s trajectory remained comparatively stable.
中国的 ASMR 在两个窗口内下降（2004-2007 年 APC -3.78%;2010-2013 年 APC -4.12%），随后被温和反弹（2007-2010 年 APC 0.67%） 所打断 （ 图。 2A）。 净下降趋势反映了急性中风护理、抗凝和综合房颤管理的累积收益。相反，东南亚、欧洲和全球的 ASMR 在 2019 年之前都在上升;此后，欧洲和全球在新冠疫情期间出现了急剧下降，而中国的发展轨迹则保持相对稳定。

3.2.4 DALY trends
3.2.4 DALY 趋势

China’s ASDR fell between 2004 and 2015, yet an upswing since 2016 (APC 1.56 %) suggests that quality-of-life improvements are eroding under the weight of aging, multimorbidity and healthcare inequality (Fig. 2E). Europe achieved sustained post-2004 reductions that steepened during the pandemic (Fig. 2G), whereas Southeast Asia’s ASDR rose monotonically (Fig. 2F).
中国的 ASDR 在 2004 年至 2015 年期间有所下降，但自 2016 年以来的上升（APC 1.56%）表明，在老龄化、多种疾病和医疗保健不平等的重压下，生活质量的改善正在受到侵蚀（图 2E）。欧洲在 2004 年后实现了持续的下降，并在大流行期间急剧下降（图 2G），而东南亚的 ASDR 则单调上升（图 2F）。

Figure 1. The Annual Percentage Change (APC) of ASIR and ASPR in China, South-East Asia Region, European Region and Global in 1990 and 2021 (*P < 0.05 and significant results).
图 1. 1990 年和 2021 年中国、东南亚地区、欧洲地区和全球 ASIR 和 ASPR 的年百分比变化（APC）（*P < 0.05，结果有统计学意义）。

(A) The APC of ASIR in China; (B)The APC of ASIR in South-East Asia Region; (C) The APC of ASIR in European Region; (D) The APC of ASIR in Global; (E) The APC of ASPR in China; (F) The APC of ASPR in South-East Asia Region; (G) The APC of ASPR in European Region; (H) The APC of ASPR in Global
（A） ASIR 在中国的 APC;（二）东南亚地区 ASIR 的 APC;（c） ASIR 在欧洲区域的 APC;（D） 全球 ASIR 的 APC;（E） 中国 ASPR 的 APC;（f） 东南亚区域 ASPR 的 APC;（g） 欧洲区域 ASPR 的 APC;（H） 全球 ASPR 的 APC

(A) The APC of ASMR in China; (B)The APC of ASMR in South-East Asia Region; (C) The APC of ASMR in European Region; (D) The APC of ASMR in Global; (E) The APC of ASDR in China; (F) The APC of ASDR in South-East Asia Region; (G) The APC of ASDR in European Region; (H) The APC of ASDR in Global
（A）中国 ASMR 的 APC;（二）东南亚地区 ASMR 的 APC;（c） 欧洲区域 ASMR 的 APC;（D） 全球 ASMR 的 APC;（E） 中国 ASDR 的 APC;（f） 东南亚区域 ASDR 的 APC;（g） ASDR 在欧洲区域的 APC;（H） 全球 ASDR 的 APC.

3.3 Age-specific burden profiles in AF/AFL.
3.3 AF/AFL 中特定年龄的负担概况 。

3.3.1 Incidence by age
3.3.1 按年龄划分的发病率

Across all regions, crude incidence peaks at 65-74 years. In China, however, the modal age shifted downwards from 70-74 in 1990 to 65-69 in 2021, hinting at earlier onset driven by cardiometabolic risk accumulation (Fig.3A). By contrast, Southeast Asia, Europe and the global average recorded upward shifts to 70-74 years. Notably, China is the only region where incidence in (40-49)-year-olds declined continuously after 1990, a testament to primary prevention successes among working-age adults.
在所有地区，粗发病率在 65-74 岁达到峰值 。然而，在中国，模式年龄从 1990 年的 70-74 岁向下移动到 2021 年的 65-69 岁，暗示心脏代谢风险积累导致发病提前 （ 图 1990 年）。3A） 的。相比之下，东南亚、欧洲和全球平均水平则向上移动至 70-74 岁。值得注意的是，中国是唯一一个在 1990 年后 （40-49） 岁人群发病率持续下降的地区，这证明了工作年龄成年人的一级预防取得了成功。

3.3.2 Prevalence by age
3.3.2 按年龄划分的患病率

Prevalence distributions mirror incidence: China’s peak moved from 70-74 to 65-69, and the 40-49 bracket declined (Fig. 3E). Southeast Asia exhibited the only net increase in age-standardized prevalence across all age groups, reflecting both longer survival and rising incidence (Fig. 3F). Europe’s standardized peak occurred at 75-79, slightly older than the crude peak - indicating selective survival and diagnostic intensity among the oldest old (Fig. 3G).
患病率分布反映了发病率：中国的峰值从 70-74 岁移动到 65-69 岁 ，40-49 岁范围下降 （ 图。3E） 的。东南亚在所有年龄组中表现出年龄标准化患病率的唯一净增长，反映了生存期的延长和发病率的上升 （ 图。3F） 的。欧洲的标准化峰值出现在 75-79 岁， 略早于粗峰值 —— 表明最年长老年人的选择性生存和诊断强度 （ 图。3G）。

3.3.3 Mortality by age
3.3.3 按年龄划分的死亡率

Deaths concentrate at 80-94 years. In China the mortality peak migrated from 80-84 to 85-89, while crude rates above age 74 fell below 1990 levels - consistent with therapeutic progress (Fig. 4A). Southeast Asia displayed the opposite pattern: post-2019 mortality exceeded 1990 levels above age 70, underscoring lagging stroke prevention (Fig. 4B).
死亡集中在 80-94 岁。在中国，死亡率峰值从 80-84 岁迁移到 85-89 岁 ，而 74 岁以上的粗死亡率低于 1990 年的水平 —— 与治疗进展一致 （ 图 1990 4A）。 东南亚则表现出相反的模式：2019 年后 70 岁以上的死亡率超过 1990 年的水平，凸显了中风预防滞后 （ 图 1990）。4B） 的。

3.3.4 DALYs by age
3.3.4 按年龄划分的 DALY

DALYs peak at 80-84 years across regions. China’s burden shifted from 70-79 to 80-84, with post-2019 levels below 1990 - again suggesting successful compression of morbidity (Fig. 4E). Southeast Asia recorded DALY rates above 1990 levels beyond age 70, echoing its mortality findings (Fig. 4F).
各地区的 DALY 在 80-84 岁达到峰值 。中国的负担从 70-79 岁转变为 80-84 岁 ，2019 年后的水平低于 1990 年 ， 这再次表明发病率的压缩成功 （ 图。4E） 的。东南亚记录的 DALY 率高于 1990 年 70 岁以上的水平，与其死亡率调查结果相呼应 （ 图 1990）。 4F） 的。

Figure 3. Comparative of the incidence, prevalence, deaths, and DALYs counts, along with their crude rates, by age group from 1990 to 2021.
图 3.比较 1990 年至 2021 年按年龄组划分的发病率、患病率、死亡率和 DALY 计数及其粗率 。

(A) Incident cases and CIR in China; (B) Incident cases and CIR in South-East Asia Region; (C) Incident cases and CIR in European Region; (D) Incident cases and CIR in Global; (E) Prevalent cases and CPR in China; (F) Prevalent cases and CPR in South-East Asia Region; (G)Prevalent cases and CPR in European Region; (H) Prevalent cases and CPR and CIR in Global.
（A） 中国的事件案例和 CIR;（b） 东南亚区域的事件个案和 CIR;（C） 欧洲区域的事件病例和 CIR;（D） 全球事件案例和 CIR;（E）中国流行病例和心肺复苏术;（f） 东南亚区域的流行病例和心肺复苏术;（庚）欧洲地区的流行病例和心肺复苏术;（H） 全球流行病例以及心肺复苏术和 CIR。

Figure 4. Comparative of the incidence, prevalence, deaths, and DALYs counts, along with their crude rates, by age group from 1990 to 2021
图 4.1990 年至 2021 年按年龄组划分的发病率、患病率、死亡人数和 DALYs 计数及其粗率的比较.

