Progression of Device-Detected Subclinical Atrial Fibrillation and the Risk of Heart Failure
Key result
Progression to clinical or >24-hour subclinical AF linked to ~358% higher HF hospitalization risk.
- HR 4.58
- 95% CI 1.64 to 12.80
- P=0.004
- n=415
Why the study?
The relationship between short-lasting subclinical atrial fibrillation (SCAF), its progression to longer episodes, and the development of heart failure was unclear.
Does progression of subclinical atrial fibrillation increase the risk of heart failure hospitalization in older patients with pacemakers or defibrillators?
Key Points
- This study aimed to investigate the relationship between progression of subclinical atrial fibrillation (SCAF) episodes and heart failure (HF) hospitalization.
- Patients aged ≥65 years with a history of hypertension and implanted pacemaker/defibrillator were observed.
- The study included patients whose longest SCAF episode was >6 min but ≤24 h (n = 415).
- Time-dependent Cox models assessed the link between SCAF progression and HF hospitalization.
- 65 patients (15.7%) progressed to SCAF >24 h or clinical AF, incidence 8.8% per year.
- HF hospitalization rate for those with SCAF progression was 8.9% per year vs 2.5% for others.
- SCAF progression had an independent HR of 4.58 for HF hospitalization (95% CI: 1.64 to 12.80; p = 0.004).
Study Design
Type
Cohort (n=415)
Structured PICO
Does progression of subclinical atrial fibrillation increase the risk of heart failure hospitalization in older patients with pacemakers or defibrillators?
P
Population
415 patients ≥65 years old with a pacemaker or defibrillator, hypertension, and a 6-minute to 24-hour SCAF episode in the first year, followed for a mean of 2 years.
E
Exposure
Progression to SCAF episodes >24 h or clinical AF
C
Comparator
No progression to SCAF >24 h or clinical AF
O
Outcome
Heart failure hospitalizationhard clinical
Main Result
Hazard Ratio: 4.58 (95% CI 1.64–12.8)
Absolute Event Rate: 8.9% vs 2.5%
p-value: p=0.004
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“targeting patients with progressive subclinical A-fib with either intensified heart failure therapy or lifestyle interventions to better control cardiovascular risk factors could reduce admissions for heart failure and maybe even mortality”
NMN.A. Mark Estes IIIElectrophysiologist, Tufts University School of Medicine
“This is really an opportunity to prevent progression of A-fib, to prevent progression of heart failure. There are very few conditions in cardiovascular disease in which we can do really primordial prevention with lifestyle interventions. So I think clinicians should be aware of this new data, they should be aware of the clinical implications of it, and I think that clinical trialists and researchers should also move forward with a trial randomizing patients with subclinical A-fib over 6 minutes to lifestyle interventions versus standards of therapy and see if some of these key outcomes, such as heart failure hospitalizations, really can be influenced.”
Implication
Progression of subclinical atrial fibrillation to episodes >24 hours or clinical AF is strongly associated with a significantly increased risk of heart failure hospitalization.
Abstract
BACKGROUND Long-term continuous monitoring detects short-lasting, subclinical atrial fibrillation (SCAF) in approximately one-third of older individuals with cardiovascular conditions. The relationship between SCAF, its progression, and the development of heart failure (HF) is unclear. OBJECTIVES This study examined the relationship between progression from shorter to longer SCAF episodes and HF hospitalization. METHODS Subjects in ASSERT (Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial) were ≥65 years old, had history of hypertension, no prior clinical AF, and an implanted pacemaker or defibrillator. We examined patients whose longest SCAF episode during the first year after enrollment was >6 min but ≤24 h (n = 415). Using time-dependent Cox models, we evaluated the relationship between subsequent development of SCAF >24 h or clinical AF and HF hospitalization. RESULTS Over a mean follow-up of 2 years, 65 patients (15.7%) progressed to having SCAF episodes >24 h or clinical AF (incidence 8.8% per year). Older age, greater body mass index, and longer SCAF duration within the first year were independent predictors of SCAF progression. The rate of HF hospitalization among patients with SCAF progression was 8.9% per year compared with 2.5% per year for those without progression. After multivariable adjustment, SCAF progression was independently associated with HF hospitalization (hazard ratio [HR]: 4.58; 95% confidence interval [CI]: 1.64 to 12.80; p = 0.004). Similar results were observed when we excluded patients with prior history of HF (HR: 7.06; 95% CI: 1.82 to 27.30; p = 0.005) or when SCAF progression was defined as development of SCAF >24 h alone (HR: 3.68; 95% CI: 1.27 to 10.70; p = 0.016). CONCLUSIONS In patients with a pacemaker or defibrillator, SCAF progression was strongly associated with HF hospitalization.
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Cite This Study
Wong et al. (2018) conducted a cohort in Subclinical atrial fibrillation (n=415). Progression to SCAF episodes >24 h or clinical AF vs. No SCAF progression was evaluated on Heart failure hospitalization (HR 4.58, 95% CI 1.64 to 12.80, p=0.004). Progression to subclinical atrial fibrillation >24 hours or clinical AF was associated with increased heart failure hospitalization (HR 4.58; 95% CI 1.64-12.80; p=0.004).