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Magnitude and associated factors of atrial fibrillation, and its complications among adult rheumatic heart diseases patients in governmental hospitals in Bahir Dar Town, Northwest Ethiopia 2024

BMC Cardiovascular Disorders volume 25, Article number: 122 (2025) Cite this article

Abstract

Introduction

Atrial fibrillation (AF) is characterized by high frequency stimulation of the atrium, causes dyssynchronous atrial contraction and irregular ventricular excitation. It is the most known cardiac arrhythmia in adults, doubles the risk of stroke five times and is associated with an increasing public health burden. This study was aimed to assess the magnitude and associated factors of atrial fibrillation and its complication among adult rheumatic heart diseases patients in governmental hospitals in Bahir Dar town, Northwest Ethiopia 2024.

Methods

An institutional based cross-sectional study design was conducted with a sample size of 421. A simple random sampling technique was used to select participants. The data were entered into the Statistical Package for the Social Sciences (SPSS) version 26 for analysis. Adjusted Odds Ratio (AOR) with a 95% confidence interval was used to determine associated factors of atrial fibrillation. A binary logistic regression model was used, and a P-value < 0.05 in multivariate was considered as a statistically significant.

Results

The response rate was 95% and atrial fibrillation was developed in 51.2% of patient. Majority of them were Female (56%). The median age of patients was 41, with an interquartile range (IQR) of 26–51. Age > 50 years old (AOR = 7.20(2.03–25.46)), sever tricuspid regurgitation 4.50(1.18–17.20)), and left ventricular ejection fraction (LVEF) % (AOR = 0.94(0.89–0.99)), left atrium size (AOR = 1.23(1.14–1.33)) were independently associated with atrial fibrillation. For every unit increment of left ventricular ejection fraction in percent, the odds of developing atrial fibrillation decreased by 6%. For every unit increment of left atrial size in millimeter2 (mm2), the odds of developing atrial fibrillation increased by 23%. The present study showed that complication related to AF was heart failure (HF) (72.8%), ischemic stroke (34.4%), systemic thromboembolism (12.1).

Conclusion

More than half of the study participants were found to have atrial fibrillation in patients with rheumatic heart disease. Being age > 50 years old, left atrium size, severity of tricuspid regurgitation (severe), and LVEF% were associated in developing atrial fibrillation. The atrial fibrillation was linked to an increased risk of ischemic stroke, heart failure, systemic thromboembolism, and death.

Peer Review reports

Introduction

One of the most prevalent and avoidable types of acquired heart disease is rheumatic heart disease, caused by repeated severe or recurrent acute rheumatic fever episodes that damage the heart valves over time [1]. Valvular damage due to rheumatic heart disease results from an abnormal autoimmune reaction after repeated infection with group A streptococcal (GAS) bacteria [2]. In low- and middle income countries (LMICs), rheumatic heart disease (RHD) is the main cause of atrial fibrillation (AF); in high income countries (HICs), hypertension and coronary artery disease are the most known causes of AF [3, 4].

According to research done shows the prevalence of AF in RHD is 32.8% worldwide, with significant variation (4.3%–79.9%) based on the degree of development in each nation [5]. Rheumatic heart disease (RHD) is a common risk factor for AF in Sub-Saharan Africa (SSA), with a prevalence ranging from 4.6% to 46.8% [6,7,8,9].

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias, causing from high-frequency stimulation of the atrium and resulting causing dyssynchronous atrial contraction and irregular ventricular excitation [10]. This abnormal rhythm is due to increased atrial pressure, chronic inflammation, fibrosis, and left atrial enlargement [11, 12]. In clinical practice, atrial fibrillation is the most prevalent persistent cardiac arrhythmia, and its prevalence is rising, nowadays [13,14,15,16].

The most common type of AF in developed countries is paroxysmal; however, permanent AF is more seen in Africans. This is because low rates of rhythm strategy and a low detection probability of paroxysmal AF, leading it to quickly become permanent [17]. Atrial fibrillation in rheumatic heart disease is seen in many countries around the world. It mostly affects young people, causing severe morbidity and mortality [3]. According to a 2020 evaluation in Africa, institution based studies had a prevalence of AF was 0.7% to 55.7%, and community-based studies had a prevalence of 0.03% to 1.25% [18]. In Ethiopia, prevalence was 4.3% of people over age 40, 5.1% of people between 40 and 49, and 6.9% of people over 80 years old [19].

