Analysis of Outcomes in Ischemic vs Nonischemic Cardiomyopathy in Patients With Atrial Fibrillation

Ramón Corbalán; Jean‐Pierre Bassand; Laura Illingworth; Giuseppe Ambrosio; A. John Camm; David Fitzmaurice; Keith A.A. Fox; Samuel Z. Goldhaber; Shinya Goto; Sylvia Haas; Gloria Kayani; LG Mantovani; Frank Misselwitz; Karen S. Pieper; Alexander G.G. Turpie; Freek W.A. Verheugt; Ajay K. Kakkar

doi:10.1001/jamacardio.2018.4729

May 8, 2019JAMA CardiologyOpen Access

Analysis of Outcomes in Ischemic vs Nonischemic Cardiomyopathy in Patients With Atrial Fibrillation

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Why the study?

CHF is commonly associated with nonvalvular AF, and their combination may affect treatment strategies and outcomes.

Does ischemic cardiomyopathy etiology compared to nonischemic cardiomyopathy affect treatment strategies and 1-year clinical outcomes in patients with newly diagnosed atrial fibrillation and congestive heart failure?

Structured PICO

Does ischemic cardiomyopathy etiology compared to nonischemic cardiomyopathy affect treatment strategies and 1-year clinical outcomes in patients with newly diagnosed atrial fibrillation and congestive heart failure?

P

Population

11,738 patients 18 years and older with newly diagnosed atrial fibrillation (≤6 weeks' duration), at least 1 investigator-determined stroke risk factor, and concomitant congestive heart failure (4,717 with ischemic cardiomyopathy and 7,021 with nonischemic cardiomyopathy) from the GARFIELD-AF registry.

I

Intervention

Ischemic cardiomyopathy (ICM) etiology

C

Comparator

Nonischemic cardiomyopathy (NICM) etiology

O

Outcome

1-year follow-up rates of death, stroke/systemic embolism, and major bleedinghard clinical

In patients with newly diagnosed atrial fibrillation and congestive heart failure, ischemic cardiomyopathy is associated with higher 1-year rates of mortality and major bleeding, and lower use of oral anticoagulants compared to nonischemic cardiomyopathy.

Implication

Should not yet alter AF/HF management by cardiomyopathy etiology; supports further research on differential outcomes.

Abstract

Importance: Congestive heart failure (CHF) is commonly associated with nonvalvular atrial fibrillation (AF), and their combination may affect treatment strategies and outcomes. Objective: To assess the treatment strategies and 1-year clinical outcomes of antithrombotic and CHF therapies for patients with newly diagnosed AF with concomitant CHF stratified by etiology (ischemic cardiomyopathy [ICM] vs nonischemic cardiomyopathy [NICM]). Design, Setting, and Participants: The GARFIELD-AF registry is a prospective, noninterventional registry. A total of 52 014 patients with AF were enrolled between March 2010 and August 2016. A total of 11 738 patients 18 years and older with newly diagnosed AF (≤6 weeks' duration) and at least 1 investigator-determined stroke risk factor were included. Data were analyzed from December 2017 to September 2018. Exposures: One-year follow-up rates of death, stroke/systemic embolism, and major bleeding were assessed. Main Outcomes and Measures: Event rates per 100 person-years were estimated from the Poisson model and Cox hazard ratios (HRs) and 95% confidence intervals. Results: The median age of the population was 71.0 years, 22 987 of 52 013 were women (44.2%) and 31 958 of 52 014 were white (61.4%). Of 11 738 patients with CHF, 4717 (40.2%) had ICM and 7021 (59.8%) had NICM. Prescription of oral anticoagulant and antiplatelet drugs was not balanced between groups. Oral anticoagulants with or without antiplatelet drugs were used in 2753 patients with ICM (60.1%) and 5082 patients with NICM (73.7%). Antiplatelets were prescribed alone in 1576 patients with ICM (34.4%) and 1071 patients with NICM (15.5%). Compared with patients with NICM, use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (72.6% [3439] vs 60.3% [4236]) and of β blockers (63.3% [2988] vs 53.2% [3737]) was higher in patients with ICM. Rates of all-cause and cardiovascular death per 100 patient-years were significantly higher in the ICM group (all-cause death: ICM, 10.2; 95% CI, 9.2-11.1; NICM, 7.0; 95% CI, 6.4-7.6; cardiovascular death: ICM, 5.1; 95% CI, 4.5-5.9; NICM, 2.9; 95% CI, 2.5-3.4). Stroke/systemic embolism rates tended to be higher in ICM groups compared with NICM groups (ICM, 2.0; 95% CI, 1.6-2.5; NICM, 1.5; 95% CI, 1.3-1.9). Major bleeding rates were significantly higher in the ICM group (1.1; 95% CI, 0.8-1.4) compared with the NICM group (0.7; 95% CI, 0.5-0.9). Conclusions and Relevance: Patients with ICM received oral anticoagulants with or without antiplatelet drugs less frequently and antiplatelets alone more frequently than patients with NICM, but they received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers more often than patients with NICM. All-cause and cardiovascular death rates were higher in patients with ICM than patients with NICM. Trial Registration: ClinicalTrials.gov Identifier: NCT01090362.