Congestion and quality of life in atrial fibrillation and heart failure

Background Prior studies suggested that Heart Failure (HF) patients with Atrial Fibrillation (AF) have more signs of congestion and a worse quality of life. However, the interaction between congestion and QoL in HF patients with AF versus those without AF have not been well addressed. Purpose This study evaluated the association between congestion markers and QoL and short-term HF rehospitalization in HF patients with and without AF. Methods This was a post-hoc secondary analysis of the BIOSTAT-CHF cohort including 1338 hospitalized HF patients, of whom 539 (40.4%) had AF. Individual signs and symptoms, along with the clinical congestion score, were assessed. QoL was evaluated using the Kansas City Cardiomyopathy Questionnaire-23 (KCCQ-23). Findings were validated in an independent cohort. Results HF patients with AF had more signs of congestion and lower QoL scores at baseline and 9-months (34.4 vs. 41.9, p< 0.001; 57.6 vs. 64.1, p< 0.001, respectively), but showed greater QoL improvement (Δ18.6 vs. Δ14.4, p< 0.001), compared to no AF. Congestion markers including orthopnea, peripheral edema, third heart sound, hepatomegaly and pulmonary crackles were independent predictors of baseline QoL, irrespective of AF (P for interaction >0.05). Approximately 22% of the association between AF and lower KCCQ scores was mediated by the clinical congestion score. Presence of AF was not associated with an increased 60-day HF rehospitalization risk (aHR:1.33 (95% CI 0.88-2.01); P=0.17), whereas low baseline QoL conferred a 2.4-fold higher risk (aHR:2.40 (95%CI 1.13-5.12); P= 0.023, compared to high QoL). Conclusion HF patients with AF had more congestion and worse QoL at baseline, but showed greater QoL improvement, compared to no AF. However, the association between AF and worse QoL was only modestly mediated through clinical signs of congestion. These results indicate that other factors may explain why HF patients with AF have worse QoL.