(A) Death cases and CMR in China; (B)Death cases and CMR in South-East Asia Region; (C) Death cases and CMR in European Region; (D) Death cases and CMR in Global; (E) DALYs counts and CDR in China; (F) DALYs counts and CDR in South-East Asia Region; (G) DALYs counts and CDR in European Region; (H) DALYs counts and CDR in Global
（A） 中国的死亡病例和 CMR;（二）东南亚区域死亡病例和 CMR;（C） 欧洲区域的死亡病例和 CMR;（D） 全球死亡病例和 CMR;（E） 中国的 DALY 计数和 CDR;（F） 东南亚区域的 DALYs 计数和 CDR;（G） 欧洲区域的 DALY 计数和 CDR;（H） 全球的 DALY 计数和 CDR.

3.4 Sex disparities in AF/AFL burden.
3.4 AF/AFL 负担的性别差异 。

3.4.1 Incidence
3.4.1 发生率

In 1990, Chinese men peaked at 65-69 years, women at 70-74 (Fig. 5A). By 2021 the sex-specific modal ages remained unchanged, yet after age 80 female incidence eclipsed male incidence - a pattern replicated in Southeast Asia, Europe and globally. This feminisation of late-life AF/AFL reflects women’s greater longevity and possibly differential autonomic, hormonal or atrial substrate effects.
1990 年，中国男性在 65-69 岁达到峰值 ，女性在 70-74 岁达到峰值 （ 图。 5A）。 到 2021 年，特定性别的模式年龄保持不变，但在 80 岁之后，女性发病率超过了男性发病率 —— 这种模式在东南亚、欧洲和全球范围内都得到了复制。晚年 AF/AFL 的这种女性化反映了女性更长的寿命以及可能不同的自主神经、激素或心房基质效应。

4.2 Prevalence
4.2 患病率

Prevalence sex ratios follow incidence patterns. Globally, however, women exhibit a broader plateau (70-84 years) in 2021 (Fig. 5P), implying longer duration of disease and delayed mortality. China’s sex gap is less pronounced than Europe’s, where female prevalence beyond age 80 surpasses male prevalence by 30-40 %.
患病率性别比遵循发病率模式。然而，在全球范围内，女性在 2021 年表现出更广泛的平台期（70-84 岁）（ 图 1 5P）， 意味着病程更长，死亡率更晚。中国的性别差距不如欧洲明显，欧洲 80 岁以上的女性患病率比男性高出 30-40%。

4.3 Mortality
4.3 死亡率

Chinese female deaths exceeded male deaths beyond age 70 in both 1990 and 2021 (Fig. 6A, 6E); the divergence becomes extreme above age 85. Southeast Asia displayed a smaller sex gradient, suggesting either competing causes of death or under-diagnosis in women.
1990 年和 2021 年，中国女性死亡人数均超过 70 岁以上男性死亡人数（ 图 6A、6E）;85 岁以上差异极大。东南亚的性别梯度较小，这表明女性的死亡原因要么相互竞争，要么诊断不足。

4.4 DALYs
4.4 每日

DALY sex ratios mirror mortality, but the female excess is attenuated in China and globally, implying that women’s longer survival is partly offset by lower disability weights or better functional status. Europe again showed the starkest female excess (Fig. 6K, 6O).
DALY 性别比反映了死亡率，但女性的过剩在中国和全球都有所减弱，这意味着女性的生存时间更长被较低的残疾体重或更好的功能状态部分抵消。欧洲再次显示出最明显的女性过剩 （ 图。6K，6 O）。

Fig. 5. Comparison of of the number incidence and prevalence of AF/AFL in males and females of different age groups in China, South-East Asia Region, European Region and Global in 1990 and 2021. (A) 1990 number of incidence in China; (B) 1990 number of incidence in South-East Asia Region; (C) 1990 number of incidence in European Region; (D) 1990 number of incidence in Global; (E) 2021 number of incidence in China; (F) 2021number of incidence in South-East Asia Region; (G) 2021 number of incidence in European Region; (H) 2021 number of incidence in Global; (I) 1990 number of prevalence in China; (J) 1990 number of prevalence in South-East Asia Region; (K) 1990 number of prevalence in European Region; (L) 1990 number of prevalence in Global; (M) 2021 number of prevalence in China; (N) 2021 number of prevalence in South-East Asia Region; (O) 2021 number of prevalence in European Region; (P) 2021 number of prevalence in Global
图 5 1990 年和 2021 年中国、东南亚地区、欧洲地区和全球不同年龄组男女房颤/房颤发病率的发病率和患病率对比。（A）1990 年中国发病率;（B） 1990 年东南亚区域发病率;（C） 1990 年欧洲区域发病率;（D） 1990 年全球发病率;（E）2021 年中国发病数;（F）2021 年东南亚地区发病数;（G）2021 年欧洲地区发病率;（H） 2021 年全球发病率;（一）1990 年中国患病率;（J） 1990 年东南亚区域的患病率;（K） 1990 年欧洲区域的患病率;（L） 1990 年全球流行率;（M）2021 年中国患病率;（N）东南亚地区 2021 年患病率;（O）2021 年欧洲地区患病率;（P） 2021 年全球患病率.

Figure 6. Comparison of of the number mortality and DALYs of AF/AFL in males and females of different age groups in China, South-East Asia Region, European Region and Global in 1990 and 2021. (A) 1990 number of mortality in China; (B) 1990 number of mortality in South-East Asia Region; (C) 1990 number of mortality in European Region; (D) 1990 number of mortality in Global; (E) 2021 number of mortality in China; (F) 2021number of mortality in South-East Asia Region; (G) 2021 number of mortality in European Region; (H) 2021 number of mortality in Global; (I) 1990 number of DALYs in China; (J) 1990 number of DALYs in South-East Asia Region; (K) 1990 number of DALYs in European Region; (L) 1990 number of DALYs in Global; (M) 2021 number of DALYs in China; (N) 2021 number of DALYs in South-East Asia Region; (O) 2021 number of DALYs in European Region; (P) 2021 number of prevalence in Global
研究 6 1990 年和 2021 年中国、东南亚地区、欧洲地区和全球不同年龄组男女房颤/肺病死亡率及 DALYs 比较 。（A） 1990 年中国死亡人数; （B） 1990 年东南亚区域死亡人数;（C） 1990 年欧洲区域的死亡率;（D） 1990 年全球死亡率 ; （E）2021 年中国死亡人数; （F） 2021 年东南亚区域死亡人数;（G） 2021 年欧洲区域死亡人数;（H） 2021 年全球死亡率 ; （ 一 ）1990 年中国 DALY 数量; （J） 1990 年东南亚区域的 DALY 数量 ;（K） 1990 年欧洲区域的 DALY 数量 ;（L） 1990 年全球 DALY 数量 ; （M）2021 年中国 DALY 数量; （N） 2021 年东南亚地区 DALY 数量;（O） 2021 年欧洲地区 DALY 数量 ;（P） 2021 年全球 p 流行率 .

3.5 Age-period-cohort (APC) modelling in AF/AFL burden.
3.5 AF/AFL 负担中的年龄-期-队列 （APC） 建模 。

3.5.1 China
3.5.1 中国

Age deviation curves for incidence and prevalence displayed a U-shaped reversal: risk rises from age 30, peaks at 50-55, then declines until age 85, hinting at a mid-life “vulnerable window” related to hypertension and obesity amplification. Mortality and DALY deviations became increasingly negative after age 70, consistent with effective geriatric care (Fig. 7A). Period effects (2005 baseline) revealed an early-2000s rise followed by a post-2015 rebound (Fig. 7C), while cohort effects (1940 baseline) showed initial risk declines for generations born after 1960, then renewed increases - likely reflecting obesogenic environments (Fig. 7D).
发病率和患病率的年龄偏差曲线呈现 U 形反转：风险从 30 岁开始上升，在 50-55 岁达到峰值 ，然后下降到 85 岁，暗示与高血压和肥胖放大相关的中年“脆弱窗口”。70 岁后死亡率和 DALY 偏差变得越来越负，这与有效的老年护理一致 （ 图 7A）。 周期效应（2005 年基线）显示 2000 年代初上升，随后在 2015 年后反弹 （ 图 7C）， 而队列效应（1940 年基线）显示 1960 年之后出生的几代人的风险最初下降，然后重新增加 - 可能反映了致肥胖环境 （ 图 1940）。 7D）。

Figure 7. Age-period-cohort analysis of China AF/AFL burden from 1992 to 2021.
图 7.1992—2021 年中国 AF/AFL 负担年龄段队列分析。

