Characteristics, treatment, and outcomes of newly diagnosed atrial fibrillation patients with heart failure: GARFIELD-AF

Abstract

Aims: Heart failure (HF) and atrial fibrillation (AF) may coexist and influence each other. However, characteristics, anticoagulant treatment, and outcomes of contemporary AF patients with concurrent HF are ill-defined. This study analyses characteristics, treatment, and 2 year outcomes in newly diagnosed Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) patients with vs. without HF.

Methods and results: GARFIELD-AF is the world's largest observational AF patient study. At enrolment, 11 758 of 52 072 patients (22.6%) had HF; 76.3% were New York Heart Association class II-III. Patients with HF had comparable demographics, blood pressure, and heart rate but more likely had permanent (15.6% vs. 11.9%) or persistent AF (18.9% vs. 13.8%), acute coronary syndromes (16.7% vs. 8.9%), vascular disease (40.8% vs. 20.2%), and moderate-to-severe chronic kidney disease (14.6% vs. 9.0%) than those without. Anticoagulant prescription was similar between the two groups. At 2 year follow-up, patients with HF showed a greater risk of all-cause mortality [hazard ratio (HR), 2.06; 95% confidence interval (CI), 1.91-2.21; P < 0.0001], cardiovascular mortality (HR, 2.91; 95% CI, 2.58-3.29; P < 0.0001), acute coronary syndromes (HR, 1.25; 95% CI, 1.02-1.52; P = 0.03), and stroke/systemic embolism (HR, 1.24; 95% CI, 1.07-1.43; P = 0.0044). Major bleeding rate was comparable (adjusted HR, 1.00; 95% CI, 0.84-1.18; P = 0.968). Among patients without HF at baseline, incidence of new HF was low [0.69 (95% CI, 0.63-0.75) per 100 person-years], whereas propensity to develop worsening HF was higher in those with HF [1.62 (95% CI, 1.45-1.80) per 100 person-years].

Conclusions: Patients with AF and HF have a high risk of all-cause and cardiovascular mortality and stroke/systemic embolism and may develop worsening HF.

Keywords: Anticoagulant; Atrial fibrillation; GARFIELD-AF; Heart failure; Stroke.

Figure 1

Baseline therapy—heart failure vs. no heart failure: baseline treatment with anticoagulants/antiplatelet agents. AP, antiplatelet; DTI, direct thrombin inhibitor; FXa, factor Xa inhibitor; HF, heart failure; VKA, vitamin K antagonist.

Figure 2

Antithrombotic treatment patterns in patients stratified by the presence and severity of heart failure (HF). HF severity was categorized according to the New York Heart Association (NYHA) functional classification. AP, antiplatelet; DTI, direct thrombin inhibitor; FXa, factor Xa inhibitor; VKA, vitamin K antagonist.

Figure 3

Cumulative incidence rates of (A) all‐cause mortality, (B) stroke/SE, and (C) ACS in atrial fibrillation patients. Rates are stratified by the presence and absence of heart failure at baseline over a 2 year observation period. ACS, acute coronary syndromes; MI, myocardial infarction; SE, systemic embolism.

Figure 4

Major adverse outcomes in atrial fibrillation patients with heart failure vs. without heart failure (reference): adjusted hazard ratios (HRs). This figure is the central illustration of the manuscript. ACS, acute coronary syndromes; CI, confidence interval; MI, myocardial infarction; SE, systemic embolism.

Figure 5

Unadjusted and adjusted 2 year outcomes [hazard ratios vs. no heart failure (HF)] in patients stratified by severity of HF. Severity of HF is stratified via the New York Heart Association (NYHA) functional classes I–IV. ACM, all‐cause mortality; ACS, acute coronary syndromes; CI, confidence interval; CV, cardiovascular; MI, myocardial infarction; SE, systemic embolism.