Outcomes of incident atrial fibrillation in heart failure with preserved or reduced ejection fraction: A community-based study

Abstract

Introduction: The best management strategy for patients with atrial fibrillation (AF) with heart failure (HF) and preserved left ventricular ejection fraction (LVEF) is unknown.

Methods and results: This cohort study was conducted in Olmsted County, Minnesota, with resources of the Rochester Epidemiology Project. Patients with incident AF occurring between 2000 and 2014 with a prior or concurrent HF were included. Patients with LVEF ≥ 50% were designated as HF and preserved ejection fraction (HFpEF) and those with LVEF < 50% were designated as HF and reduced ejection fraction (HFrEF). Rhythm control in the first year after AF diagnosis was defined as prescriptions for an antiarrhythmic drug, catheter ablation, or maze procedure. The primary endpoint was all-cause mortality. The secondary endpoints were cardiovascular death, cardiovascular hospitalization, and stroke or transient ischemic attack. Of 859 patients (age, 77.2 ± 12.1 years; 49.2%, female), 447 had HFpEF-AF, and 412 had HFrEF-AF. There was no difference in all-cause mortality (10-year mortality, 83% vs 79%; p = .54) or secondary endpoints between the HFpEF-AF and HFrEF-AF, respectively. Compared with the rate control strategy, rhythm control in HFpEF-AF patients (n = 40, 15.9%) offered no survival benefits (adjusted HR, 0.70; 95% CI, 0.42-1.16; p = .16), whereas rhythm control in HFrEF-AF patients (n = 52, 22.5%) decrease cardiovascular mortality (HR, 0.38; 95% CI, 0.17-0.86; p = .02).

Conclusions: Patients with HFpEF-AF and HFrEF-AF had similar poor prognoses. Rhythm control strategy was seldom adopted in community care in patients with HF and AF. A rhythm control strategy may provide survival benefit for patients with HFrEF-AF and the benefit of rhythm control in patients with HFpEF-AF warrants further study.

Keywords: atrial fibrillation; heart failure with preserved ejection fraction; heart failure with reduced ejection fraction; rate control; rhythm control.

Figure 1.. Flow Chart of Patient Selection

There was no significant difference in all-cause mortality,cardiovascular death, cardiovascular hospitalization and stroke or transient ischemic attack between the HFpEF-AF and HFrEF-AF. Compared with the rate control strategy, rhythm control in HFpEF-AF patients offered no survival benefits,whereas rhythm control decrease cardiovascular mortality in HFrEF-AF patients. AAD=antiarrhythmic drug;AF=atrial fibrillation;AVN= atrioventricular node;HF=heart failure; HFpEF-AF= atrial fibrillation and heart failure with preserved left ventricular ejection fraction; HFrEF-AF= atrial fibrillation and heart failure with reduced left ventricular ejection fraction.

Figure 2.. Kaplan-Meier Survival Curves for Primary and Secondary End Points

Primary and secondary end points for patients with atrial fibrillation and heart failure with preserved ejection fraction (HFpEF-AF) or atrial fibrillation and heart failure with reduced ejection fraction (HFrEF-AF) were not significantly different (by log-rank test) between the 2 groups. A, All-cause mortality. B, Cardiovascular mortality. C, Cardiovascular hospitalization. D, Ischemic stroke or transient ischemic attack.

3.. Kaplan-Meier Survival Curves for Survival

All-cause mortality (A) and cardiovascular mortality (B) compared with the rate control strategy for patients with atrial fibrillation and heart failure with preserved ejection fraction (HFpEF-AF) or atrial fibrillation and heart failure with reduced ejection fraction (HFrEF-AF).