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Prognostic Implications of Atrial Fibrillation in Heart Failure
Study Questions:
What are the long-term prognostic implications (up to ~2.2 years) of atrial fibrillation (AF) compared to sinus rhythm (SR) between acute and chronic heart failure (HF) with reduced (HFrEF <40%), mid-range (HFmrEF 40-49%), and preserved (HFpEF ≥50%) ejection fraction (EF)?
Methods:
The study authors analyzed data from the observational, prospective HF long-term registry of the European Society of Cardiology (ESC), which is a prospective, multicenter, observational study of inpatients and outpatients at 211 diverse cardiology centers in 21 European and Mediterranean countries that are ESC members. The final study cohort was comprised of a total of 14,964 HF patients (ages 66 ± 13 years, 67% male; 53% HFrEF, 21% HFmrEF, 26% HFpEF) enrolled in the registry. A Cox regression was used to determine the hazard ratio of all-cause death and HF hospitalizations associated with AF in each of the HF EF subtypes.
Results:
The study authors found that the prevalence of AF was 27% in HFrEF, 29% in HFmrEF, and 39% in HFpEF. The prevalence of AF was age dependent in both genders, reaching 50% in HF patients above the age of 80 years. AF was associated with higher representation of women in HFpEF and HFmrEF, but not in HFrEF. AF was associated with older age, lower functional capacity, and heightened physical signs of HF. Crude rates of mortality and HF hospitalizations were higher in patients with AF compared to SR, in each EF subtype. After multivariable adjustment, the long-term hazard ratio of AF for all-cause death was: 0.923 (95% confidence interval [CI], 0.782–1.091; p = 0.347) in HFrEF, 1.296 (95% CI, 0.993–1.691; p = 0.057) in HFmrEF, and 1.198 (95% CI, 0.954–1.504; p = 0.120) in HFpEF; the hazard ratio of AF for HF hospitalizations was: 1.036 (95% CI, 0.888–1.208; p = 0.652) in HFrEF, 1.430 (95% CI, 1.087–1.882; p = 0.011) in HFmrEF, and 1.487 (95% CI, 1.195–1.851; p < 0.001) in HFpEF; and for combined all-cause death or HF hospitalizations: 0.957 (95% CI, 0.843–1.087; p = 0.502), 1.302 (95% CI, 1.055–1.608; p = 0.014), and 1.365 (95% CI, 1.152–1.619; p < 0.001), respectively. In patients with HFrEF, AF was not associated with worse outcomes in those presenting with either an acute or a chronic presentation of HF.
Conclusions:
The authors concluded that the prevalence of AF increases with increasing EF, but its association with worse cardiovascular outcomes remained significant in patients with HFpEF and HFmrEF, but not in those with HFrEF.
Perspective:
This is an important study because it suggests that AF may have worse outcomes in those with a stiff heart (i.e., HFpEF and HFmrEF) when compared to those who have systolic HF. This in turn suggests that the benefits of AF ablation may be greater in HFpEF and HFmrEF patients when compared to HFrEF patients. Also, the approach to management of AF may differ at different ages. Future studies of AF patients with HF are needed to validate these conclusions.
Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Chronic Heart Failure
Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Geriatrics, Heart Failure, Heart Failure, Diastolic, Heart Failure, Systolic, Prognosis, Stroke Volume, Systole
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