Atrial fibrillation burden and heart failure: Data from 39,710 individuals with cardiac implanted electronic devices

Abstract

Background: Atrial fibrillation (AF) and heart failure (HF) often accompany one another, and each is independently associated with poor outcomes. However, the association between AF burden and outcomes is poorly understood.

Objective: The purpose of this study was to describe the association between device-based AF burden and HF clinical outcomes.

Methods: We used a nationwide, remote monitoring database of cardiac implantable electronic devices (CIEDs) linked to Medicare claims. We included patients with nonpermanent AF, undergoing new CIED implant, stratified by baseline HF. The outcomes were new-onset HF, HF hospitalization, and all-cause mortality at 1 and 3 years.

Results: We identified 39,710 patients who met inclusion criteria (25,054 with HF; 14,656 without HF). Patients with HF were younger (mean age 76.3 vs 78.5 years; P <.001), more often male (65% vs 54%; P <.001), and had higher mean CHA₂DS₂-VASc scores (5.4 vs 4.1; P <.001). Among those without HF, increasing device-based AF burden was significantly associated with increased risk of new-onset HF (adjusted hazard ratio [HR] 1.09 per 10% AF burden; 95% confidence interval [CI] 1.06-1.12; P <.001) and all-cause mortality (adjusted HR 1.05 per 10% AF burden; 95% CI 1.01-1.10; P = .012). Among patients with HF, increasing AF burden was significantly associated with increased risk of HF hospitalization (adjusted HR 1.05 per 10% AF burden; 95% CI 1.04-1.06; P <.001) and all-cause mortality (adjusted HR 1.06 per 10% AF burden; 95% CI 1.05-1.08; P <.001).

Conclusion: Among older patients with AF receiving a CIED, increasing AF burden is significantly associated with increasing risk of adverse HF outcomes and all-cause mortality.

Keywords: Arrhythmia burden; Atrial fibrillation; Heart failure; Medicare; Outcomes; Remote monitoring.

Figure 1.

Cumulative incidence curves of new-onset heart failure (HF) and mortality, stratified by atrial fibrillation (AF) burden (categorical, percent in AF) (A), and adjusted event rates of new-onset HF (B) and mortality (C) among patients without HF at baseline. Parentheses indicate exclusive borders; brackets indicate inclusive borders. CI 5 confidence interval.

Figure 2.

(Forest plots of new heart failure (HF) and all-cause mortality among patients with no HF at baseline (A) and HF hospitalization and mortality among Q7 patients with pre-existing HF (B) by percentage of atrial fibrillation burden. Parentheses indicate exclusive borders; brackets indicate inclusive borders. CI 5 confidence interval; HR 5 hazard ratio..

Figure 3.

Cumulative incidence curves of heart failure (HF) hospitalization and mortality, stratified by atrial fibrillation (AF) burden (categorical, percent in AF) (A), and adjusted event rates of HF hospitalization (B) and mortality (C) among patients with HF at baseline. Parentheses indicate exclusive borders; brackets indicate inclusive borders. CI 5 confidence interval.