According to the worldwide burden of cardiovascular disease, the number of mortality from atrial fibrillation in 2021 was 366,000, and the disability-adjusted life year was 8,200,000 [20]. In the world atrial fibrillation affects 37,574 million people (0.51% of the global population), and its magnitude has risen by 33% in the past 20 years. Future estimates suggest that its absolute burden could rise by more than 60% by 2050 [21].

A 2019 study found that among people with rheumatic heart disease (RHD), the estimated magnitude of AF in Sub-Saharan Africa ranged from 9.5% to 46.8% [22]. In industrialized nations with primary underlying causes of AF is hypertensive heart disease, cardiomyopathy, hypertension,,alcohol drinking, and cigarate smoking whereas rheumatic valvular heart disease showed that is the main contributors of AF in nation like Africa [23].

Globally, 6.9 million reported cases of ischemic stroke associated to AF were documented in 2019 [24, 25]. The average annual risk of stroke is elevated by 2.3% (lethality 30%) in atrial fibrillation [26]. The economic burden of AF is associated to its symptoms, their effects, therapy, and complications [27].

A study at Tikur Anbessa specialized hospital found that the magnitude of AF among patients with rheumatic heart disease was 46.8% and cardio embolic stroke was 9.2% [9]. As far as authors knowledge, there is no prior studies on the magnitude and, associated factors of atrial fibrillation and its complications among patients with rheumatic heart diseases in a governmental hospital in Bahir Dar town, Northwest Ethiopia. There are several predictors that remain to be researched; this study will be a valuable input to the existing body of knowledge.

Methods

Study design, study area and study period

This study was an institutional-based cross-sectional study conducted at two purposively selected governmental hospitals in Bahir Dar city, Northwestern Ethiopia. Bahir Dar city is located 587 km northwest of Addis Ababa, Ethiopia. Tibebe Ghion specialized hospital (TGSH) and Felege Hiwot compressive specialized hospitals (FHCSH) have been giving service for different illness including cardiac problems. The hospitals were selected considering flow rate of RHD patients at cardiac clinics in respective hospitals. Three years medical records of patients with rheumatic heart disease from January 1, 2021 to December 30, 2023 were reviewed in this study. The study period was from May 10, 2024 to June 9, 2024.

Eligibility criteria

All medical records of adult patients with diagnosis of rheumatic heart disease within two hospitals were included. Patients’ with replaced valve, post percutaneous trans-venous mitral commissurotomy (PTMC) and incomplete medical record (lack of electrocardiography (ECG) or/and echocardiography) were excluded from this study.

Sample size determination

The sample size calculated by using single proportion formula and adding a non-respondent rate of 10% was 421. The sample size for the factors of atrial fibrillation was 414 by using Epi Info Version 7, statcalc and considering 85% power, a 95% CI, and a 10% non-response rate. Therefore, the final and the largest sample size for this study were 421.

Sampling technique

Totally, 1844 RHD patients were seen at Tibebe Ghion specialized hospital and FelegHiwot compressive specialized hospitals in the past three consecutive years. A proportion-to-size allocation method was implemented to determine the number of rheumatic heart disease cases to be included from each hospital. The sample was selected by taking index rheumatic heart disease patients’ chart numbers who visited from January 1, 2021, to December 30, 2023, from the registry book. Simple random sampling technique was used to select the charts of the patients with the help of a computer-generated number. The number of patients with rheumatic heart disease included in each hospital was calculated as; (Number of rheumatic heart disease patients in each hospital × sample size) / total population from all hospitals (Fig. 1).

Fig. 1
figure 1

Sampling procedure for selecting medical records of rheumatic heart disease patients from TGSH and FHCSH hospitals in Bahir Dar town, Northwest Ethiopia, 2024 (n = 421)

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Variables

Dependent variables

Atrial fibrillation.

Atrial fibrillation’s Complication.

Independent variables

Socio-demographic factor

Sex, age.

Behavioral factor

Cigarate smoking, alcohol drinking.

