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Time-averaged cumulative pulse pressure in midlife and incident atrial fibrillation: the atherosclerosis risk in communities study

Journal of Human Hypertension volume 40, pages 23–28 (2026)Cite this article

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Abstract

While elevated arterial stiffness is recognized as a predictor of atrial fibrillation (AF), the relationship between long-term pulse pressure (PP) and the incidence of AF remains to be fully elucidated. We assessed the influence of time-averaged cumulative PP in midlife on incident AF. The analysis included 9150 adults from the Atherosclerosis Risk in Communities (ARIC) cohort who were free of AF at visit 4. The time-averaged cumulative blood pressure (BP) was calculated as the sum of the averaged BPs from the adjacent consecutive visits (visits 1–4), with the values being indexed to the total exposure time. At visit 4, the mean age of the study population was 62.9 years, with 4045 (44.2%) of the population being male. In 1455 individuals (15.9%) with a median follow-up of 16 years, incident AF was seen. The greatest predictor of incident AF, as indicated by the decline in the −2 Log likelihood statistic, was time-averaged cumulative PP, which was linked to an elevated risk for AF (HR = 1.20 (1.13–1.27)) in adjusted Cox models (per 1-SD increment). The correlation between incident AF and time-averaged cumulative systolic blood pressure (SBP) was 1.14 (1.07–1.22). In contrast, the diastolic relation tended to be opposite (HR = 0.94 (0.88–1.00)). Moreover, among persons aged < 65 years, without hypertension or antihypertensive treatment, these associations were even more remarkable (P < 0.05 for all interactions). Time-averaged cumulative PP in midlife was an important risk factor for incident AF with the strongest predictive effect, especially in persons who were younger, normotensive, or without antihypertensive treatment.

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Fig. 1
Fig. 2: Adjusted hazard ratios of atrial fibrillation by time-averaged cumulative pulse pressure as a continuous variable.
Fig. 3

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Data availability

Additional data are available from the corresponding author on reasonable request.

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Acknowledgements

We thank the staff and participants of the ARIC study (Atherosclerosis Risk in Communities) for their important contribution.

FUNDING

This study was supported by the National Natural Science Foundation of China (81870195, 82070384 to X.Liao; 81900329 to Y.Guo), Guangdong Basic and Applied Basic Research Foundation (2019A1515011582, 2021A1515011668 to X.Liao; 2019A1515011098, 2022A1515010416 to Y.Guo; 2021A1515110266 to Z. Xiong), the China Postdoctoral Science special Foundation funded project (2021TQ0386, 2021M703738 to Z. Xiong).

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Author notes

  1. These authors contributed equally: Yiquan Huang, Ziwei Zhou.

Authors and Affiliations

  1. Department of Cardiology, Xiamen Key Laboratory of Cardiac Electrophysiology, Xiamen Institute of Cardiovascular Diseases, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361003, China

    Yiquan Huang

  2. Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, 510080, Guangzhou, Guangdong, China

    Yiquan Huang, Ziwei Zhou, Yifen Lin, Shaozhao Zhang, Zhenyu Xiong, Menghui Liu, Yue Guo, Wenjing Zhang, Xiaodong Zhuang & Xinxue Liao

  3. NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), 510080, Guangzhou, Guangdong, China

    Yiquan Huang, Ziwei Zhou, Yifen Lin, Shaozhao Zhang, Zhenyu Xiong, Menghui Liu, Yue Guo, Wenjing Zhang, Xiaodong Zhuang & Xinxue Liao

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  1. Yiquan Huang
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Contributions

ZZ, YH, XZ and XL conceived and designed the study, interpreted the data and wrote the manuscript. YL, SZ, ZX, ML, WZ and YG interpreted the data and revised the manuscript draft for important intellectual content. All authors agree to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript.

Corresponding authors

Correspondence to Xiaodong Zhuang or Xinxue Liao.

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Ethics approval and consent to participate

This study involved human participants and was approved by institutional review boards at all participating institutions in the Atherosclerosis Risk in Communities (ARIC) study as well as by a review panel at the National Heart, Lung, and Blood Institute (NHLBI). The current analysis of the ARIC study data was approved by IEC for Clinical Research and Animal Trials of the First Affiliated Hospital of Sun Yat-Sen University (2020429). Participants provided written informed consent. All methods were performed in accordance with the relevant guidelines and regulations.

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Huang, Y., Zhou, Z., Lin, Y. et al. Time-averaged cumulative pulse pressure in midlife and incident atrial fibrillation: the atherosclerosis risk in communities study. J Hum Hypertens 40, 23–28 (2026). https://doi.org/10.1038/s41371-025-01050-4

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