Prediabetes and the risk of atrial fibrillation and heart failure: a propensity-matched analysis in a real-world cohort.

BACKGROUND: Although diabetes is a recognized risk factor for atrial fibrillation (AF) and heart failure (HF), the cardiovascular consequences of prediabetes remain unclear, particularly regarding AF subtypes and HF development. OBJECTIVE: This study aimed to evaluate the association of prediabetes with new-onset AF, including subtype specificity, and its association with HF development using an international, real-world cohort. METHODS: We analyzed de-identified electronic health records from the TriNetX network, including adults aged 18-79 years without prior AF or atrial flutter. Prediabetes was defined as hemoglobin A1c (HbA1c) 5.7-6.4% or a documented diagnosis; normoglycemic controls had normal HbA1c (≤ 5.6%). Propensity score matching (1:1) was applied to match the cohorts. Primary outcome was new-onset AF, stratified by paroxysmal and persistent AF. Secondary outcome was HF incidence. Follow-up extended from 90 days to 5 years post-index. RESULTS: After matching, 207,385 patients were included in each cohort. During the follow-up period, prediabetes was associated with a modestly increased risk of new-onset AF (risk ratio [RR] 1.154, 95% confidence interval [CI] 1.035-1.286, P=0.010), primarily driven by persistent AF (RR 1.411, 95% CI 1.085-1.835, P=0.010), while paroxysmal AF incidence was unaffected. Prediabetes was also associated with increased HF incidence among individuals without established AF (RR 1.296, 95% CI 1.119-1.500, P=0.001) but not in those with concomitant AF. CONCLUSION: Prediabetes was associated with a modestly increased risk of new-onset AF, particularly persistent AF, and was associated with HF development among individuals without established arrhythmia.