Investigation related factor

Echocardiography (mitral valve stenosis, mitral valve regurgitation, tricuspid valve regurgitation, aortic valve regurgitation, left atrial size, mitral valve area in mm2, EF in %) and laboratory investigations (erythrocyte sedimentation rate(ESR), international normalization rate (INR)and lipid profile).

Comorbidities

Heart failure, Diabetes Mellitus (DM), IHD, hyperthyroidism, dyslipidemia, medication.

Operational definition

Atrial Fibrillation

Is a common cardiac arrhythmia in which the normal sinus rhythm is replaced by an ineffective rhythm or made by reviewing the attached 12 lead ECG strips, if available, or if an ECG reading report with an index of AF was found in the case records [28].

Rheumatic heart disease (RHD)

Documented echocardiography finding that shows rheumatic valvular heart disease in the patients chart.

Complications

Are Ischemic stroke, heart failure, systemic thromboembolism, cardiogenic shock and death that documented on medical records of patients.

Ischemic stroke

An episode of acute neurological dysfunction presumed to be caused by focal cerebral, spinal, or retinal infarction persisting ≥ 24 h or until death is recorded on the patient’s medical chart [29].

Systemic thromboembolism

A vascular disorder characterized by obstruction of blood vessels (arteries or veins) due to the formation of an embolus (movement of blood clot from one place to another place) [30].

Complete patient chart

Refers to patient medical records at least that contain echocardiography and electrocardiography findings of patients with rheumatic heart disease.

Data collection

Data were collected with structured checklist which was adapted from reviews of various literature sources [5, 9, 31, 32]. The checklist consists of five parts. Part I: socio-demographic and behavioral factors; part II: investigation related factors; part III: comorbidity-related factors; part IV: medication- related factors and part V: complication-related factors. The registration book was used to obtain the card numbers of rheumatic heart disease patients. The patients’ charts were retrieved from the record and documentation office. The data was collected by trained four BSc nurses and a supervisor. The training was about the purpose of the study, the details of the check list, the importance of privacy, and ensuring the confidentiality of the extracted data.

A pre-test was done with 10% of the patient’s chart other than the selected years of the study at Tibebe Ghion Specialized Hospital to check clarity and to modify the data collection instrument. Based on the findings of the pretest, corrections and modifications were made. The reliability of the tool was checked by Guttmann Split-Half Coefficient (71%). Every day, the collected data was reviewed and checked for completeness and consistency.

Data analysis

The data was collected by kobo toolbox. All data was undergoing visual checked to be coded, and exported into the SPSS version 26 software package for analysis. Descriptive analysis was conducted for each of the independent variables, utilizing frequencies, cross tabulation and percentages. The outcome of interests was computed and presented through text, tables, graphs and charts. For continuous variables medians (interquartile range) were used.

Association was investigated by using bivariable logistic regression analysis. All independent variables with a p value < 0.2 in the unadjusted model were selected as candidates for multivariable analysis to control the effect of confounding variables. In the multivariable analysis, variables with a p-value < 0.05 were considered statistically significant. The complications of AF were analyzed by comparing the differences in distribution of HF, ischemic stroke, systemic thromboembolism, cardiogenic shock and death between the group with and without AF using Chi-squared tests and two-sided p value of < 0.05 was taken as statistically significant. Multicollineartiy and model fitting was assessed using the hosemer and lemeshow tests to ensure it is non-significant at a specified level in multivariable analysis. The degree of associations was expressed by using the odds ratio (ORs) with 95% confidence intervals (CIs).

Ethical consideration

An approval letter for data collection was obtained from the St. Paul’s hospital millennium medical college Institutional Ethical Review Board with Ref 23/1147. This official letter was submitted to Tibebe Ghion specialized hospital and FelegHiwot compressive specialized hospital in Bahir Dar town, Northwest Ethiopia. Subsequently, a letter of permission was obtained from administrative bodies in the area, enabling communication with relevant entities at the hospital. To uphold confidentiality, the names of patients on the charts were replaced with codes, mitigating the risk of individual identifiers.

