Peripheral Artery Disease and Atrial Fibrillation: A Systematic Review and Meta-analysis on 763,919 Patients

Background: Several cardiovascular risk factors and comorbidities have been linked to an increased risk of new-onset atrial fibrillation (NOAF). However, the relationship between peripheral artery disease (PAD) and NOAF has been less extensively investigated. Objectives: The purpose of this study was to estimate the risk of NOAF in PAD patients. Methods: We performed a systematic review of MEDLINE (via PubMed) and EMBASE from inception to January 2026 and a meta-analysis of observational studies reporting risk of NOAF in PAD patients. For studies using the ankle-brachial index (ABI), we stratified results according to ABI <1.0 or >1.4. Results: We included 7 studies with 763,919 patients (56,207 with PAD) and 26,064 NOAF events. The pooled analysis showed an association between PAD and NOAF (HR: 1.34; 95% CI: 1.18-1.50, I2 = 85%). PAD defined by low ABI<1.0 was associated with NOAF (HR: 1.18; 95% CI: 1.09-1.28; P < 0.001, I2 = 37%) while ABI>1.4 did not reach statistical significance (HR: 1.14; 95% CI: 0.99-1.32; P = 0.07, I2 = 33%). PAD defined using International Classification of Diseases-Ninth Revision or clinical history (ie, clinically overt PAD) showed the strongest association with NOAF (HR: 1.40; 95% CI: 1.19-1.66; P < 0.001, I2 = 81%). The certainty of the evidence according to GRADE (Grading of Recommendations, Assessment, Development and Evaluations) was low. Conclusions: Data from observational studies suggest that PAD may be associated with a 34% increased risk of NOAF. In patients diagnosed with PAD (ie, low ABI), proactive management of common atherosclerotic risk factors may be considered to potentially reduce the risk of NOAF.