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ORIGINAL ARTICLE

:

:

FREQUENCY OF NEW-ONSET ATRIAL FIBRILLATION IN CHRONIC OBSTRUCTIVE

PULMONARY DISEASE PATIENTS: INSIGHTS FROM A HOSPITAL-BASED CROSS-SECTIONAL

STUDY

Sobia Ahmed Qureshi

1

, Fawad Rahim

2

, Muhammad Ahmed Yar

3

, Ayesha Bangash

4

, Sheema Tariq

5

,

Ayesha Hamid

6

or

–

65], p < 0.001). Likewise, patients with AF

ABSTRACT

OBJECTIVES

This study aimed to determine the frequency of new-onset atrial ﬁbrillation

(AF) in patients with chronic obstructive pulmonary disease (COPD).

METHODOLOGY

This cross-sectional study was conducted in the Department of Medicine at

Hayatabad Medical Complex, Peshawar, Pakistan, from July 20, 2023, to

January 15, 2025. Patients of COPD who were in normal sinus rhythm within

the three months before admission were eligible for the study. Patients with

the following were excluded: Ischemic heart disease, mitral valve disease,

left-sided heart failure, diabetes mellitus, hypertension, hypo-

hyperkalemia, or thyroid disorders. A total of 147 patients who met the

inclusion and exclusion criteria were enrolled in the study. All study

participants underwent an electrocardiogram on admission and daily until

discharge to look for new-onset AF.

RESULTS

Most patients were male (74.1%, n = 109) with a median age of 60 years

(IQR: 53–67) and a median duration of COPD of 5 years (IQR: 4–7). New-

onset AF was identiﬁed in 22 patients (15%; 95% CI: 9 –21%). Patients with

AF were signiﬁcantly older than those w ithout AF (71.5 years [IQR: 63.75

75.5] versus 58 years [IQR: 52–

had a signiﬁcantly longer duration of COPD [8 years (IQR: 6 – 9)] than

those without AF [5 years (IQR: 4 – 7)] (p<0.001). There was no signiﬁcant

diﬀerence in the frequency of AF by gender.

CONCLUSION

Older age and higher duration of COPD are signiﬁcant risk factors for the

development of AF in patients with COPD. Patients with COPD need regular

surveillance for the timely diagnosis of AF and subsequent risk stratiﬁcation

to guide optimal management.

KEYWORDS: Chronic Obstructive Pulmonary Disease, Atrial Fibrillation,

Frequency, Risk factor, Hospitalization

How to cite this article

Qureshi SA, Rahim F, Yar MA,

Bangash A, Tariq S, Hamid A.

Frequency of New-Onset Atrial

Fibrillation in Chronic Obstructive

Pulmonary Disease Patients: Insights

from a Hospital-Based Cross-Sectional

Study. J Gandhara Med Dent Sci.2025;

12(4

12-4.771

):9-12.https://doi.org/10.37762/jgmds.

Date of Submission: 23-05-2025

Date Revised: 04-05-2025

Date Acceptance: 05-06-2025

1

Post Graduate Resident, Department of

Medicine, Hayatabad Medical Complex,

Peshawar

3

Post Graduate Resident, Department of

Medicine, Hayatabad Medical Complex,

Peshawar

4

Post Graduate Resident, Department of

Medicine, Hayatabad Medical Complex,

Peshawar

5

Post Graduate Resident, Department of

Medicine, Hayatabad Medical Complex,

Peshawar

6

Post Graduate Resident, Department of

Medicine, Hayatabad Medical Complex,

Peshawar

Correspondence

2

Fawad Rahim, Associate Professor,

Department of Medicine, Hayatabad

Medical Complex, Peshawar

+92- 333-9351983

drfawadrahim@outlook.com

INTRODUCTION

Progressive airﬂow restriction and tissue damage

characterize chronic obstructive pulmonary disease

(COPD), a prevalent and curable condition. It aﬀects

over 212.3 million people worldwide and is currently

the fourth leading cause of death globally.

1

Tobacco

smoking and household air pollution, mainly from the

use of solid fuels for cooking and heating, are its major

risk factors.

