What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial fibrillation (n=1063). Intervention: Presence of heart failure vs. Absence of heart failure. Primary outcome: All-cause mortality (HR 2.17, 95% CI 1.70-2.77, p=<0.001).

What does this research mean for the field?

In patients with atrial fibrillation, the presence of heart failure at baseline is independently associated with a significantly higher risk of all-cause mortality (HR 2.17) compared to no heart failure, and this increased risk is evident across all left ventricular ejection fraction subtypes. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

June 3, 2021ESC Heart FailureOpen Access

Τhe Association of Heart Failure Across Left Ventricular Ejection Fraction with Mortality in Atrial Fibrillation

Q: What are the key findings of this study?

In patients with atrial fibrillation, the presence of heart failure at baseline was independently associated with a significantly higher risk of all-cause mortality (HR 2.17) compared to no heart failure.

Q: What does this research mean for the field?

In patients with atrial fibrillation, the presence of heart failure at baseline is independently associated with a significantly higher risk of all-cause mortality (HR 2.17) compared to no heart failure, and this increased risk is evident across all left ventricular ejection fraction subtypes. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

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Key result

Baseline heart failure in AF patients linked to ~117% higher all-cause mortality risk.

HR 2.17
95% CI 1.70-2.77
P<0.001
n=1,063

Why the study?

The prognostic implications of the presence of heart failure across the range of left ventricular ejection fraction in patients with comorbid atrial fibrillation remained to be investigated.

Does the presence of heart failure across the LVEF spectrum increase mortality in patients hospitalized with atrial fibrillation?

Study Design

Type

Cohort (n=1,063)

Multicenter

Structured PICO

Does the presence of heart failure across the LVEF spectrum increase mortality in patients hospitalized with atrial fibrillation?

Population

1,063 patients (median age 76 years, 54.6% male) discharged from the cardiology ward with a primary or secondary diagnosis of atrial fibrillation (AF). Excluded: valvular AF (moderate-to-severe mitral valve stenosis or mechanical valves), terminal illness, or no LVEF evaluated during index hospitalization.

Intervention

Presence of comorbid heart failure (HF) across the range of left ventricular ejection fraction (LVEF), including HFrEF, HFmrEF, and HFpEF.

Comparator

Absence of heart failure (AF without HF).

Outcome

All-cause mortality (death from any cause).hard clinical

Main Result

Effect estimate: HR 2.17 (95% CI 1.70-2.77)

Absolute Event Rate: 50.5% vs 22.4%

p-value: p=<0.001

In patients hospitalized with atrial fibrillation, the presence of comorbid heart failure independently doubles the risk of death across all LVEF subtypes, with mortality risk rising steeply as LVEF drops below 25%.

Limitations

Retrospective and non-randomized analysis confined to a single-center dataset
Potential for unrecognized biases and unmeasured confounders
Restricting analysis to hospitalized AF patients limits generalizability to outpatients
Inability to account for newly ensuing comorbidities during follow-up
Unavailability of additional prognostic data such as duration of AF/HF prior to hospitalization
Questionable reproducibility and validity of LVEF measurements in AF
Potential differential misclassification due to challenges in diagnosing HFpEF in the context of AF
Retrospective and non-randomized design
Single-center data set
Restricted to hospitalized AF patients, limiting generalizability to outpatients
Potential for unmeasured confounders and reverse causation
Lack of data on duration/timing of AF and HF diagnosis, CRT/ICD devices, serial LVEF values, and OAC treatment quality (e.g., time in therapeutic range)

Implication

May warrant vigilance for HF in AF hospitalizations; leaves open whether LVEF-targeted therapies improve survival.

Abstract

AIMS: The aim of this study is to investigate the prognostic implications of the presence of heart failure (HF) across the range of left ventricular ejection fraction (LVEF) in patients with comorbid atrial fibrillation (AF). METHODS AND RESULTS: We conducted a retrospective cohort study of 1063 patients (median age 76 years), discharged from the cardiology ward with a primary or secondary diagnosis of AF between 2015 and 2018. We used Cox proportional-hazards and spline models to examine the association of the presence of HF, across the range of LVEF, with the primary outcome of all-cause mortality. HF was documented in 52.9% of patients at baseline. During a median follow-up of 31 months (interquartile range 10 to 52 months), 37.3% of patients died. The presence of HF was associated with a significantly higher risk of mortality [adjusted hazard ratio (aHR) 2.17; 95% confidence interval (CI), 1.70 to 2.77; P < 0.001], which was evident across HF with reduced (aHR 3.03; 95% CI 2.41 to 4.52), mid-range (aHR 2.08; 95% CI 1.47 to 2.94), and preserved LVEF (aHR 1.94; 95% CI 1.47 to 2.55). Among patients with HF, the spline curve depicted a non-linear association between LVEF and the risk of death, in which there was a steep and progressive increase in mortality for every 5% reduction in LVEF below 25% (aHR 1.97, 95% CI 1.04 to 3.73, P = 0.04). CONCLUSIONS: In patients with AF who were discharged from the hospital, the presence of HF at baseline was independently associated with a twofold risk of death, which was significant across LVEF-classified HF subtypes. Among patients with AF and HF, the risk of death rose significantly as LVEF was reduced below 25%.

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Published by ESC Heart Failure · CC BY-NC

Cite This Study

Κάρτας et al. (2021) conducted a cohort in Atrial fibrillation (n=1,063). Presence of heart failure vs. Absence of heart failure was evaluated on All-cause mortality (HR 2.17, 95% CI 1.70-2.77, p=<0.001). In patients with atrial fibrillation, the presence of heart failure at baseline was independently associated with a significantly higher risk of all-cause mortality (HR 2.17) compared to no heart failure.

synapsesocial.com/papers/6a192558990f10e02126567c https://doi.org/10.1002/ehf2.13440