Insulin resistance and atrial fibrillation: from disease onset to post-ablation outcomes: a systematic review and meta-analysis

TL;DR

This study shows that insulin resistance increases the risk of developing and recurring atrial fibrillation, suggesting its importance in managing and preventing the condition.

Contribution

The study provides new evidence that insulin resistance is a significant risk factor for both new-onset and recurrent atrial fibrillation.

Findings

Insulin resistance increases the risk of new-onset atrial fibrillation by 34%.

Insulin resistance increases the risk of post-ablation recurrence by 57%.

Mechanistic pathways include inflammation, oxidative stress, and atrial remodeling.

Abstract

To systematically evaluate the impact of insulin resistance (IR) on the risk of new-onset atrial fibrillation (AF) and post-ablation recurrence, and to elucidate underlying mechanisms and translational implications for early identification and precision management of high-risk populations.

A comprehensive meta-analysis was conducted by integrating 30 high-quality cohort studies from multiple countries, incorporating IR markers such as TyG index and HOMA-IR. Random-effects models were used to estimate the association between IR and both AF incidence and ablation recurrence. Subgroup analyses, sensitivity analyses, meta-regression, and GRADE quality assessment were performed to explore heterogeneity and robustness. Mechanistic pathways were systematically summarized. This study was registered in PROSPERO (CRD420251142441).

Pooled results demonstrated that IR significantly increased the risk of new-onset AF (HR = 1.34, 95%CI: 1.24–1.46) and post-ablation recurrence (HR = 1.57, 95%CI: 1.39–1.78), with consistent effects across subgroups by country, IR index, study type, and follow-up. Mechanistic evidence revealed that IR promotes AF development and recurrence via enhanced inflammation, oxidative stress, atrial structural remodeling, and electrical abnormalities. IR-related indices showed higher clinical utility for risk stratification in Chinese and Asian populations. Meta-regression and sensitivity analyses confirmed the robustness of these findings. The quality of evidence was rated as moderate.

Insulin resistance is an independent risk factor for both new-onset and recurrent AF. IR-related indices have translational value for early risk identification and personalized management. Incorporating IR assessment into AF management and prevention strategies—integrating metabolic and electrophysiological perspectives—may optimize long-term outcomes and provide a foundation for precision medicine and tailored follow-up in AF care.

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420251142441, PROSPERO CRD420251142441.

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