Result

Socio-demographic and behavioral characteristics of participants

A total of 421 charts of adult RHD patients were selected at TGSH and FHCSH from January 1, 2021, to December 30, 2023. Of those, 402 fulfilled the inclusive criteria. The response rate was 95%. The median age of patients was 41, with an IQR of 26–51. The majority of the patients were less than 31 years old 125 (31.1%). The female accounts 225 (56%). Among all patients, 78 (19.4%) had a history of alcohol drinking (Table 1).

Table 1 Socio-demographic and behavioral characteristics of adult rheumatic heart disease patients at TGSH and FHCSH hospitals in Bahir Dar town, Northwest Ethiopia, 2024 (n = 402)
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Clinical characteristics of participants

This study revealed that median left atrium size in mm was 49 with an IQR of 39.75–56 and the median left ventricular ejection fraction was 52 with an IQR of 43–60. Mitral valve regurgitation (MVR) was the most common valve lesion, found in 308 (76.6%) of patients. The majority of them were moderate mitral valve regurgitation 152 (37.8%). Mitral stenosis in 293 (72.9%); the majority of them was severe mitral stenosis 150 (37.3%). The highest magnitude of AF was found in those patients with tricuspid valve regurgitation and mitral valve stenosis (68.6% and 65.5%, respectively). It was found that the magnitude of AF increased from moderate (67.4%) to severe MS (83.3%) compared to mild MS (9.8%). The most commonly identified comorbid disease was heart failure in 271 (67.4%), with the majority of them being NYHA class III, 95 (23.6%). The most frequently prescribed RHD treatment was benzathin penicillin in 343 (85.3%) with other drugs (Table 2).

Table 2 Clinical characteristics of adult rheumatic heart disease patients at TGSH and FHCSH hospitals in Bahir Dar town, Northwest Ethiopia, 2024(n = 402)
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Magnitude of atrial fibrillation among RHD patients

Out of 402 adult rheumatic heart disease patients, 206 (51.2%) with a 95% CI; 46–55 were diagnosed with atrial fibrillation (Fig. 2).

Fig. 2
figure 2

Magnitude of atrial fibrillation among adult rheumatic heart disease patients at TGSH and FHCSH hospitals in Bahir Dar town, Northwest Ethiopia, 2024 (n = 402)

Full size image

Factors associated with atrial fibrillation among adult rheumatic heart diseases patients

The independent variables that are candidates for multivariate analysis after bivariate analysis with a p-value of < 0.2 were- age, severity of mitral valve stenosis, severity of mitral regurgitation, left atrium size, severity of tricuspid valve regurgitation, severity of aortic valve regurgitation, NYHA class of heart failure, ischemic heart disease, ESR, dyslipidemia, LVEF%, alcohol drinking, cigarate smoking, and benzathin penicillin. The model has a good fit since the Hosmer and Lemeshow tests could not reject the hypothesis of model appropriateness, as the chi-square value is 9.05 and p = 0. 338.

In the adjusted analysis, factors that continued to be associated with increased odds of AF were age > 50 years old, left atrium size, severity of tricuspid regurgitation (severe), and LVEF%. These factors were statistically significant for atrial fibrillation at a p-value of < 0.05 with a 95% confidence interval. According to this analysis, patients with an age greater than 50 years were seven times more likely to increase the odds of developing atrial fibrillation as compared with patients less than 31 years old. For every unit increment of left atrial size in mm, the odds of developing atrial fibrillation increased by 23%. Patients with severe tricuspid valve regurgitation had nearly five times more likely increased the odds of atrial fibrillation as compared with patients without tricuspid valve regurgitation. For every unit increment of left ventricular ejection fraction in percent, the odds of developing atrial fibrillation decreased by 6% (Table 3).

Table 3 Logistics regression analysis of atrial fibrillation among adult rheumatic heart disease patients at TGSH and FHCSH hospitals in Bahir Dar town, Northwest Ethiopia, 2024(n = 402)
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Complications of atrial fibrillation among adult rheumatic heart disease patients

This study showed that the complications of atrial fibrillation among rheumatic heart disease increases the risks of heart failure (72.8% vs. 25%) p < 0.001), ischemic stroke, systemic thromboembolism, cardiogenic shock and death in patients with AF as compared to those without AF. It showed atrial fibrillation was associated with a fivefold increased risk of ischemic stroke and a twofold increased risk of systemic thromboembolism compared to sinus rhythm (Table 4).

