The Impact of Atrial Fibrillation on Clinical Outcomes in Heart Failure with Mid-range and Preserved Ejection Fraction Patients

Overview

Journal Heart Rhythm

Publisher Elsevier

Specialty Cardiology & Vascular Diseases

Date 2024 May 26

PMID 38797306

Authors

Irina Mustafina

Khaled Elkholey

Marat Fudim

Stavros Stavrakis

Affiliations

Soon will be listed here.

Abstract

Background: The combined effect of left ventricular ejection fraction (LVEF) and atrial fibrillation (AF) on clinical outcomes in heart failure (HF) remains complex.

Objective: In this post hoc analysis of the TOPCAT trial, we aimed to evaluate the impact of AF on clinical outcomes in patients with HF stratified by LVEF range.

Methods: A total of 3442 patients were included, stratified into 3 groups according to LVEF range-HF with mid-range ejection fraction (HFmrEF), LVEF of 45%-50% (n = 823); HF with preserved ejection fraction (HFpEF), LVEF of 51%-60% (n = 1682); and HF with normal ejection fraction (HFnEF), LVEF >60% (n = 937)-and subdivided according to the presence of AF at enrollment. Cox regression analysis was used to define independent associations between AF and clinical outcomes.

Results: AF was prevalent in 38.6% in HFmrEF, 34.6% in HFpEF, and 33.7% in HFnEF (P = .07). AF was associated with worse primary outcome in each subgroup and with HF hospitalizations and worse cardiovascular mortality in HFpEF and HFnEF. The hazard ratio for the primary outcome in those with AF compared with sinus rhythm (SR) was 1.11 (1.01-1.22; P = .03) in HFmrEF, 1.20 (1.11-1.29; P < .001) in HFpEF, and 1.16 (1.05-1.28; P = .004) in HFnEF. When LVEF was treated as a continuous variable, there was a linear negative association between LVEF and the effect of AF vs SR for the primary end point and HF hospitalizations and a linear positive association for cardiovascular mortality.

Conclusion: Compared with SR, AF was independently associated with worse outcomes across all LVEF ranges.

References

Kotecha D, Lam C, Van Veldhuisen D, Van Gelder I, Voors A, Rienstra M . Heart Failure With Preserved Ejection Fraction and Atrial Fibrillation: Vicious Twins. J Am Coll Cardiol. 2016; 68(20):2217-2228. DOI: 10.1016/j.jacc.2016.08.048. View

Lund L, Claggett B, Liu J, Lam C, Jhund P, Rosano G . Heart failure with mid-range ejection fraction in CHARM: characteristics, outcomes and effect of candesartan across the entire ejection fraction spectrum. Eur J Heart Fail. 2018; 20(8):1230-1239. DOI: 10.1002/ejhf.1149. View

Komajda M, Carson P, Hetzel S, McKelvie R, McMurray J, Ptaszynska A . Factors associated with outcome in heart failure with preserved ejection fraction: findings from the Irbesartan in Heart Failure with Preserved Ejection Fraction Study (I-PRESERVE). Circ Heart Fail. 2010; 4(1):27-35. DOI: 10.1161/CIRCHEARTFAILURE.109.932996. View

Joglar J, Chung M, Armbruster A, Benjamin E, Chyou J, Cronin E . 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2023; 149(1):e1-e156. PMC: 11095842. DOI: 10.1161/CIR.0000000000001193. View

Carlisle M, Fudim M, DeVore A, Piccini J . Heart Failure and Atrial Fibrillation, Like Fire and Fury. JACC Heart Fail. 2019; 7(6):447-456. DOI: 10.1016/j.jchf.2019.03.005. View

Nakagawa A, Yasumura Y, Yoshida C, Okumura T, Tateishi J, Yoshida J . Predictors and Outcomes of Heart Failure With Preserved Ejection Fraction in Patients With a Left Ventricular Ejection Fraction Above or Below 60. J Am Heart Assoc. 2022; 11(15):e025300. PMC: 9375469. DOI: 10.1161/JAHA.122.025300. View

Rosch S, Kresoja K, Besler C, Fengler K, Schober A, von Roeder M . Characteristics of Heart Failure With Preserved Ejection Fraction Across the Range of Left Ventricular Ejection Fraction. Circulation. 2022; 146(7):506-518. DOI: 10.1161/CIRCULATIONAHA.122.059280. View