2,3

Atrial ﬁbrillation (AF) is a common

cardiac arrhythmia, with an estimated 37.6 million

people aﬀected globally, representing approximately

0.51% of the global population.

4

Several serious health

issues, including coronary heart disease, stroke,

pulmonary embolism, persistent congestive heart

failure, and poor quality of life, have been linked to

AF.

5,6

Chronic obstructive pulmonary disease is

increasingly acknowledged as a signiﬁcant risk factor

for new-onset AF.

7

A study has reported new-onset AF

in 8.42% of COPD patients.

8

People with COPD have a

28% higher odds of developing AF compared to those

without COPD.

5

A meta-analysis by Jiale et al. in 2022

reported higher overall and cardiovascular mortalities in

patients with AF and COPD than those with AF alone.

9

The risk of ischemic cerebrovascular events in patients

with COPD and AF is also 2.8 times higher than that of

those with AF only.

10

Apart from the increased

morbidity and mortality, the co-existence of COPD and

AF has therapeutic implications too.

11

Beta blockers,

which negatively impact lung function, are often used

to control the ventricular rate in AF. Conversely, beta

agonists and theophylline, commonly prescribed to

10

J Gandhara Med Dent Sci

October - December 2025

improve airway function in COPD, can aggravate

cardiac rhythm abnormalities. This therapeutic conﬂict

presents a clinical challenge, often necessitating

adjustments in the medications of COPD patients once

they develop AF.

12

While AF is known to worsen the

clinical course and increase the risk of adverse

outcomes, its onset in COPD is often overlooked and

underdiagnosed in resource-constrained developing

countries like Pakistan. Given the lack of local and

regional data, this study aims to determine the

frequency and clinical risk factors of new-onset AF in

COPD patients. This will be crucial for several reasons.

First, it will enable targeted screening and, as a result,

early recognition of AF in high-risk COPD patients.

Secondly, early diagnosis will result in timely risk

stratiﬁcation and introduction of preventive measures to

reduce the risk of complications such as

thromboembolism and cardiovascular events. The

integrated approach of managing comorbidities like AF

in COPD patients will ultimately translate into better

outcomes in these patients. Lastly, the study ﬁndings

will ensure that our population gets due representation

in the pooled data in systematic reviews on the topic.

METHODOLOGY

The cross-sectional study was conducted at the

Department of Medicine, Hayatabad Medical Complex,

Peshawar, Pakistan, from July 20, 2023, to January 15,

2025. The Institutional Review and Ethics Board of

Hayatabad Medical Complex, Peshawar, approved the

study. (No. 1310, dated: 06.06.2023). The inclusion

criteria were patients with COPD who had documented

evidence of a normal sinus rhythm, as indicated by an

electrocardiogram performed within the three months

preceding admission. COPD was deﬁned as the

presence of symptoms such as shortness of breath,

sputum production, or chronic cough persisting for

more than three months up to two consecutive years,

along with an FEV1/FVC ratio of <70% of predicted

values on post-bronchodilator spirometry.

13

Atrial

fibrillation was deﬁned as an irregular pulse on

examination, conﬁrmed by irregular R-R intervals and

absence or replacement of P-waves by ﬁbrillatory

waves on ECG.

14

The exclusion criteria included

diagnoses of ischemic heart disease, mitral valve

disease, left-sided heart failure, diabetes mellitus,

hypertension, hypo- or hyperkalemia, or thyroid

disorders. The sample size was 147, with an 8.42%

frequency of new-onset AF, a 4.5% absolute precision,

and a 95% conﬁdence level.

8

All patients meeting the

inclusion criteria underwent an initial assessment,

which included a history, physical examination, and the

following investigations: random blood sugar, thyroid

function tests, serum electrolytes, and an

echocardiogram. Patients who met the inclusion and

exclusion criteria after initial assessment were informed

about the study. Those who agreed to participate were

enrolled in the study through a consecutive sampling

technique. All enrolled patients underwent an

electrocardiogram (ECG) on admission and had daily

ECGs until discharge. New-onset atrial ﬁbrillation was

diagnosed if a patient, having a normal sinus rhythm

previously as outlined in the inclusion criteria,

demonstrated changes typical of AF on the ECG

performed on admission or thereafter during hospital

stay. The data were analyzed using the Statistical

Package for the Social Sciences (SPSS), version 21.