(A) Age Deviation (B) Longitudinal Age Curves; (C) Period Rate Ratio (D) Cohort Rate Ratio
（a）年龄偏差（b）纵向年龄曲线;（C） 周期率比 （D） 队列率比

3.5.2 Southeast Asia
3.5.2 东南亚

Age deviation peaks were delayed (incidence 65-70, prevalence 55-60) (Fig. 8A). Period effects rose monotonically, diverging from China’s mid-2000s inflection (Fig. 8C). Cohort effects exhibited a sharp drop for the 1970 birth cohort, possibly linked to economic transition and changing dietary patterns (Fig. 8D).
年龄偏差峰值延迟（发病率 65-70，患病率 55-60）（ 图。8A）。 周期效应单调上升，与中国 2000 年代中期的拐点不同 （ 图。8C）。1970 年出生队列的队列效应急剧下降，可能与经济转型和饮食模式的变化有关 （ 图 1970 年出生队列 8D） 的。

Figure 8. Age-period-cohort analysis of South-East Asia Region AF/AFL burden from 1992 to 2021.
图 8.1992—2021 年东南亚地区 AF/AFL 负担的年龄-期-队列分析。

(A) Age Deviation (B) Longitudinal Age Curves; (C) Period Rate Ratio (D) Cohort Rate Ratio
（a）年龄偏差（b）纵向年龄曲线;（C） 周期率比 （D） 队列率比

3.5.3 Europe
3.5.3 欧洲

Age deviation patterns resembled China, but incidence peaked at 65-70 and prevalence exhibited a secondary crest at 80-84, illustrating differential survival (Fig. 9A). Period effects turned downward after 2005 for all indicators except mortality (p > 0.05) (Fig. 9C), while cohort effects showed early-century risk declines - consistent with aggressive primary prevention (Fig. 9D).
年龄偏差模式与中国相似，但发病率在 65-70 岁时达到峰值，患病率在 80-84 岁时表现出次级波峰，说明生存率差异（图 9A）。2005 年后，除死亡率外的所有指标的时期效应均呈下降趋势（p > 0.05）（图 9C），而队列效应则显示出本世纪初的风险下降——与积极的一级预防一致（图 9D）。

Figure 9. Age-period-cohort analysis of European Region AF/AFL burden from 1992 to 2021.
图 9.1992 年至 2021 年欧洲地区 AF/AFL 负担的年龄期队列分析。

(A) Age Deviation (B) Longitudinal Age Curves; (C) Period Rate Ratio (D) Cohort Rate Ratio
（a）年龄偏差（b）纵向年龄曲线;（C） 周期率比 （D） 队列率比.

3.5.4 Global
3.5.4 全球

Global age deviations followed the European template (Fig. 10A). Period effects dipped after 2005 but rebounded post-2015 (Fig. 10C). signalling uneven diffusion of interventions. Cohort effects traced a 1960-born dip followed by a late-century rise, mirroring globalisation of cardiometabolic risk (Fig. 10D).
全球年龄偏差遵循欧洲模板 （ 图。10A）。 周期效应在 2005 年之后下降，但在 2015 年之后反弹 （ 图。10C）。 表明干预措施的传播不均匀。队列效应追溯了 1960 年出生的下降，然后是本世纪末的上升，反映了心脏代谢风险的全球化 （ 图 196010D）。

Figure 10. Age-period-cohort analysis of Global AF/AFL burden from 1992 to 2021.
图 10.1992 年至 2021 年全球 AF/AFL 负担的年龄期队列分析。

(A) Age Deviation (B) Longitudinal Age Curves; (C) Period Rate Ratio (D) Cohort Rate Ratio
（a）年龄偏差（b）纵向年龄曲线;（C） 周期率比 （D） 队列率比.

3.6 Forecasting of AF/AFL burden from 2022 to 2050.
3.6 2022-20 年 AF/AFL 负担预测 5 0.

3.6.1 China
3.6.1 中国

Nationwide ASIR and ASPR are projected to rise modestly (≈ 5-7 % by 2050) (Fig. 11A and 11B). with minimal sex divergence. ASMR will continue to decline (≈ －10 %) (Fig. 11C). while ASDR remains flat-indicating that ageing-related incident cases will be counterbalanced by survival gains (Fig. 11D).
全国范围内的 ASIR 和 ASPR 预计将小幅上升（ 到 2050 年≈ 5-7%）（ 图 1 图 11A 和 11B）。 性别差异最小。ASMR 将继续下降（≈-10%）（ 图。11C）。 而 ASDR 保持持平 ，表明与衰老相关的事件病例将被生存率的提高所抵消 （ 图 11D）。

3.6.2 Southeast Asia
3.6.2 东南亚

Both ASIR and ASPR are forecast to fall markedly (≈ －15 %) (Fig. 11E and 11F). driven by demographic stabilisation and accelerating risk-factor control. ASMR and ASDR will also decline, narrowing the gap with China (Fig. 11G and 11H).
预计 ASIR 和 ASPR 都将显着下降（≈-15%）（ 图。11E 和 11F）。 在人口稳定和加速风险因素控制的推动下。ASMR 和 ASDR 也将下降，缩小与中国的差距 （ 图。11G 和 11H）。

3.6.3 Europe
3.6.3 欧洲

ASIR and ASPR will edge upward (≈ 3 %) (Fig. 12A and 12B). but ASMR is predicted to fall heterogeneously - female ASMR declining faster than male, reflecting sex-specific uptake of novel oral anticoagulants (NOACs) and catheter ablation (Fig. 12C).
ASIR 和 ASPR 将小幅上升（≈3%）（ 图。12A 和 12B）。 但预计 ASMR 将异质性下降 - 女性 ASMR 下降速度快于男性，反映了新型口服抗凝剂 （NOAC） 和导管消融的性别特异性吸收 （ 图 112C） 的。

3.6.4 Global
3.6.4 全球

Global ASIR and ASPR will increase slightly, propelled by low- and middle-income countries (LMICs) (Fig. 12E and 12F). Female ASIR/ASPR growth will outpace male, yet female ASMR/ASDR will decline more steeply, suggesting an emerging gender paradox of better risk-factor management in women (Fig. 12G and 12H).
在中低收入人口 （LMIC） 的推动下，全球 ASIR 和 ASPR 将略有上升 （ 图。12E 和 12F）。 女性 ASIR/ASPR 的增长速度将超过男性，但女性 ASMR/ASDR 的下降幅度更大 ， 这表明女性中存在更好的风险因素管理的新性别悖论 （图 112G 和 12H）。

Figure 11. Predictions of AF/AFL trends was projected by BAPC-INLA model
图 11.通过 BAPC-INLA 模型预测 AF/AFL 趋势的预测.

The projected ASRs of incidence (A), prevalence (B), death (C), and DALYs (D) for AF/AFL by sex from in China form 1990 to 2050. The projected ASRs of incidence (E), prevalence (F), death (G), and DALYs (H) for AF/AFL by sex from in South-East Asia Region form 1990 to 2050,. The dots represent the observed values, and the fan shape represent the predictive distribution between the 2.5 and 97.5 % quantiles. The solid line represents the predicted ASRs during 2020-2050.
1990—2050 年中国按性别划分的房颤/房颤发病发病率（A）、患病率（B）、死亡率（C）和 DALYs（D）的预测 ASR。1990 年至 2050 年东南亚地区按性别划分的 AF/AFL 发病率 （E）、患病率 （F）、死亡率 （G） 和 DALY （H） 的预测 ASR。点代表观测值，扇形代表 2.5% 和 97.5 % 分位数之间的预测分布。实线代表 2020-2050 年预测的 ASR。

Figure 12. Predictions of AF/AFL trends was projected by BAPC-INLA model
图 12.通过 BAPC-INLA 模型预测 AF/AFL 趋势的预测.

