Relative Importance of Heart Failure Events Compared to Stroke and Bleeding in AF Patients

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial Fibrillation (n=4973). Intervention: Incident hospitalization for decompensated heart failure vs. No incident hospitalization for decompensated heart failure. Primary outcome: All-cause mortality associated with incident hospitalization for decompensated heart failure (adjusted for baseline characteristics) (HR 3.67, 95% CI 3.12 to 4.31, p=<0.001).

Q: What does this research mean for the field?

Incident heart failure is the most frequent adverse event in atrial fibrillation outpatients, occurring significantly more often than ischemic stroke or major bleeding, and is strongly associated with high mortality. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Sandro Ninni; Gilles Lemesle; Thibaud Meurice; Olivier Tricot; Nicolas Lamblin; Christophe Bauters

doi:10.3390/jcm10050923

February 28, 2021Journal of Clinical MedicineOpen Access

Relative Importance of Heart Failure Events Compared to Stroke and Bleeding in AF Patients

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Key result

In outpatients with atrial fibrillation, incident heart failure was the most frequent adverse event (10.5% at 3 years) and was strongly associated with increased all-cause mortality (HR 3.67).

Figures

Why the study?

Incident HF, ischemic stroke/systemic embolism, and anticoagulation-related major bleeding remain frequent in AF, but their comparative 3-year incidence, predictors, and related mortality required assessment.

Study Design

Type

Cohort (n=4,973)

Multicenter

Yes

Structured PICO

P

Population

4,973 outpatients with atrial fibrillation, followed for a median of 3.2 years to assess the incidence and mortality of heart failure, stroke, and major bleeding.

O

Outcome

3-year cumulative incidence, predictors, and related mortality of ischemic stroke and systemic embolism (IS/SE), major bleeding (BARC type ≥3), and hospitalization for decompensated heart failurehard clinical

Main Result

Hazard Ratio: 3.67 (95% CI 3.12–4.31)

p-value: p=<0.001

In outpatients with atrial fibrillation, incident heart failure is the most frequent residual cardiovascular event and carries a high mortality risk, emphasizing the need for intensive upstream management of modifiable risk factors.

Limitations

Data reflect practice in a single regional area (Nord-Pas-de-Calais, France) and may not be generalizable.
Inclusion was determined by cardiologists, which may limit generalizability to the overall community AF population.
The BARC classification was used to define major bleedings instead of ISTH criteria.
The AF subpopulation may have been enriched with coronary artery disease and/or heart failure, putting them at higher baseline risk for incident heart failure.
Data reflect practice in a regional area and may not be generalizable
Inclusion determined by cardiologists, which may cause selection bias
Use of BARC classification instead of ISTH for major bleeding
AF subpopulation may be enriched with CAD and/or HF due to the registry's inclusion criteria

Implication

Incident HF exceeds stroke/bleeding rates in AF outpatients with strong mortality link; hypothesis-generating for prevention trials.

Abstract

INTRODUCTION: Incident heart failure (HF), ischemic stroke and systemic embolism (IS/SE), and major bleeding related to anticoagulation therapy are still the most frequent events occurring in patients with atrial fibrillation (AF). The aim of this study was to assess the 3-year incidence, predictors, and related mortality of IS/SE, major bleeding, and HF in a large cohort of AF outpatients. METHODS AND RESULTS: Vasc score was 3.4 ± 1.7. After a median follow-up of 3.2 years (IQR: 2.8 to 3.5), incident HF, IS/SE and major bleeding occurred in 10.5%, 3.3% and 2.1% of patients, respectively. When analyzed as time-dependent variables, IS/SE, major bleeding and hospitalization for decompensated HF were all strongly associated with mortality. The independent predictors of incident HF were age, women, hypertension, diabetes mellitus, coronary artery disease and a previous history of HF. A sensitivity analysis in patients without history of HF at inclusion revealed that incident HF remained the most frequent adverse event, occurring in 5.3% of patients, compared to IS/SE (1.7%) and major bleeding (2.5%). CONCLUSION: HF is a common residual cardiovascular adverse event occurring in AF outpatients and is associated with a very high mortality. Since modifiable risk factors are associated with incident HF, upstream intensive management of these risk factors would be of interest.

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Cite This Study

Ninni et al. (2021) conducted a cohort in Atrial Fibrillation (n=4,973). Incident hospitalization for decompensated heart failure vs. No incident hospitalization for decompensated heart failure was evaluated on All-cause mortality associated with incident hospitalization for decompensated heart failure (adjusted for baseline characteristics) (HR 3.67, 95% CI 3.12 to 4.31, p=<0.001). In outpatients with atrial fibrillation, incident heart failure was the most frequent adverse event (10.5% at 3 years) and was strongly associated with increased all-cause mortality (HR 3.67).

synapsesocial.com/papers/6a1c512500ee29383e9dc623 https://doi.org/10.3390/jcm10050923