Atrial fibrillation associated with worse long-term CV outcomes in HFmRF and HFpEF
Prognostic implications of atrial fibrillation in heart failure with reduced, mid-range, and preserved ejection fraction: a report from 14 964 patients in the European Society of Cardiology Heart Failure Long-Term RegistryLiterature - Zafrir B, Lund LH, Laroche C et al. - Eur Heart J 2018; published online ahead of print
Introduction and methods
There are established treatments for heart failure (HF) with reduced ejection fraction (HFrEF), which is frequently caused by coronary artery disease. On the other hand, HF with preserved ejection fraction (HFpEF) is associated with older age, non-cardiac comorbidities, higher rates of atrial fibrillation (AF), and fewer treatment options exist. The optimal treatment for the last category of HF, with mid-range ejection fraction (HFmrEF), defined as HF with an ejection fraction (EF) of 40% to 49%, is uncertain.
This study assessed the clinical characteristics and prognostic impact of AF compared to sinus rhythm (SR) in patients with acute heart failure (AHF) and chronic heart failure (CHF), including all three subtypes of HF defined by left ventricular EF. For this purpose, the data of all adult patients with HF included in the HF Long-Term Registry of the European Society of Cardiology (HFLTRESC) [3,4] were analyzed (N=19,134). The HFLTRESC is a prospective, multicentre, observational study with comparative data on long-term outcomes (up to 2.2 years) of survival or HF hospitalizations in both outpatients with CHF and inpatients admitted for AHF, enrolled from May 2011 to April 2013. For the present analysis, patients with missing information of interest were excluded, leaving a sample of 14,964 patients.
- Mean age was 66±13 years, 67% were male, 26% had HFpEF, 21% had HFmrEF, and 53% HFrEF.
- The rates of AF were 39% in HFpEF, 29% in HFmrEF, and 27% in HFrEF.
- In all three types of HF, compared with SR, AF was associated with older age, reduced functional capacity, previous HF hospitalizations, higher heart rates, more peripheral edema and elevated jugular venous pressure.
After multivariable adjustment, when comparing AF patients with SR patients, the long-term HRs for all-cause death were:
- in HFrEF: 0.923; 95%CI: 0.782–1.091; P=0.347
- in HFmrEF: 1.296; 95%CI: 0.993–1.691; P=0.057
- in HFpEF: 1.198; 95%CI: 0.954–1.504; P=0.120
After multivariable adjustment, when comparing AF patients with SR patients, the long-term HRs for HF hospitalizations were:
- in HFrEF: 1.036; 95%CI: 0.888–1.208; P=0.652
- in HFmrEF: 1.430; 95%CI: 1.087–1.882; P=0.011
- in HFpEF: 1.487; 95%CI: 1.195–1.851; P<0.001
After multivariable adjustment, when comparing AF patients with SR patients, the HRs for the combined endpoint of long-term all-cause death or HF hospitalizations were:
- in HFrEF: 0.957; 95%CI: 0.843–1.087; P=0.502
- in HFmrEF: 1.302; 95%CI: 1.055–1.608; P=0.014
- in HFpEF: 1.365; 95%CI: 1.152–1.619; P<0.001
The odds ratio distribution across EF subtypes associated with AF was similar between AHF and CHF patients for most clinical characteristics.
In patients with HF, AF rates increase as EF increases, and compared with SR, AF was associated with worse long-term CV outcomes with regard to HF hospitalization and the combined endpoint in HFmrEF and HFpEF. AF in HFrEF was not found to be related to worse outcomes compared with SR, not in the chronic presentation of HFrEF, nor in acute decompensation.