The projected ASRs of incidence (A), prevalence (B), death (C), and DALYs (D) for AF/AFL by sex from in European Region form 1990 to 2050. The projected ASRs of incidence (E), prevalence (F), death (G), and DALYs (H) for AF/AFL by sex from in Global form 1990 to 2050,. The dots represent the observed values, and the fan shape represent the predictive distribution between the 2.5 and 97.5 % quantiles. The solid line represents the predicted ASRs during 2020–2050.
1990 年至 2050 年欧洲地区按性别划分的 AF/AFL 发病率 （A）、患病率 （B）、死亡率 （C） 和 DALY （D） 的预测 ASR。1990 年至 2050 年按性别划分的 AF/AFL 发病率 （E）、患病率 （F）、死亡率 （G） 和 DALY （H） 的预测 ASR。点代表观测值，扇形代表 2.5% 和 97.5 % 分位数之间的预测分布。实线代表 2020-2050 年期间预测的 ASR。

3.7 Decomposition analysis in AF/AFL burden from 1990 to 2021.
3.7 1990—2021 年 AF/AFL 负荷分解分析 。

Between 1990 and 2021, population growth accounted for 68 % of the increase in incident cases in China; aging contributed 24 % and epidemiological change －8 %. The same pattern held for prevalence. For mortality, population growth contributed 52 %, ageing 48 %, but epidemiological change contributed －35 %, attesting to the life-saving impact of anticoagulation, rate control and integrated stroke systems. Globally, population growth dominated incidence and prevalence increases, while Europe experienced the largest epidemiological dividend in mortality (－42 %), plausibly through widespread NOAC adoption and AF catheter ablation programmes (Fig. 13).
1990 年至 2021 年间，人口增长占中国发病病例增长的 68%;老龄化占 24%，流行病学变化占-8%。同样的模式也适用于流行。死亡率方面，人口增长贡献了 52%，老龄化贡献了 48%，但流行病学变化贡献了 -35%，证明了抗凝、心率控制和综合中风系统的挽救生命的影响。在全球范围内，人口增长主导了发病率和患病率的增加，而欧洲的死亡率在流行病学方面取得了最大的红利（-42%），这可能是通过广泛的 NOAC 采用和 AF 导管消融计划（ 图 1999 年）。13） 的。

Figure 13. Impact of Aging, Epidemiological Shifts, and Population Growth on AF/AFL Burden (1990-2021) in China, South-East Asia Region, European Region and Global
图 13.老龄化、流行病学变化和人口增长对中国、东南亚地区、欧洲地区和全球 AF/AFL 负担的影响（1990-2021 年）.

(A)Incidence (B)Prevalence (C)Death (D)DALYs
（一）发病率 （B）患病率 （C）死亡 （D）DALYs.

3.8 Frontier analysis in AF/AFL burden base on SDI index from 1990 to 2021.
3.8 基于 1990—2021 年 SDI 指数的 AF/AFL 负荷前沿分析 。

Using data-envelopment analysis with 100-bootstrap iterations, we constructed efficiency frontiers linking Socio-demographic Index (SDI) to ASMR and ASDR for 200+ countries, 1980-2021. In 2021 China (orange) lay markedly closer to the frontier than in 2019 (blue), outperforming many high-SDI European nations (purple), which drifted rightward - indicating rising mortality despite affluence. Singapore (green) remained on the frontier across high SDI values, exemplifying optimal AF care. Frontier convergence accelerated with SDI, yet dispersion widened post-2015 among high-income countries, signalling that income alone does not guarantee efficiency. China’s trajectory suggests that policy-driven improvement (national stroke screening, tiered diagnosis, universal NOAC reimbursement) can yield outsized mortality reductions even at moderate SDI levels.
使用具有 100 次引导迭代的数据包络分析，我们构建了 1980-2021 年 200+ 个国家的社会人口指数 （SDI） 与 ASMR 和 ASDR 联系起来的效率前沿 。2021 年，中国（橙色）明显比 2019 年（蓝色）更接近边境，优于许多向右偏移的高 SDI 欧洲国家（紫色 ）， 表明尽管富裕，但死亡率仍在上升。新加坡 （绿色）在高 SDI 值方面仍然处于前沿，体现了最佳的 AF 护理。随着 SDI 的加速，前沿趋同加速，但 2015 年后，高收入国家之间的分散扩大，这表明仅靠收入并不能保证效率。中国的发展轨迹表明，即使在中等 SDI 水平下，政策驱动的改进（全国中风筛查、分层诊断、普遍 NOAC 报销）也可以大幅降低死亡率。

Taken together, these findings portray China as a region where demographic momentum and mid-life risk-factor surges inflate incidence and prevalence, yet aggressive downstream management compresses mortality and disability. Southeast Asia faces an earlier-stage transition, Europe confronts plateauing incidence but persistent late-life mortality, and the global average reflects a mosaic of unmet need and emerging success stories (Fig. 14 and Fig. 15).
综上所述，这些发现将中国描绘成一个人口势头和中年风险因素激增导致发病率和患病率上升的地区，但积极的下游管理却压缩了死亡率和残疾。东南亚面临早期转型，欧洲发病率趋于稳定，但晚年或期持续存在 ，全球平均水平反映了未满足的需求和新兴成功案例的马赛克 （图。14 和图 1。15）。

Figure 14. Frontier analysis of ASMR for AF/AFLbased on the SDI from 1990 to 2021.
图 14.1990—2021 年基于 SDI 的 AF/AFLASMR 前沿分析

(A) Global Mortality Patterns by SDI. ASMR for AF/AFL vs. SDI values across countries. Points colored red indicate ASMR increased since 2019, blue indicates decreased. China (orange-red), European (purple), and Southeast Asian (green) countries are highlighted. (B) Spatiotemporal dynamic distribution of ASMR. Color gradient (light to dark blue) denotes year progression (1990 to 2020).
（A） 按 SDI 分列的全球死亡率模式。AF/AFL 与不同国家/地区 SDI 值的 ASMR。红色点表示 ASMR 自 2019 年以来有所增加，蓝色表示有所下降。突出显示了中国（橙红色）、欧洲（紫色）和东南亚（绿色）国家。（B）ASMR 的时空动态分布。颜色渐变（浅蓝色到深蓝色）表示年份递进（1990 年至 2020 年）。

Figure 15. Frontier analysis of ASDR for AF/AFL based on the SDI from 1990 to 2021.
图 15.1990—2021 年基于 SDI 的 AF/AFLASDR 前沿分析

(A) Global DALYs Patterns by SDI. ASDR for AF/AFL vs. SDI values across countries. Points colored red indicate ASDR increased since 2019, blue indicates decreased. China (orange-red), European (purple), and Southeast Asian (green) countries are highlighted. (B) Spatiotemporal dynamic distribution of ASDR. Color gradient (light to dark blue) denotes year progression (1990 to 2020).
（A） SDI 的全球 DALY 模式。AF/AFL 与 SDI 值的 ASDR 跨国家/地区。红色点表示 ASDR 自 2019 年以来有所增加，蓝色表示有所下降。突出显示了中国（橙红色）、欧洲（紫色）和东南亚（绿色）国家。（B）ASDR 的时空动态分布。颜色渐变（浅蓝色到深蓝色）表示年份递进（1990 年至 2020 年）。

Discussion
讨论

AF/AFL have emerged as dominant contributors to global cardiovascular morbidity, and the GBD 1990-2021 repository now allows us to trace their footprint with unprecedented precision. Worldwide, 52.6 million people lived with AF/AFL in 2021, 4.5 million were newly diagnosed, 8.36 million DALYs were accrued, and 340 000 deaths were recorded. China alone accounted for 10.8 million prevalent cases, 0.91 million incident cases, 165,000 DALYs and 60,000 deaths-figures that dwarf those of entire continents. Yet the age-standardised mortality rate in China has fallen by 2.3 % per year since 2005, while Europe, despite lower absolute numbers, now records the highest regional ASMR. This divergence underscores that disease burden is a compound of demography, biology and health-system architecture; headline statistics, while sobering, can obscure the more nuanced story of who dies, when, and why.
AF/AFL 已成为全球心血管发病率的主要贡献者，GBD 1990-2021 存储库现在使我们能够以前所未有的精度追踪它们的足迹。2021 年，全球有 5260 万人患有 AF/AFL，450 万人新诊断，累积 836 万 DALY，记录了 34 万人死亡。仅中国就占了 1080 万例流行病例、91 万例发病病例、165000 例 DALY 和 60000 例死亡 —— 这些数字使整个大陆相形见绌。然而，自 2005 年以来，中国的年龄标准化死亡率每年下降 2.3%，而欧洲尽管绝对数字较低，但目前是地区 ASMR 最高的国家。这种差异强调，疾病负担是人口学、生物学和卫生系统结构的复合体;头条新闻虽然发人深省，但可能会掩盖谁死、何时死以及为什么死的更微妙的故事。

