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Overconsumption of beverages with added sugar or artificial sweetener, already associated with several cardiometabolic diseases, showed new links to atrial fibrillation (Afib or AF) in a prospective cohort study.

Within the U.K. Biobank, people who drank more than an estimated 2 L (~8.5 cups) of sugar-sweetened beverages (adjusted HR 1.10, 95% CI 1.01-1.20) or artificially sweetened beverages (adjusted HR 1.20, 95% CI 1.10-1.31) weekly had a greater risk of incident Afib within 10 years compared with nonconsumers.

Consuming 1 L or less of pure fruit juice, on the other hand, showed no such relationship and in fact appeared mildly protective against this established risk factor for stroke (adjusted HR 0.92, 95% CI 0.87-0.97), reported Ningjian Wang, MD, PhD, of Shanghai Ninth People's Hospital and Shanghai Jiao Tong University in China, and colleagues in .

The association between lots of sweetened beverages and Afib persisted after adjustment for genetic susceptibility to Afib. However, drinking less than the weekly 8.5 cups did not statistically correlate with Afib risk.

"To the best of our knowledge, this is the first study to estimate the associations of the consumption of different sweetened beverages with the risk of AF in a large prospective cohort," the authors wrote. "This study does not demonstrate that consumption of SSB [sugar-sweetened beverages] and ASB [artificially sweetened beverages] alters AF risk but rather that the consumption of SSB and ASB may predict AF risk beyond traditional risk factors."

The present findings on sweetened beverages thus add to the literature on diet and Afib, which has been dominated by studies on coffee and alcohol.

Current already urge limiting foods and beverages with added sugars to under 10% of daily calories.

"SSB are one of the largest sources of added sugar in the diet. They include energy-containing sweeteners, such as sucrose, high-fructose corn syrup, or fruit juice concentrates. High consumption of SSB is associated with a high risk of obesity, type 2 diabetes, cardiovascular diseases, and even all-cause mortality," Wang's group noted.

American guidelines do not endorse eating or drinking foods with low- and no-calorie sweeteners, either.

Recently marketed as a healthy, low-calorie artificial sweetener, even erythritol, for example, has still been associated with cardiovascular disease. One study showed that erythritol-sweetened drinks increased plasma erythritol to levels that lingered above thresholds associated with heightened platelet reactivity and thrombosis potential.

Wang's team reported that the highest risk of Afib was observed in people at high genetic risk who also drank more than 8.5 cups of artificially sweetened -- not sugar-sweetened -- beverages per week.

"Somewhat surprising was that subjects with increased consumption of ASB were at the highest risk of incident AF. These findings raise the possibility that artificial sweeteners may have a more important role and contribute to the pathogenesis of AF," wrote Robert Koeth, MD, PhD, and two colleagues of Cleveland Clinic, in an .

Koeth's group said many questions surround the potential link between artificial sweeteners and Afib. The report by Wang and colleagues was unable to identify exact types of artificial sweeteners and other additives consumed by participants.

"Among ASB, what artificial sweetener(s) are associated with AF? What underlies the pathogenesis of this observation? Are there indirect or direct effects of artificial sweeteners on the myocardium? Finally, should longer term studies be required before the introduction of artificial nutrients into the food?" the editorialists asked.

Included in the present study were 201,856 U.K. Biobank participants (45.1% men, mean age 56 years) free of baseline Afib when they completed a 24-hour diet questionnaire. They were followed for a median 9.9 years, and some people answered multiple questionnaires during the study. Study authors sought records of incident Afib from primary care, hospital, and death records.

Diet questionnaires asked people to report various eating habits, including how many cups of beverages they drank the previous day. Wang's group extrapolated this information to weekly consumption estimates.

While a large majority of participants did not report drinking any sugar-sweetened or artificially sweetened beverages in their questionnaire, there were 6.6% and 5.5% of people reportedly drinking over 8.5 cups a week, respectively, of these drinks.

Heavy consumers tended to be young people with a higher BMI and a higher prevalence of coronary heart disease or diabetes.

A standard polygenic risk score was the basis for classifying people as high, intermediate, or low genetic risk for Afib.

Wang and colleagues acknowledged that their observational study left room for unmeasured confounding. Additionally, diet habits were possibly misreported or inherently biased in survey data, and the findings from relatively healthy participants from Britain may not apply to other groups.

"Despite these drawbacks, this study is the first to demonstrate a link between high consumption of SSB and ASB to AF. Further epidemiological and mechanistic studies are needed to confirm and extend these findings," Koeth's group wrote.

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