What is the clinical evidence from this study?

Study design: Cohort. Population: Chronic Heart Failure (CHF) (n=2541). Intervention: Atrial Fibrillation (AF) vs. Sinus Rhythm (SR). Primary outcome: All-cause mortality (HR 0.91, 95% CI 0.66-1.25, p=0.56).

July 1, 2019ESC Heart FailureOpen Access

N-Terminal Pro Brain Natriuretic Peptide Eliminates the Prognostic Effect of Atrial Fibrillation in Patients with Chronic Heart Failure

Q: What are the key findings of this study?

After matching for NT-proBNP and clinical characteristics, concomitant atrial fibrillation did not independently worsen prognosis in patients with chronic heart failure (HR 0.91, 95% CI 0.66-1.25, p=0.56).

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Key result

Concomitant AF is not linked to worse mortality in chronic heart failure after NT-proBNP matching.

HR 0.91
95% CI 0.66-1.25
P=0.56
n=2,541

Why the study?

It was unclear whether AF worsens prognosis independently from NT-proBNP in CHF, and whether NT-proBNP cut-offs need adjustment for AF.

Does atrial fibrillation independently increase all-cause mortality in patients with chronic heart failure when matched for NT-proBNP levels?

Study Design

Type

Cohort (n=2,541)

Multicenter

Structured PICO

Does atrial fibrillation independently increase all-cause mortality in patients with chronic heart failure when matched for NT-proBNP levels?

Population

2,541 ambulatory patients with chronic heart failure from a German registry (matched cohort of 500 patients) followed for a minimum of 365 days to determine if atrial fibrillation independently affects prognosis when matched for NT-proBNP.

Exposure

Atrial fibrillation (AF) diagnosed on 12-lead ECG at baseline

Comparator

Sinus rhythm (SR) diagnosed on 12-lead ECG at baseline, matched 1:1 for NT-proBNP (within ±15%), NYHA class, sex, age, and CHF etiology

Outcome

All-cause mortality at a minimum of 365 days follow-uphard clinical

Main Result

Hazard Ratio: 0.91 (95% CI 0.66–1.25)

Absolute Event Rate: 28.8% vs 34%

p-value: p=0.56

Concomitant atrial fibrillation may act as a surrogate for more advanced heart failure rather than an independent risk factor, meaning NT-proBNP cut-offs for risk prediction do not need adjustment for heart rhythm.

Limitations

Observational design preventing causal inferences
Potential hidden bias due to unmeasured confounders
Single-center university hospital setting may cause patient selection bias
Low proportion of women (16%) in the matched sample
Unable to differentiate between paroxysmal, permanent, and persistent AF
Exclusion of 181 AF patients who could not be matched
Observational nature of the study
Cannot rule out hidden bias due to unmeasured confounders
Patient selection bias from a university hospital setting
Unable to differentiate between AF types (paroxysmal, permanent, persistent)
Exclusion of 181 AF patients without a matching SR partner skewed selection

Implication

AF may not independently worsen CHF prognosis beyond NT-proBNP; leaves open whether rhythm-specific thresholds improve risk stratification.

Abstract

AIMS: Co-morbid atrial fibrillation (AF) increases both mortality and N-terminal pro brain natriuretic peptide (NT-proBNP) concentrations in patients with chronic heart failure (CHF). It is unclear whether AF worsens prognosis independently from NT-proBNP concentrations. If AF was an independent risk factor, NT-proBNP levels for outcome prediction would need to be adjusted in patients with AF. We aimed to analyse the influence of AF on the prognostic value of NT-proBNP in patients with CHF. METHODS AND RESULTS: A total of 2541 consecutive CHF patients with sinus rhythm (SR) or AF were identified in the outpatients' CHF registry of the University of Heidelberg, Germany. Of these, 250 patients with SR were individually matched to 250 patients with AF with respect to NT-proBNP, New York Heart Association functional class, sex, age, and aetiology of CHF. In the general sample, both AF and NT-proBNP were associated with all-cause mortality [hazard ratio (HR) = 1.96, 95% confidence interval (CI) 1.61-2.39, P < 0.001; and HR = 1.03 per 1000 ng/L increase, 95% CI 1.02 to 1.04, P < 0.001, respectively]. After matching, NT-proBNP retained its prognostic power (HR = 1.13 per 1000 ng/L increase, 95% CI 1.10 to 1.16, P < 0.001), but AF did not (HR = 0.91, 95% CI 0.66 to 1.25, P = 0.56). Despite similar prognosis, matched patients with SR were in more advanced CHF than were AF patients as indicated by a lower left ventricular ejection fraction (30 ± 13% vs. 34 ± 14%, P < 0.001). CONCLUSIONS: The prognostic value of NT-proBNP in CHF is not influenced by concomitant AF. AF, in return, might be a surrogate of a worse cardiac condition rather than an independent risk factor.

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Published by ESC Heart Failure · CC BY-NC

Cite This Study

Schnorbach et al. (2019) conducted a cohort in Chronic Heart Failure (CHF) (n=2,541). Atrial Fibrillation (AF) vs. Sinus Rhythm (SR) was evaluated on All-cause mortality (HR 0.91, 95% CI 0.66-1.25, p=0.56). After matching for NT-proBNP and clinical characteristics, concomitant atrial fibrillation did not independently worsen prognosis in patients with chronic heart failure (HR 0.91, 95% CI 0.66-1.25, p=0.56).

synapsesocial.com/papers/6a2100a2894b966f6186df73 https://doi.org/10.1002/ehf2.12464