The impact of socioeconomic deprivation on the risk of atrial fibrillation in patients with diabetes mellitus: a nationwide population-based study
Authors: Han M J , Lee S R , Choi E K , Han K D , Lip G Y H 
Published: February 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Although the prevalence of atrial fibrillation (AF) is increasing worldwide, little is known about the exact risk factors of AF; and the disease"s association with socioeconomic status (SES) is under debate.

Purpose
This study aimed to examine the association between SES and the risk of AF in Korean patients with diabetes mellitus.

Methods
We studied 2,429,610 diabetic patients (mean age 56.9 years, female 40%) who underwent health check-ups from 2009 to 2012, using the National Health Insurance Service (NHIS) database of Korea. Subjects were categorized into 6 groups according to the number of times (0 through 5) entitled for medical aid (MA) recipient, within the past 5 years from the date of check-up. (Fig. 1)
Division of Medical Care Assistance in the Ministry of Health and Welfare selects the medical aid beneficiaries. The recipients should not have a reliable caregiver, nor their income be more than 40% of the standard median income.
Among the study population, 64,818 were classified as MA group: 10,697 in MA 1, 11,005 in MA 2, 12,431 in MA 3, 10,689 in MA 4, 19,996 in MA 5, respectively. The remaining 2,364,792 were never entitled to MA recipients within 5 years and were assigned to the non-MA group. The incidence rate and hazard ratio of AF were then calculated for each group.

Results
Risk factors for cardiovascular disease were measured at baseline. More current smokers were in MA 5 group (28.7% in MA 5, 26.7% in non-MA, 26.2% in MA 1, 23.8% in MA 2, 23% in MA 3, 23.2% in MA 4, respectively, p &lt; 0.001), while more heavy drinkers were in the non-MA group than among the MA groups (20.7% vs. 6.2–7.9%, p &lt; 0.001).
Hypertension and dyslipidemia were generally higher in MA groups than in the non-MA group (hypertension, 60.8–65.8% in MA groups vs. 54.8% in non-MA group; dyslipidemia, 44.1–54.9% in MA groups vs. 39.6% in non-MA group, all, p &lt; 0.001), and the non-MAs tended to do more physical activities (20.7% vs. 15.4–15.8%, p &lt; 0.001). Obese people with BMI≥30 were more in MA groups, especially in the MA 5, than in the non-MA group (7.5% in non-MA, 9.3%–9.7% in MA 1–4, and 12.2% in MA 5, all, p &lt; 0.001).
80,257 were newly identified as AF in the retrospective 5 years. All the MA groups showed a higher risk of AF than the non-MA group: hazard ratio (95% confidence interval [CI]) for each group, 1.44 (1.32–1.58) in MA 1, 1.58 (1.45–1.73) in MA 2, 1.52 (1.39–1.65) in MA 3, 1.53 (1.40–1.68) in MA 4, and 1.35 (1.24–1.45) in MA 5. Adjusting with multi-variables, the MA 5 showed 54% increased risk of AF compared to the non-MA group (HR, 1.54, [95% CI, 1.42–1.67]). (Fig. 2)

Conclusion
The risk of AF increased more than 50% in patients who needed medical aid 5 years in a row, and the risk also rose greatly in patients with only a short experience of socioeconomic hardship. Based on the findings, we need more attention to individuals with recent socioeconomic deprivation to provide timely management for AF and its complications. Abstract Figure. Fig. 1