Table 4 Complications of atrial fibrillation among adult rheumatic heart disease patients at TGSH and FHCSH hospitals in Bahir Dar town, Northwest Ethiopia, 2024(n = 402)
Full size table

Discussion

This study revealed the magnitude and associated factors of atrial fibrillation, and its complications among adult rheumatic heart disease patients. According to this finding RHD patients had a magnitude of AF (51.2%; 95% CI- 46–55). This is consistent with a study conducted at Tikur Anbessa Hospital, Ethiopia (46.8%) [9]. This may be due to similar socio-demographic characteristics, and a similar study design. However, it is higher than the prevalence found the studies conducted in HP-RF/RHD Registry, in which the AF prevalence was reported in India (23.9%), Nepal (36.3%), South Korea (20.9%), and Iran (33%) [31,32,33,34]. This discrepancy may be due to different socio-demographic characteristics, variations in healthcare infrastructure, management of RHD and different economic status. But lower than a study conducted in Tanzania reported that the prevalence of AF was 57% [35]. This discrepancy may be due to resting electrocardiography and 24 h ambulatory Holter monitoring electrocardiography was done but in the this study only resting electrocardiography was done.

In this study, patients age > 50 was 7 times increased the odds developing atrial fibrillation as compared with patients age < 31 years [AOR = 7.20; 95% (2.03–25.46)] with a p-value of 0.002. This finding is supported by several studies conducted in Ethiopia at Tikur Anbessa Hospital, Australia, Buellton, Spain, USA, India, and Pakistan [9, 32, 36,37,38,39]. This may be because the atrial myocardium undergoes electrical and structural remodeling with age, both of which may play an important role in the initiation of atrial fibrillation. A longer disease period and inflammatory processes in older patients were also suggested to be contributing factors predisposing to AF [40]. Other contributing factors included the type of valve lesion, LVEF%, and left atrial size.

According to this study, patients with increased left atrial size the odds of developing atrial fibrillation was increased by 23%, [AOR = 1.23; 95% CI (1.14–1.33)]. This finding supported by study conducted in India and Tanzania [32, 35]. This may be due to atrial dilation and fibrosis, as multiple re-entrant circuits can occur in an enlarged atrium [41].

Based on this study, severe TR had increased the odds of atrial fibrillation nearly five times as compared with patients without tricuspid regurgitation [AOR = 4.50(1.18–17.20)] with a p- value of 0.028. Another study also showed that severity of TR was also reported as risk factors for AF in Tikur Anbesa Hospital, Ethiopia and India [9, 32]. This might be brought on by pressure and volume overload, as they could trigger the biological processes that generate atrial myocardial hypertrophy and myocardial fibrosis, which could put a person at risk for atrial fibrillation (AF) [42].

Atrial fibrillation with LVEF% [AOR = 0.94; 95% CI (0.89–0.99)] was related the study conducted in Iran [34]. This may be due to structural and neuro-hormonal changes in cardiac muscle, as a reduced ejection fraction increases the possibility of AF development.

According to this study, a higher prevalence of HF, ischemic stroke, and systemic thromboembolism were seen in patients with atrial fibrillation as compared to studies conducted in India and Nepal [31, 32]. This is might be healthcare settings have limited access to preventive measures or specialized care for conditions like HF or stroke. But lower than studies in western India, the prevalence of heart failure (85%), and cardiogenic shock (10%) among AF patients [43]. This may be due to a sample size variation. In the present study, the sample size was much higher as compared to western India (421 vs. 40). Based on this study, the prevalence of death among AF patients is also higher (3.4%) as compared with studies conducted in South Korea (2.1%) [44]. This discrepancy may be due to different socio-demographic characteristics and economic status.

Conclusion

More than half of the study participants with RHD were found to have atrial fibrillation. In addition, this research identified risk factors associated with the development of atrial fibrillation in rheumatic heart disease patients were age > 50 years old, left atrium size, severity of tricuspid regurgitation (severe), and LVEF%. AF was linked to an increased risk of ischemic stroke, heart failure, systemic thromboembolism, and death. The study showed atrial fibrillation was associated with a fivefold increased risk of ischemic stroke and a twofold increased risk of systemic thromboembolism compared to sinus rhythm.