From A, Scott C, Chen H . The development of heart failure in patients with diabetes mellitus and pre-clinical diastolic dysfunction a population-based study. J Am Coll Cardiol. 2010; 55(4):300-5. PMC: 3878075. DOI: 10.1016/j.jacc.2009.12.003. View

Cheng C, Huang P, Chen J, Chiu F, Chang S, Wang Y . Both HFpEF and HFmrEF should be included in calculating CHADS-VASc score: A Taiwanese longitudinal cohort. Heart Rhythm. 2024; 21(9):1500-1506. DOI: 10.1016/j.hrthm.2024.02.048. View

10.

Sartipy U, Dahlstrom U, Fu M, Lund L . Atrial Fibrillation in Heart Failure With Preserved, Mid-Range, and Reduced Ejection Fraction. JACC Heart Fail. 2017; 5(8):565-574. DOI: 10.1016/j.jchf.2017.05.001. View

11.

Okura H, Takada Y, Kubo T, Iwata K, Mizoguchi S, Taguchi H . Tissue Doppler-derived index of left ventricular filling pressure, E/E', predicts survival of patients with non-valvular atrial fibrillation. Heart. 2006; 92(9):1248-52. PMC: 1861171. DOI: 10.1136/hrt.2005.082594. View

12.

Santhanakrishnan R, Wang N, Larson M, Magnani J, McManus D, Lubitz S . Atrial Fibrillation Begets Heart Failure and Vice Versa: Temporal Associations and Differences in Preserved Versus Reduced Ejection Fraction. Circulation. 2016; 133(5):484-92. PMC: 4738087. DOI: 10.1161/CIRCULATIONAHA.115.018614. View

13.

Vaduganathan M, Patel R, Michel A, Shah S, Senni M, Gheorghiade M . Mode of Death in Heart Failure With Preserved Ejection Fraction. J Am Coll Cardiol. 2017; 69(5):556-569. DOI: 10.1016/j.jacc.2016.10.078. View

14.

Kotecha D, Piccini J . Atrial fibrillation in heart failure: what should we do?. Eur Heart J. 2015; 36(46):3250-7. PMC: 4670966. DOI: 10.1093/eurheartj/ehv513. View

15.

Pitt B, Pfeffer M, Assmann S, Boineau R, Anand I, Claggett B . Spironolactone for heart failure with preserved ejection fraction. N Engl J Med. 2014; 370(15):1383-92. DOI: 10.1056/NEJMoa1313731. View

16.

Zafrir B, Lund L, Laroche C, Ruschitzka F, Crespo-Leiro M, Coats A . Prognostic implications of atrial fibrillation in heart failure with reduced, mid-range, and preserved ejection fraction: a report from 14 964 patients in the European Society of Cardiology Heart Failure Long-Term Registry. Eur Heart J. 2018; 39(48):4277-4284. DOI: 10.1093/eurheartj/ehy626. View

17.

Savelieva I, Camm A . Atrial fibrillation and heart failure: natural history and pharmacological treatment. Europace. 2004; 5 Suppl 1:S5-19. DOI: 10.1016/j.eupc.2004.07.003. View

18.

Packer D, Piccini J, Monahan K, Al-Khalidi H, Silverstein A, Noseworthy P . Ablation Versus Drug Therapy for Atrial Fibrillation in Heart Failure: Results From the CABANA Trial. Circulation. 2021; 143(14):1377-1390. PMC: 8030730. DOI: 10.1161/CIRCULATIONAHA.120.050991. View

19.

Dunlay S, Roger V, Redfield M . Epidemiology of heart failure with preserved ejection fraction. Nat Rev Cardiol. 2017; 14(10):591-602. DOI: 10.1038/nrcardio.2017.65. View

20.

Hayashi H, Abe Y, Morita Y, Yamaji Y, Nakane E, Haruna Y . Impact of stroke volume on prognostic outcome in patients with atrial fibrillation and concomitant heart failure with preserved ejection fraction. J Cardiol. 2018; 73(4):307-312. DOI: 10.1016/j.jjcc.2018.12.011. View