Modifiable Risk Factors for Atrial Fibrillation/Flutter in the Association of Southeast Asian Nations

BACKGROUND: Atrial fibrillation (AF) and atrial flutter (AFL) is increasingly contributing to cardiovascular mortality in Southeast Asia; however, region-specific data on modifiable risk factors remain limited. OBJECTIVES: This study aimed to assess the burden of AF/AFL attributable to modifiable risk factors across the Association of Southeast Asian Nations (ASEAN) using Global Burden of Disease 2021 data. METHODS: We analyzed the Global Burden of Disease 2021 data for all 10 ASEAN nations (1990-2021). The burden of AF/AFL attributable to metabolic, behavioral, and environmental risk factors was assessed, stratified by sex. The outcomes included age-standardized mortality rates (ASMRs), disability-adjusted life years (DALYs), and years lived with disability. Forecasts to 2035 were generated using validated time-series models. RESULTS: Between 1990 and 2021, the ASMRs for AF/AFL attributable to modifiable risk factors varied markedly across ASEAN countries. Metabolic risks rose from 1.30 (0.48-2.14) in 1990 to 1.78 (0.98-2.87) in 2021, followed by behavioral (0.42-0.45) and environmental (0.08-0.11) risks. Vietnam had the highest metabolic-attributable ASMR at 2.06 in 2021, whereas Singapore's declined to 0.31 in the same year. Metabolic DALYs peaked in Indonesia at 52.29 in 2021 and were lowest in Singapore at 12.35. Males consistently showed higher ASMRs and DALYs than females, a gap projected to persist through 2035, reflecting persistent metabolic dominance and uneven progress across ASEAN. CONCLUSIONS: Metabolic risk factors remain the dominant contributors to AF/AFL mortality across ASEAN, with widening disparities across countries and sexes. Strengthening targeted prevention strategies is essential to reduce cardiovascular risk and achieve equitable progress by 2035.