Modifiable Risk Factors for Incident Heart Failure in Atrial Fibrillation

Abstract

Objectives: This study sought to identify modifiable risk factors and estimate the impact of risk factor modification on heart failure (HF) risk in women with new-onset atrial fibrillation (AF).

Background: Incident HF is the most common nonfatal event in patients with AF, although strategies for HF prevention are lacking.

Methods: We assessed 34,736 participants in the Women's Health Study who were free of prevalent cardiovascular disease at baseline. Cox models with time-varying assessment of risk factors after AF diagnosis were used to identify significant modifiable risk factors for incident HF.

Results: Over a median follow-up of 20.6 years, 1,495 women developed AF without prevalent HF. In multivariable models, new-onset AF was associated with an increased risk of HF (hazard ratio [HR]: 9.03; 95% confidence interval [CI]: 7.52 to 10.85). Once women with AF developed HF, all-cause (HR: 1.83; 95% CI: 1.37 to 2.45) and cardiovascular mortality (HR: 2.87; 95% CI: 1.70 to 4.85) increased. In time-updated, multivariable models accounting for changes in risk factors after AF diagnosis, systolic blood pressure >120 mm Hg, body mass index ≥30 kg/m², current tobacco use, and diabetes mellitus were each associated with incident HF. The combination of these 4 modifiable risk factors accounted for an estimated 62% (95% CI: 23% to 83%) of the population-attributable risk of HF. Compared with women with 3 or 4 risk factors, those who maintained or achieved optimal risk factor control had a progressive decreased risk of HF (HR for 2 risk factors: 0.60; 95% CI: 0.37 to 0.95; 1 risk factor: 0.40; 95% CI: 0.25 to 0.63; and 0 risk factors: 0.14; 95% CI: 0.07 to 0.29).

Conclusions: In women with new-onset AF, modifiable risk factors including obesity, hypertension, smoking, and diabetes accounted for the majority of the population risk of HF. Optimal levels of modifiable risk factors were associated with decreased HF risk. Prospective assessment of risk factor modification at the time of AF diagnosis may warrant future investigation.

Keywords: atrial fibrillation; epidemiology; heart failure; prevention; risk factor.

Figure 1. Heart Failure Risk in Atrial Fibrillation – Impact of Risk Factor Modification

This study estimated the influence of risk factor modification on HF risk in women with new-onset AF. In women with new-onset AF, the onset of HF was associated with significant increases in mortality (all-cause, cardiovascular) and morbidity (myocardial infarction) (Left Panel). Risk factors for incident HF in women with new-onset AF included directly modifiable factors (obesity, hypertension, smoking, diabetes) as well as other significant risk factors (age, chronic kidney disease, incident coronary heart disease [myocardial infarction, revascularization]). All 4 directly modifiable risk factors accounted for 62% of the population attributable fraction of HF in the cohort (Middle Panel). Compared to women with the least favorable risk factor profile (3-4 modifiable risk factors), women who maintained or achieved more favorable risk factor profiles after new-onset AF were at progressively lower risk of incident HF (Right Panel).