Joinpoint regression reveals a synchronised upward inflection in incidence and prevalence after 2019, coinciding with the COVID-19 pandemic. SARS-CoV-2 triggers atrial injury through ACE-2 down-regulation, cytokine storm and autonomic imbalance^23,24; population-level data from Sweden and the United States already show a 15-20 % relative rise in new AF within thirty days of infection²⁵. China’s strict containment measures and universal vaccination appear to have blunted this surge, allowing ASMR to continue its secular decline, whereas Europe experienced a transient but sharp drop in deaths that more likely reflects differential COVID-19 mortality than improved arrhythmia care. The episode illustrates how exogenous shocks can masquerade as therapeutic success, and why disentangling period effects from genuine health-system gains remains essential²⁶
Joinpoint 回归显示，2019 年之后发病率和患病率同步上升，与 COVID-19 大流行同时发生。SARS-CoV-2 通过 ACE-2 下调、细胞因子风暴和自主神经失衡引发心房损伤 ^23,24;瑞典和美国的人口水平数据已经显示 ， 在感染后 30 天内，新发房颤的相对增加 15-20%²⁵。中国严格的遏制措施和全民疫苗接种似乎减缓了这一激增，使 ASMR 继续长期下降，而欧洲的死亡人数经历了短暂但急剧下降，这更可能反映了 COVID-19 死亡率的差异，而不是心律失常护理的改善。这一事件说明了外源性休克如何伪装成治疗成功，以及为什么将经期影响与真正的卫生系统收益分开仍然至关重要 ²⁶.

Age-period-cohort (APC) modelling provides a nuanced understanding of AF/AFL burden across regions, revealing critical disparities that demand tailored interventions. Globally, relative risk follows an inverted U-shape, peaking at 60–74 years, but regional variations are stark, with a trend toward younger onset driven by modern lifestyle shifts such as fast-food culture in China and Southeast Asia, which exacerbate abdominal obesity and circadian rhythm disruptions, alongside genetic predispositions like MYBPC3 variants in European populations that heighten cardiomyopathy risks. Crucially, mid-life vulnerability (50–55 years) is amplified by comorbid metabolic disorders, particularly obstructive sleep apnea (OSA), whose pathological mechanisms involve intermittent hypoxia-induced oxidative stress and sustained sympathetic-adrenal axis activation; this increases vascular permeability, stimulates atrial β1-receptors, elevates autonomic tone, and shortens effective refractory periods, directly promoting atrial remodeling and AF initiation—underscoring OSA as a critically underestimated risk factor in recent studies.In China, age deviation curves exhibit a distinct U-shaped reversal, with risk rising sharply from age 30 to peak at 50–55 years—reflecting this "vulnerable window"—and declining post-85 due to effective geriatric care; Period effects diverge more starkly: China shows rising incidence but falling mortality since 2005, consistent with the third phase of the obesity-diabetes-AF transition in which acute cardiovascular care outpaces primary prevention²⁷; while cohort effects (1940 baseline) indicate initial declines for post-1960 births followed by increases mirroring cardiometabolic risk accumulation.Conversely. Southeast Asia displays delayed peaks (incidence at 65–70 years, prevalence at 55–60 years) and exhibits uniformly adverse period trends, reflecting widening rural–urban disparities and fragile primary-care systems²⁸. These patterns caution against one-size-fits-all policies: the same birth cohort may carry different risk trajectories across geographies, demanding age-specific and context-specific interventions^29,30. To address this in China, interventions must be age-stratified and context-specific, beginning with intensified early identification for 40–70-year-olds through AI-driven targeted screening (e.g., leveraging existing clinical data to enhance asymptomatic case detection, as supported by recent AI models that boost efficacy by 20–30% in community settings), combined with mobile ECG deployments in rural areas to bridge healthcare gaps; simultaneously, mid-life high-risk groups (50–55 years) require integrated metabolic management, such as OSA-pathway incorporation (e.g., routine polysomnography in primary care) and obesity control programs in urban hubs, while elderly-focused strategies must expand NOAC reimbursement and sex-specific approaches for women over 70 (who show higher mortality) to harness projected ASMR declines. Furthermore, policy enhancements should build on China's "Healthy China 2030" initiatives—which narrowed rural–urban divides through AF center networks and NOAC/LAAC coverage—by embedding multidisciplinary comorbidity management (e.g., diabetes–AF integrated clinics) and adopting APHRS's "ABC pathway" for holistic age-tailored care, ultimately mitigating burden amplification from aging and urbanization through precision public health.
年龄段队列 （APC） 模型提供了对各地区 AF/AFL 负担的细致入微的了解，揭示了需要量身定制干预措施的关键差异。在全球范围内，相对风险呈倒 U 形，在 60-74 岁达到峰值，但地区差异明显，现代生活方式的转变推动了年轻发病的趋势，例如中国和东南亚的快餐文化，加剧了腹部肥胖和昼夜节律紊乱，以及欧洲人群中的 MYBPC3 变异等遗传易感性，增加了心肌病风险。 至关重要的是，中年脆弱性（50-55 岁）会因合并代谢紊乱而放大，特别是阻塞性睡眠呼吸暂停 （OSA），其病理机制涉及间歇性缺氧诱导的氧化应激和持续的交感神经-肾上腺轴激活;这增加了血管通透性，刺激心房 β1 受体，提高了自主神经张力，并缩短了有效的不应期，直接促进了心房重塑和 AF 的启动——这突显了 OSA 在最近的研究中是一个被严重低估的风险因素。在中国，年龄偏差曲线呈现出明显的 U 形反转，风险从 30 岁急剧上升到 50-55 岁达到峰值——反映了这个“脆弱窗口”——而 85 岁后则由于有效的老年护理而下降; 经期效应差异更为明显：自 2005 年以来，中国的发病率上升，但死亡率下降，与肥胖-糖尿病-房颤过渡的第三阶段一致，其中急性心血管护理超过了一级预防 ²⁷;而队列效应（1940 年基线）表明 1960 年后出生的最初下降，随后增加，反映了心脏代谢风险的积累。相反。 东南亚出现延迟高峰（发病率为 65-70 岁，患病率为 55-60 岁），并表现出一致的不利时期趋势，反映出城乡差距的扩大和初级保健系统的脆弱性 ²⁸ 这些模式警告不要采取一刀切的政策：同一出生队列可能在不同地区携带不同的风险轨迹，需要针对特定年龄和特定环境的干预措施 ^29,30 为了在中国解决这个问题，干预措施必须按年龄分层和针对具体情况进行，首先是通过人工智能驱动的靶向筛查（例如，利用现有临床数据加强无症状病例检测，最近的人工智能模型支持，在社区环境中将疗效提高 20-30%），结合在农村地区部署移动心电图以弥合医疗保健差距;同时，中年高危人群（50-55 岁）需要综合代谢管理，例如 OSA 通路纳入（例如，初级保健中的常规多导睡眠图）和城市中心的肥胖控制计划，而以老年人为中心的战略必须扩大 NOAC 报销和针对 70 岁以上女性（死亡率较高）的性别特定方法，以利用预计的 ASMR 下降。 此外，政策的加强应以中国的“健康中国 2030”倡议为基础，通过 AF 中心网络和 NOAC/LAAC 覆盖范围缩小城乡差距，嵌入多学科合并症管理（例如，糖尿病-AF 综合诊所）并采用 APHRS 的“ABC 途径”进行全面的年龄定制护理，最终通过精准公共卫生减轻老龄化和城市化带来的负担放大。

Decomposition attributes 70 % of China’s increased prevalent cases to population growth and ageing, 22 % to worsening metabolic risk, and 8 % to improved survival. Europe, by contrast, sees demography contribute only 42 %, with the remainder driven by persistent obesity and hypertension. The arithmetic is sobering: without aggressive metabolic risk reduction, China could add another 1.9 million prevalent cases by 2035 even if incidence rates remain constant. Conversely, a five percent population-level reduction in BMI could avert 190 000 incident cases, underlining the outsized leverage of primordial prevention.
分解将中国 70% 的患病病例增加归因于人口增长和老龄化，22% 归因于代谢风险恶化，8% 归因于生存率的提高。相比之下，欧洲的人口结构仅占 42%， 其余由持续肥胖和高血压驱动。这个算术发人深省：如果不积极降低代谢风险，即使发病率保持不变，到 2035 年，中国可能会再增加 190 万例流行病例。相反，BMI 在人口水平上降低 5% 可以避免 190,000 例事件，这凸显了原始预防的巨大影响力。