Limitations of the study

Even though; it provides insights and clues about the magnitude and associated factor of atrial fibrillation among adult RHD patients and its complications; it had some limitations that were identified. First, a cross-sectional study was used, and it did not show a cause and effect relationship. Second, the use of secondary data, and as a result, some important information to regarding factors associated atrial fibrillation to assess death outcome were not found.

Data availability

All important data supporting the findings of the study are included in the manuscript. The necessary detailed information and raw data are available from the corresponding author.

Abbreviations

AF:

Atrial Fibrillation

AOR:

Adjusted Odds Ratio

AV:

Atrioventricular

BSC:

Bachelor of Science

CAD:

Coronary Artery Disease

CI:

Confidence Interval

COR:

Crude Odds Ratio

ECG:

Electrocardiography

ESR:

Erythrocyte Sedimentation Rate

EF:

Ejection Fraction

FGSH:

Felege Hiwot Comprehensive Specialized Hospital

GAS:

Group A streptococcal

HIC:

High Income Country

INR:

International Normalization Ratio

IQR:

Interquartile Range

LA:

Left Atrium

LMIC:

Low and Middle Income Country

LVEF:

Left Ventricular Ejection Fraction

MR:

Mitral Regurgitation

MS:

Mitral Stenosis

MV:

Mitral Valve

MVA:

Mitral Valve Area

MVR:

Mitral Valve Regurgitation

NYHA:

New York Heart Disease

OR:

Odds Ratio

PTMC:

Percutaneous Trans venous Mitral Commissurotomy

RHD:

Rheumatic Heart Disease

RVHD:

Rheumatic Valvular Heart Disease

SSA:

Sub-Saharan Africa

SPSS:

Statistical Package for the Social Science

TGSH:

Tibebe Ghion Specialized Hospital

TR:

Tricuspid Regurgitation

VHD:

Valvular Heart Disease

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Acknowledgements

We thank St. Paul’s Hospital Millennium Medical College Research Office and the School of Nursing for providing the opportunity to prepare for the study. We thank the medical registration staff and administration of Tibebe Ghion specialized hospital and FelegHiwot compressive specialized hospitals for continuous support. At last we would like gratitude supervisors and data collectors for their time and voluntary facilitation of the data collection process.

Clinical trial number

Not applicable.

Funding

This study was funded by SPHMMC. The sponsors of this work had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to the data in the study and the decision to submit.

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Authors and Affiliations

  1. Department of Medical-Surgical Nursing, School of Nursing, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia

    Diress Abebe Beyene, Melese Adane Cheru & Tekalign Markos Chamiso

  2. Department of Emergency and Critical Care Nursing; School of Nursing, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia

    Helina Bogale Abayneh

Authors
  1. Diress Abebe Beyene
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  2. Helina Bogale Abayneh
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  3. Melese Adane Cheru
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  4. Tekalign Markos Chamiso
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Contributions

DAB, HBA, TMC and MAC contribute in conceptualization, literature search, study selection, data extraction and manuscript writing. DAB and TMC took part in drafting the article or revising it critically for important intellectual content. HBA gave final approval of the version to be published. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Tekalign Markos Chamiso.

Ethics declarations

Ethics approval and consent to participate

The research was performed in accordance with the Declaration of Helsinki. The Institutional Review Board (IRB) of St. Paul ‘s Hospital Millennium Medical College guaranteed the approval of this research with reference number pm 23/1147. Following approval, a written official letter of cooperation was submitted to Tibebe Ghion and FelegHiwot hospitals’ office before data collection. The data were anonymous and informed consent was waived by the approving Institutional Review Board because of the retrospective nature of the study.

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None.

Competing interests

The authors declare no competing interests.

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Beyene, D.A., Abayneh, H.B., Cheru, M.A. et al. Magnitude and associated factors of atrial fibrillation, and its complications among adult rheumatic heart diseases patients in governmental hospitals in Bahir Dar Town, Northwest Ethiopia 2024. BMC Cardiovasc Disord 25, 122 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12872-025-04562-6

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Keywords

BMC Cardiovascular Disorders

ISSN: 1471-2261

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