Type of Atrial Fibrillation and Outcomes in Heart Failure

Study Questions:

Does the type of atrial fibrillation (AF) affect outcomes in patients with systolic heart failure (HF)?


This was a post hoc analysis of two clinical trials in patients with systolic HF (PARADIGM-HF and ATMOSPHERE). There were 9,828 patients without AF, 1,645 patients with paroxysmal AF, 3,770 patients with persistent AF, and 369 patients with new-onset AF. The mean ages of the patients in these subgroups were 61.6, 66.9, 67.2, and 64.3 years, respectively. The mean ejection fraction was 0.28-0.30. The median follow-up was 27-36 months. The primary outcome was a composite of cardiovascular death or HF hospitalization.


Compared to patients without AF, patients with paroxysmal (but not persistent) AF had a significantly higher risk of the composite endpoint (hazard ratio [HR], 1.20), HF hospitalization (HR, 1.34), and stroke (HR, 1.34). Compared to patients without AF, patients with new-onset AF also had a significantly higher risk of the composite endpoint (HR, 2.21), HF hospitalization (HR, 2.11), and stroke (HR, 2.20), and also a higher risk of all-cause mortality (HR, 2.26). Anticoagulation was prescribed less often for paroxysmal (53%) and new-onset (16%) AF than for persistent AF (71%).


Among patients with HF, paroxysmal and new-onset AF are associated with negative clinical outcomes, whereas persistent AF is not.


Several studies have demonstrated that underutilization of anticoagulation is common in patients with AF. The higher stroke rate in the patients with paroxysmal and new-onset AF in this study correlates with a greater degree of underutilization, stressing the importance of anticoagulation in patients who meet guideline criteria. However, the reason that persistent AF did not increase the risk of HF hospitalization as did the other types of AF is unclear.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Chronic Heart Failure

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Heart Failure, Systolic, Heart Failure, Stroke, Stroke Volume, Systole, Secondary Prevention

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