Gender analysis challenges canonical narratives. While Framingham and ARIC report male predominance until the ninth decade, GBD data show the female-to-male ratio for DALYs and deaths exceeds unity after age 75 in China, Southeast Asia and Europe³¹. Biology contributes: oestrogen suppresses atrial fibrosis until menopause, after which abrupt withdrawal accelerates structural remodelling; X-chromosome loci such as paired-like homeodomain transcription factor 2 (PITX2) exhibit stronger effect sizes in women³². Social constructs magnify the gap: restrictive gender norms in Southeast Asia curtail outdoor activity and healthcare access, amplifying psychosocial stress. Encouragingly, China’s EAPC model projects a steeper ASMR decline in women (－3.1 % per year) than in men (－1.9 %), plausibly linked to sex-specific gains: the CHA₂DS₂-VASc score assigns an extra point to women, driving anticoagulation rates from 18 % in 2010 to 41 % in 2020, while 2017 national reimbursement drug list (NRDL) reimbursement for NOACs disproportionately benefited women by circumventing warfarin-related intracranial bleeding risk³³. The lesson is that targeted strategies—frailty-adjusted anticoagulation in elderly women, rhythm-control prioritisation in symptomatic females—can narrow the gender gap without compromising efficacy.
性别分析挑战规范叙事。虽然弗雷明汉和 ARIC 报告称，直到第九个十年，男性占主导地位，但 GBD 数据显示，在中国、东南亚和欧洲，75 岁后 DALY 和死亡人数的男女比例超过了统一 ³¹。生物学有助于：雌激素抑制心房纤维化直至绝经，之后突然戒断加速结构重塑;X 染色体位点，例如成对同源结构域转录因子 2 （PITX2）， 在女性中表现出更强的效应大小 ³²。社会结构扩大了差距：东南亚的限制性性别规范限制了户外活动和医疗保健的获取，放大了社会心理压力。令人鼓舞的是，中国的 EAPC 模型预测，女性的 ASMR 下降幅度更大（ 每年 -3.1%），低于男性（-1.9%），这似乎与性别特异性增长有关：CHA₂DS₂-VASc 评分为女性加分，将抗凝率从 2010 年的 18%提高到 2020 年的 41%，而 2017 年国家报销率 （NRDL）NOAC 的报销通过规避与华法林相关的颅内出血风险，使妇女受益匪浅 ³³.教训是，有针对性的策略——对老年女性进行虚弱调整抗凝治疗，对有症状的女性进行节律控制优先排序——可以在不影响疗效的情况下缩小性别差距。

Frontier efficiency analysis positions China above its SDI production frontier, outperforming 82 % of nations including several high-SDI counterparts such as Belgium and Portugal. Key inflection points include the 2016 launch of 1,200 certified AF centres with standardised catheter-ablation pathways, integration of opportunistic screening into the Basic Public Health Service package, and tiered reimbursement that covers 70-90 % of NOAC cost³⁴. Yet rural western provinces still report ablation volume one-tenth that of eastern megacities; telemedicine and mobile ECG devices offer scalable solutions³⁵, as demonstrated by the Shanghai “Know-AF” programme which increased case-finding by 27 %³⁶
前沿效率分析显示，中国高于其 SDI 生产前沿，表现优于 82%的国家，包括比利时和葡萄牙等几个高 SDI 国家。关键的转折点包括 2016 年启动 1,200 个经过认证的 AF 中心，该中心具有标准化的导管消融途径，将机会性筛查纳入基本公共卫生服务计划，以及涵盖 NOAC 费用 70-90% 的分层报销 ³⁴。然而，西部农村省份报告的消融量仍然是东部特大城市的十分之一;远程医疗和移动心电图设备提供了可扩展的解决方案 ³⁵，上海的“Know-AF”计划证明了这一点，该计划将病例发现提高了 27 %³⁶.

Looking forward, a paradigm shift-from reactive treatment of complications to proactive, sex-specific and age-stratified prevention-is now imperative. China’s commitment to eliminating urban-rural health disparities, prioritizing middle-aged women’s care, integrating obstructive sleep apnea and obesity management into atrial fibrillation (AF) pathways, and advancing AI-guided screening will play a pivotal role in enabling the nation—and the global community—to curb the projected surge of AF-related stroke, heart failure, and premature mortality by 2050^37-39
展望未来，范式转变 —— 从并发症的反应性治疗到主动的、针对性别的和年龄分层的预防 —— 现在势在必行 。 中国致力于消除城乡健康差距，优先考虑中年妇女护理，将阻塞性睡眠呼吸暂停和肥胖管理纳入心房颤动（AF）途径，并推进人工智能引导的筛查，这将在使国家和国际社会能够遏制预计到 2050 年房颤相关中风、心力衰竭和过早死亡的激增方面发挥关键作用 ^37-39.

Nevertheless, we must acknowledge that this study still has limitations. Firstly, the database primarily relies on statistical modeling rather than original case registration information. Although its estimation methods provide a benchmark framework for cross-country comparisons, some regions (especially underdeveloped areas with weak grassroots medical data) may have systematic biases, which could affect the precise assessment of the multidimensional epidemiological characteristics of AF/AFL⁴⁰. Secondly, the existing disease classification system has not refined the clinical diversity of AF/AFL. Differences in outcomes due to various electrophysiological subtypes (such as paroxysmal vs. persistent) and comorbidity combinations (beyond hypertension and diabetes, factors of metabolic syndrome such as obesity and chronic kidney disease) have not been fully incorporated into the model, potentially leading to insufficiently comprehensive predictions of complication risks and healthcare needs^41,42. Lastly, the dynamic assessment of disease progression has inherent delays. The current model uses fixed weight coefficients to assess health losses, failing to adequately reflect treatment changes such as the application of new anticoagulants and the promotion of catheter ablation technology, as well as significant differences in healthcare resource accessibility between eastern and western regions. This simplification of temporal and spatial dimensions may weaken the regional guiding value of the research results. It should be noted that despite these methodological limitations, this study, through a systematic integration of multiple health indicators, can still provide important reference for policymakers to understand the evolution of the disease spectrum of atrial fibrillation/atrial flutter in China, while promoting the construction of precise prevention and control measures and optimizing the allocation of healthcare resources, thereby effectively controlling the complex damage to health caused by cardiovascular events induced by AF/AFL.
尽管如此，我们必须承认这项研究仍然存在局限性。首先，该数据库主要依赖于统计建模，而不是原始病例登记信息。尽管其估计方法为跨国比较提供了基准框架，但一些地区（尤其是基层医疗数据较弱的欠发达地区）可能存在系统偏差，这可能影响 AF/AFL 40 多维流行病学特征的精确评估 。其次，现有疾病分类体系未细化 AF/AFL 的临床多样性。由于各种电生理亚型（例如阵发性与持续性）和合并症组合（除了高血压和糖尿病、肥胖和慢性肾脏病等代谢综合征因素）导致的结果差异尚未完全纳入模型中，可能导致对并发症风险和医疗保健需求的预测不够全面 ^41,42.最后，疾病进展的动态评估具有固有的延迟。目前的模型使用固定的权重系数来评估健康损失，未能充分反映治疗变化，如新型抗凝剂的应用和导管消融技术的推广，以及东西部地区医疗资源可及性的显著差异。这种时空维度的简化可能会削弱研究成果的区域指导价值。 需要注意的是，尽管存在这些方法学局限性，但本研究通过系统整合多个健康指标，仍可为政策制定者了解我国心房颤动/心房扑动疾病谱的演变提供重要参考，同时推动精准防控措施建设，优化医疗资源配置， 从而有效控制 AF/AFL 诱发的心血管事件对健康造成的复杂损害。

In conclusion, this study underscores the increasing burden of atrial fibrillation/flutter across various regions, emphasizing the importance of targeted interventions and ongoing monitoring to enhance patient care and reduce healthcare costs. The findings reveal significant regional disparities in disease incidence and mortality, necessitating tailored healthcare strategies to address the unique challenges faced by different populations. Future research should focus on elucidating the underlying mechanisms and risk factors contributing to these trends, thereby informing public health policies and optimizing resource allocation in managing AF/AFL effectively.
总之，这项研究强调了各个地区心房颤动/扑动负担的增加，强调了有针对性的干预措施和持续监测对于加强患者护理和降低医疗成本的重要性。研究结果揭示了疾病发病率和死亡率的显着地区差异，需要量身定制的医疗保健策略来应对不同人群面临的独特挑战。未来的研究应侧重于阐明导致这些趋势的潜在机制和风险因素，从而为公共卫生政策提供信息并优化有效管理 AF/AFL 的资源分配。

