Stress, Insomnia Tied to Increased AF Risk for Older Women


Eight psychosocial factors, grouped into two distinct clusters, are significantly associated with risk for atrial fibrillation (AF) in postmenopausal women, with insomnia and stressful life events (SLEs) being the most strongly associated with AF, a large new study has found.


  • In addition to traditional risk factors such as obesity, advanced age, ethnicity, smoking, alcohol, hypertension, diabetes, coronary artery disease, heart failure, and emotional and psychological distress may also affect AF.

  • The study included 83,736 postmenopausal women in the Women’s Health Initiative, mean age 63.9 years and 88.1% White, who did not have AF at baseline.

  • From questionnaires, researchers collected information on psychosocial stressors and used hierarchical cluster analysis (HCA) to identify patterns of psychosocial predictors.

  • They separated these clusters into quartiles, identified associations between psychosocial exposure variables, and adjusted for traditional risk factors.

  • Over an average follow-up of 10.5 years, 23,954 participants (28.6%) developed incident AF.


  • The analysis generated two clusters of distinct psychosocial variables that were significantly associated with AF: the Stress Cluster, including SLEs, depressive symptoms, and insomnia; and the Strain Cluster, including three personality traits: optimism, cynical hostility, and emotional expressiveness; and two social measures: social support, and social strain.

  • Those in the highest quartiles of both the Stress Cluster and the Strain Cluster had greater rates of AF compared with those in the lowest quartiles.

  • In a final model, the association between SLEs (hazard ratio [HR], 1.02; 95% CI, 1.01-1.04) and insomnia (HR, 1.04; 95% CI, 1.03-1.06) were most strongly linked to increased incidence of AF, and a sensitivity analysis using snoring as a surrogate marker for sleep apnea didn’t change this outcome, supporting the independent effect of insomnia on AF.

  • In subgroup analyses, the Stress Cluster had a stronger association with AF incidence in younger (50-69 years) vs older women (70-79 years), and in non-Hispanic White and Asian women vs Hispanic and non-Hispanic Black women.


The results support the hypothesis that psychosocial predictors account for additional risk for AF “above and beyond” traditional AF risk factors, the authors write. Identifying and addressing sex-specific, modifiable risk factors, including insomnia, “may help reduce the burden of AF in aging women,” the researchers conclude.


The study was conducted by Susan X. Zhao, MD, Division of Cardiology, Department of Medicine, Santa Clara Valley Medical Center, San Jose, California, and colleagues. It was published online August 30, 2023, in the Journal of the American Heart Association.


The psychometric questionnaires were administered only at study entry, but psychosocial variables may change over time. Data on sleep apnea and other sleep disorders, which may confound the relationship between insomnia and AF, were not available, and although the study included a sensitivity analysis controlling for snoring, this is an imperfect surrogate for sleep apnea. Generalizability to other demographic, racial, and ethnic groups is limited.


The Women’s Health Initiative program is funded by the National Heart, Lung, and Blood Institute, National Institutes of Health, US Department of Health and Human Services. The authors have no relevant conflicts of interest.

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