Normality of continuous variables (Age, Duration of

COPD) was assessed using the Shapiro-Wilk test, and

these were reported as median with interquartile range.

Categorical variables (Gender, New-onset atrial

fibrillation) were reported as frequencies and

percentages. Between-group diﬀerences in the median

age and duration of COPD were compared for

significance using the Mann-Whitney test. Likewise,

diﬀerence in gender-wise distribution was evaluated by

the Chi-square test. A p-value below 0.05 was

considered signiﬁcant.

RESULTS

A total of 147 patients with COPD were included in the

study. The median age of the participants was 60 years

(interquartile range [IQR]: 53-67), and the median

duration of COPD was 5 years (IQR: 4-7). Most

patients were male (74.1%, n = 109). New-onset atrial

fibrillation (AF) was identiﬁed in 22 patients (15%;

95% CI: 9 - 21%). Table 1 reviews the characteristics

of the study participants.

Table 1: Pre and Post, 3 & 6- month Astigmatism

Variables Median (IQR) / No. (%)

Age, years

60 (53 - 67)

Duration of COPD, Years

05 (4 - 7)

Gender

Male 109 (74.1%)

Female 38 (25.9%)

New onset

AF

No 125 (85%)

Yes 22 (15%)

The median age of patients who developed new-onset

atrial ﬁbrillation (AF) was 71.5 years (IQR: 63.75 –

75.5), signiﬁcantly higher than 58 years (IQR: 52 – 65)

in those without AF (P<0.001). Similarly, the median

duration of COPD was signiﬁcantly longer in patients

with new-onset AF [8 years (IQR: 6 – 9)] compared to

those without AF [5 years (IQR: 4 – 7)], also

demonstrating a statistically signiﬁcant diﬀerence (p <

0.001). In terms of gender, 18 out of 109 male patients

(16.5%) and 4 out of 38 female patients (10.5%)

developed new-onset atrial ﬁbrillation. However, this

diﬀerence was not signiﬁcant (p = 0.373). (Table 2).

Frequency of New-Onset Artial Fibrillation in Chronic

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October - December 2025

Table 2: Comparison of Risk Factors between COPD Patients

with and without New- Onset Atrial Fibrillation

Variables New Onset AF Test

statistic

P-

Value

No (n=125) Y es(n=22)

Age (years),

Median (IQR)

58 (52 - 65)

71.5 (63.75

– 75.5)

673.5 <0.001*

Duration of

COPD (years),

Median (IQR)

05 (4 – 7) 08 (6 – 9) 703.5 <0.001*

Gender,

No(%)

Male 91 (83.5%) 18 (16.5%) 0.794 0.373

*

*

Female

34 (89.5%) 04 (10.5%)

*

Mann-Whitney U test,

**

Chi-square test

DISCUSSION

Chronic obstructive pulmonary disease is one of the

significant causes of morbidity and mortality

worldwide. Likewise, AF is the most common cardiac

arrhythmia. The co-existence of COPD and AF has

signiﬁcant implications for the management of these

patients. This study aimed to determine the frequency

and risk factors of new-onset AF in patients with

COPD. This study identiﬁed new-onset AF in 15%

(95% CI: 9-21%) of patients with COPD. This is

consistent with or slightly higher than the prevalence

figures reported in other studies. For instance, a review

by Kotlyarov and Lyubavin in 2024 indicates that

approximately 8% of patients with COPD have AF.

15

Similarly, Huang et al. reported that 11.5% of patients

with AF had concomitant COPD in a multicenter

registry study.

16

The Rotterdam Study by Grymonprez

et al. reported a 28% increased AF risk in individuals

with COPD.

5

The meta-analysis by Chen et al. also

supports a high prevalence of AF among COPD

patients.