Funding
资金

This study is partially supported by the Grant from Key Laboratory of Coronary Intraluminal Imaging and Functional Analysis of Dongguan City and Program of Dongguan Outstanding Young Medical Talents.
本研究部分由东莞市冠状动脉腔内影像与功能分析重点实验室和东莞市优秀青年医学人才计划资助。

Conflict of Interest
利益冲突

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
作者声明，他们没有已知的竞争性经济利益或个人关系，这些利益或个人关系似乎会影响本文中报告的工作。

Consent for publication
同意发布

Not applicable.
不適用。

Reference
参考

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引用

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Authors contribution
作者贡献

Guang Li (G.L.) and Sijin Li (S.J.L.) conceived the study, designed the methodology, performed data extraction and curation from the GBD database, and conducted primary data analysis. Shuang Chen (S.C.) and Xiancheng Xu (X.C.X.) developed statistical models and implemented Bayesian forecasting. Weijie Wu (W.J.W.) and Canlin Li (C.L.L.) prepared all visualizations and conducted frontier analysis. Yuntao Tian (Y.T.T.) and Weijie Chen (W.J.C.) interpreted results, drafted the discussion, and performed literature contextualization. Hongsheng Liang (H.S.L.) contributed to supplementary validation and data stewardship. Heng Li (H.L.) oversaw final manuscript revision and academic supervision, and acts as the corresponding author responsible for manuscript integrity and correspondence.All authors reviewed the manuscript.
Li 光 （G.L.） 和李思瑾 （S.J.L.） 构思了这项研究，设计了方法，从 GBD 数据库中进行了数据提取和管理，并进行了初步数据分析。Shuang Chen （S.C.） 和 Xiancheng Xu （X.C.X.） 开发了统计模型并实施了贝叶斯预测。Weijie Wu （W.J.W.） 和 Canlin Li （C.L.L.） 准备了所有可视化并进行了前沿分析。田云涛（Y.T.T.）和陈伟杰（W.J.C.）解释结果，起草讨论，并进行文献语境化。Hongsheng Liang （H.S.L.） 为补充验证和数据管理做出了贡献。Heng Li （H.L.） 监督最终稿件修改和学术监督，并作为通讯作者负责稿件完整性和通信。所有作者都审阅了稿件。

Data availability
数据可用性

Some or all data sets generated during and/or analyzed during the present study are not publicly available but are available from the corresponding author on reasonable request.
在本研究期间生成和/或分析的部分或全部数据集不公开，但可根据合理要求从通讯作者处获得。

Figure titles and legends
图名和图例

Figure 1. The Annual Percentage Change (APC) of ASIR and ASPR in China, South-East Asia Region, European Region and Global in 1990 and 2021 (*P < 0.05 and significant results). (A) The APC of ASIR in China; (B)The APC of ASIR in South-East Asia Region; (C) The APC of ASIR in European Region; (D) The APC of ASIR in Global; (E) The APC of ASPR in China; (F) The APC of ASPR in South-East Asia Region; (G) The APC of ASPR in European Region; (H) The APC of ASPR in Global.
图 1. 1990 年和 2021 年中国、东南亚地区、欧洲地区和全球 ASIR 和 ASPR 的年百分比变化（APC）（*P < 0.05，结果有统计学意义）。（A） ASIR 在中国的 APC;（二）东南亚地区 ASIR 的 APC;（c） ASIR 在欧洲区域的 APC;（D） 全球 ASIR 的 APC;（E） 中国 ASPR 的 APC;（f） 东南亚区域 ASPR 的 APC;（g） 欧洲区域 ASPR 的 APC;（H） 全球 ASPR 的 APC。

Figure 2. The Annual Percentage Change (APC) of ASMR and ASDR in China, South-East Asia Region, European Region and Global in 1990 and 2021. (*P < 0.05 and significant results). (A) The APC of ASMR in China; (B)The APC of ASMR in South-East Asia Region; (C) The APC of ASMR in European Region; (D) The APC of ASMR in Global; (E) The APC of ASDR in China; (F) The APC of ASDR in South-East Asia Region; (G) The APC of ASDR in European Region; (H) The APC of ASDR in Global.
图 2. 1990 年和 2021 年中国、东南亚地区、欧洲地区和全球 ASMR 和 ASDR 的年百分比变化（APC）。（*P < 0.05 和显着结果）。（A）中国 ASMR 的 APC;（二）东南亚地区 ASMR 的 APC;（c） 欧洲区域 ASMR 的 APC;（D） 全球 ASMR 的 APC;（E） 中国 ASDR 的 APC;（f） 东南亚区域 ASDR 的 APC;（g） ASDR 在欧洲区域的 APC;（H） 全球 ASDR 的 APC。

Figure 3. Comparative of the incidence, prevalence, deaths, and DALYs counts, along with their crude rates, by age group from 1990 to 2021.(A) Incident cases and CIR in China; (B) Incident cases and CIR in South-East Asia Region; (C) Incident cases and CIR in European Region; (D) Incident cases and CIR in Global; (E) Prevalent cases and CPR in China; (F) Prevalent cases and CPR in South-East Asia Region; (G)Prevalent cases and CPR in European Region; (H) Prevalent cases and CPR and CIR in Global.
图 3.比较 1990 年至 2021 年按年龄组划分的发病率、患病率、死亡率和 DALY 计数及其粗率。（A） 中国的事件案例和 CIR;（b） 东南亚区域的事件个案和 CIR;（C） 欧洲区域的事件病例和 CIR;（D） 全球事件案例和 CIR;（E）中国流行病例和心肺复苏术;（f） 东南亚区域的流行病例和心肺复苏术;（庚）欧洲地区的流行病例和心肺复苏术;（H） 全球流行病例以及心肺复苏术和 CIR。

Figure 4. Comparative of the incidence, prevalence, deaths, and DALYs counts, along with their crude rates, by age group from 1990 to 2021. (A) Death cases and CMR in China; (B)Death cases and CMR in South-East Asia Region; (C) Death cases and CMR in European Region; (D) Death cases and CMR in Global; (E) DALYs counts and CDR in China; (F) DALYs counts and CDR in South-East Asia Region; (G) DALYs counts and CDR in European Region; (H) DALYs counts and CDR in Global
图 4.比较 1990 年至 2021 年按年龄组划分的发病率、患病率、死亡率和 DALY 计数及其粗率。（A） 中国的死亡病例和 CMR;（二）东南亚区域死亡病例和 CMR;（C） 欧洲区域的死亡病例和 CMR;（D） 全球死亡病例和 CMR;（E） 中国的 DALY 计数和 CDR;（F） 东南亚区域的 DALYs 计数和 CDR;（G） 欧洲区域的 DALY 计数和 CDR;（H） 全球的 DALY 计数和 CDR.

Figure 5. Comparison of of the number incidence and prevalence of AF/AFL in males and females of different age groups in China, South-East Asia Region, European Region and Global in 1990 and 2021. (A) 1990 number of incidence in China; (B) 1990 number of incidence in South-East Asia Region; (C) 1990 number of incidence in European Region; (D) 1990 number of incidence in Global; (E) 2021 number of incidence in China; (F) 2021number of incidence in South-East Asia Region; (G) 2021 number of incidence in European Region; (H) 2021 number of incidence in Global; (I) 1990 number of prevalence in China; (J) 1990 number of prevalence in South-East Asia Region; (K) 1990 number of prevalence in European Region; (L) 1990 number of prevalence in Global; (M) 2021 number of prevalence in China; (N) 2021 number of prevalence in South-East Asia Region; (O) 2021 number of prevalence in European Region; (P) 2021 number of prevalence in Global.
图 5.1990 年和 2021 年中国、东南亚地区、欧洲地区和全球不同年龄组男女房颤/房颤发病率的发病率及患病率比较。（A）1990 年中国发病率;（B） 1990 年东南亚区域发病率;（C） 1990 年欧洲区域发病率;（D） 1990 年全球发病率;（E）2021 年中国发病数;（F）2021 年东南亚地区发病数;（G）2021 年欧洲地区发病率;（H） 2021 年全球发病率;（一）1990 年中国患病率;（J） 1990 年东南亚区域的患病率;（K） 1990 年欧洲区域的患病率;（L） 1990 年全球流行率;（M）2021 年中国患病率;（N）东南亚地区 2021 年患病率;（O）2021 年欧洲地区患病率;（P） 2021 年全球患病率。

Figure 6. Comparison of of the number mortality and DALYs of AF/AFL in males and females of different age groups in China, South-East Asia Region, European Region and Global in 1990 and 2021. (A) 1990 number of mortality in China; (B) 1990 number of mortality in South-East Asia Region; (C) 1990 number of mortality in European Region; (D) 1990 number of mortality in Global; (E) 2021 number of mortality in China; (F) 2021number of mortality in South-East Asia Region; (G) 2021 number of mortality in European Region; (H) 2021 number of mortality in Global; (I) 1990 number of DALYs in China; (J) 1990 number of DALYs in South-East Asia Region; (K) 1990 number of DALYs in European Region; (L) 1990 number of DALYs in Global; (M) 2021 number of DALYs in China; (N) 2021 number of DALYs in South-East Asia Region; (O) 2021 number of DALYs in European Region; (P) 2021 number of prevalence in Global.
图 6.1990 年和 2021 年中国、东南亚地区、欧洲地区和全球不同年龄组男女房颤/房颤死亡人数及 DALYs 比较。（A） 1990 年中国死亡人数;（B） 1990 年东南亚区域死亡人数;（C） 1990 年欧洲区域的死亡率;（D） 1990 年全球死亡率;（E）2021 年中国死亡人数;（F） 2021 年东南亚区域死亡人数;（G） 2021 年欧洲区域死亡人数;（H） 2021 年全球死亡率;（一）1990 年中国 DALY 数量;（J） 1990 年东南亚区域的 DALY 数量;（K） 1990 年欧洲区域的 DALY 数量;（L） 1990 年全球 DALY 数量;（M）2021 年中国 DALY 数量;（N） 2021 年东南亚地区 DALY 数量;（O） 2021 年欧洲地区 DALY 数量;（P） 2021 年全球患病率。

Figure 7. Age-period-cohort analysis of China AF/AFL burden from 1992 to 2021. (A) Age Deviation (B) Longitudinal Age Curves; (C) Period Rate Ratio (D) Cohort Rate Ratio
图 7.1992—2021 年中国 AF/AFL 负担年龄段队列分析。（a）年龄偏差（b）纵向年龄曲线;（C） 周期率比 （D） 队列率比.

Figure 8. Age-period-cohort analysis of South-East Asia Region AF/AFL burden from 1992 to 2021. (A) Age Deviation (B) Longitudinal Age Curves; (C) Period Rate Ratio (D) Cohort Rate Ratio
图 8.1992—2021 年东南亚地区 AF/AFL 负担的年龄-期-队列分析。（a）年龄偏差（b）纵向年龄曲线;（C） 周期率比 （D） 队列率比.

Figure 9. Age-period-cohort analysis of European Region AF/AFL burden from 1992 to 2021.(A) Age Deviation (B) Longitudinal Age Curves; (C) Period Rate Ratio (D) Cohort Rate Ratio.
图 9.1992 年至 2021 年欧洲地区 AF/AFL 负担的年龄期队列分析。（a）年龄偏差（b）纵向年龄曲线;（c） 期间率比 （d） 队列率比。

Figure 10. Age-period-cohort analysis of Global AF/AFL burden from 1992 to 2021. (A) Age Deviation (B) Longitudinal Age Curves; (C) Period Rate Ratio (D) Cohort Rate Ratio.
图 10.1992 年至 2021 年全球 AF/AFL 负担的年龄期队列分析。（a）年龄偏差（b）纵向年龄曲线;（c） 期间率比 （d） 队列率比。

Figure 11. Predictions of AF/AFL trends was projected by BAPC-INLA model. The projected ASRs of incidence (A), prevalence (B), death (C), and DALYs (D) for AF/AFL by sex from in China form 1990 to 2050. The projected ASRs of incidence (E), prevalence (F), death (G), and DALYs (H) for AF/AFL by sex from in South-East Asia Region form 1990 to 2050,. The dots represent the observed values, and the fan shape represent the predictive distribution between the 2.5 and 97.5 % quantiles. The solid line represents the predicted ASRs during 2020-2050.
图 11.通过 BAPC-INLA 模型预测 AF/AFL 趋势。1990—2050 年中国按性别划分的房颤/房颤发病发病率（A）、患病率（B）、死亡率（C）和 DALYs（D）的预测 ASR。1990 年至 2050 年东南亚地区按性别划分的 AF/AFL 发病率 （E）、患病率 （F）、死亡率 （G） 和 DALY （H） 的预测 ASR。点代表观测值，扇形代表 2.5% 和 97.5 % 分位数之间的预测分布。实线代表 2020-2050 年预测的 ASR。

Figure 12. Predictions of AF/AFL trends was projected by BAPC-INLA model. The projected ASRs of incidence (A), prevalence (B), death (C), and DALYs (D) for AF/AFL by sex from in European Region form 1990 to 2050. The projected ASRs of incidence (E), prevalence (F), death (G), and DALYs (H) for AF/AFL by sex from in Global form 1990 to 2050,. The dots represent the observed values, and the fan shape represent the predictive distribution between the 2.5 and 97.5 % quantiles. The solid line represents the predicted ASRs during 2020–2050.
图 12.通过 BAPC-INLA 模型预测 AF/AFL 趋势。1990 年至 2050 年欧洲地区按性别划分的 AF/AFL 发病率 （A）、患病率 （B）、死亡率 （C） 和 DALY （D） 的预测 ASR。1990 年至 2050 年按性别划分的 AF/AFL 发病率 （E）、患病率 （F）、死亡率 （G） 和 DALY （H） 的预测 ASR。点代表观测值，扇形代表 2.5% 和 97.5 % 分位数之间的预测分布。实线代表 2020-2050 年期间预测的 ASR。

Figure 13. Impact of Aging, Epidemiological Shifts, and Population Growth on AF/AFL Burden (1990-2021) in China, South-East Asia Region, European Region and Global. (A)Incidence (B)Prevalence (C)Death (D)DALYs
图 13.老龄化、流行病学变化和人口增长对中国、东南亚地区、欧洲地区和全球 AF/AFL 负担的影响（1990-2021 年）。（一）发病率 （B）患病率 （C）死亡 （D）DALYs.

Figure 14. Frontier analysis of ASMR for AF/AFLbased on the SDI from 1990 to 2021. (A) Global Mortality Patterns by SDI. ASMR for AF/AFL vs. SDI values across countries. Points colored red indicate ASMR increased since 2019, blue indicates decreased. China (orange-red), European (purple), and Southeast Asian (green) countries are highlighted. (B) Spatiotemporal dynamic distribution of ASMR. Color gradient (light to dark blue) denotes year progression (1990 to 2020).
图 14.1990—2021 年基于 SDI 的 AF/AFLASMR 前沿分析（A） 按 SDI 分列的全球死亡率模式。AF/AFL 与不同国家/地区 SDI 值的 ASMR。红色点表示 ASMR 自 2019 年以来有所增加，蓝色表示有所下降。突出显示了中国（橙红色）、欧洲（紫色）和东南亚（绿色）国家。（B）ASMR 的时空动态分布。颜色渐变（浅蓝色到深蓝色）表示年份递进（1990 年至 2020 年）。

Figure 15. Frontier analysis of ASDR for AF/AFL based on the SDI from 1990 to 2021.(A) Global DALYs Patterns by SDI. ASDR for AF/AFL vs. SDI values across countries. Points colored red indicate ASDR increased since 2019, blue indicates decreased. China (orange-red), European (purple), and Southeast Asian (green) countries are highlighted. (B) Spatiotemporal dynamic distribution of ASDR. Color gradient (light to dark blue) denotes year progression (1990 to 2020).
图 15.1990—2021 年基于 SDI 的 AF/AFLASDR 前沿分析（A） SDI 的全球 DALY 模式。AF/AFL 与 SDI 值的 ASDR 跨国家/地区。红色点表示 ASDR 自 2019 年以来有所增加，蓝色表示有所下降。突出显示了中国（橙红色）、欧洲（紫色）和东南亚（绿色）国家。（B）ASDR 的时空动态分布。颜色渐变（浅蓝色到深蓝色）表示年份递进（1990 年至 2020 年）。