17

The observed 15% new-onset AF in this

study underscores the signiﬁcant burden of this

comorbidity in the COPD population, aligning with the

general trend of increased AF risk and prevalence in

these patients as reported in the literature. The median

age of patients who developed new-onset AF (71.5

years) was signiﬁcantly higher than in those without AF

(58 years, p < 0.001). This strong association between

older age and AF in COPD patients is well-supported

by systematic reviews and meta-analyses. Qiangru

Huang et al. identiﬁed older age (speciﬁcally above 65

years and above 75 years) as a signiﬁcant demographic

risk factor for AF in COPD patients.

18

Similarly,

Kotlyarov and Lyubavin (2024) also highlighted older

age (over 65 years) as a key demographic characteristic

associated with the risk of new-onset AF in COPD.

15

These consistent ﬁndings across multiple studies

suggest that age-related physiological changes,

combined with the systemic eﬀects of COPD,

contribute substantially to the increased susceptibility to

AF in this patient group. A notable ﬁnding in our study

is the signiﬁcantly longer median duration of COPD in

patients who developed new-onset AF (8 years)

compared to those who did not (5 years, p < 0.001).

This suggests a cumulative eﬀect of the disease on

cardiac health. This observation is supported by the

systematic review and meta-analysis by Qiangru Huang

et al.

18

which proposes that the pathogenesis of AF

related to COPD is mainly due to cardiac dysfunction

resulting from the "chronic duration of COPD." This

long-standing disease burden increases the risk of

cardiovascular-related factors, which, in turn, elevates

the risk of AF in COPD patients. The results of this

study provide further evidence of this

pathophysiological link, emphasizing the importance of

long-term disease management in mitigating the risk of

AF.

LIMITATIONS

Given the high prevalence of both COPD and AF, this

study addresses an important area of clinical concern.

The study ﬁndings have direct clinical implications for

patients with COPD, as they can lead to targeted

screening of COPD patients for AF and their timely risk

stratiﬁcation to prevent complications like

thromboembolism. It ﬁlls a gap in local and regional

data, ensuring the Pakistani population is represented in

systematic reviews and meta-analyses on the topic. This

study has several potential limitations that must be

acknowledged. Selection bias may have inﬂuenced the

findings, as all patients were recruited from a single

tertiary care medical ward, thus limiting the

generalizability of the results. Recall bias is another

limitation, as variables such as duration of COPD were

based on patient self-report, which may be subject to

memory inaccuracies or underreporting. Additionally,

the study may be aﬀected by confounding bias as

variables such as smoking, body mass index, drug

history, and the use of oxygen therapy were not

collected or analyzed. Studies involving a larger sample

of patients, preferably multicenter studies, and

incorporating a broader range of risk factors may

validate the ﬁndings of this study, reduce bias, and

enhance the generalizability of the results.

CONCLUSIONS

New-onset AF was observed in 15% patients with

COPD. Older age and longer duration of COPD were

significant risk factors for the development of AF in

these patients. The frequency of new-onset AF did not

diﬀer signiﬁcantly by gender. Routine screening fo r

new-onset AF in all patients with COPD is

recommended. Early diagnosis and risk stratiﬁcation,

along with the implementation of appropriate therapy

(antiplatelets or anticoagulation), will prevent

subsequent complications and improve outcomes.

Studies with larger samples and a broader range of risk

factors are warranted to explore the association between

Frequency of New-Onset Artial Fibrillation in Chronic

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COPD and AF.

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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Sobia Ahmed Qureshi - Concept & Design; Data Acquisition;

Drafting Manuscript; Critical Revision; Final Approval

Fawad Ahmad - Concept & Design; Data

Analysis/Interpretation; Drafting Manuscript; Critical

Revision; Supervision; Final Approval

Muhammad Ahmed Yar - Concept & Design; Data

Acquisition; Data Analysis/Interpretation; Drafting

Manuscript; Critical Revision; Final Approval

Ayesha Bangash - Concept & Design; Data Acquisition;

Drafting Manuscript; Critical Revision; Final Approval

Sheema Tariq - Concept & Design; Data Acquisition; Drafting

Manuscript; Critical Revision; Final Approval

Ayesha Hamid - Concept & Design; Data Acquisition; Drafting

Manuscript; Critical Revision; Final Approval

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Frequency of New-Onset Artial Fibrillation in Chronic