Relative Importance of Heart Failure Events Compared to Stroke and Bleeding in AF Patients

Abstract

Introduction: Incident heart failure (HF), ischemic stroke and systemic embolism (IS/SE), and major bleeding related to anticoagulation therapy are still the most frequent events occurring in patients with atrial fibrillation (AF). The aim of this study was to assess the 3-year incidence, predictors, and related mortality of IS/SE, major bleeding, and HF in a large cohort of AF outpatients.

Methods and results: We studied 4973 outpatients with prevalent AF included in the CARDIONOR registry. The mean age was 72.9 ± 11.2 years, 24.1% had diabetes mellitus and 78.9% had anticoagulant therapy at baseline. The mean CHA₂DS₂Vasc score was 3.4 ± 1.7. After a median follow-up of 3.2 years (IQR: 2.8 to 3.5), incident HF, IS/SE and major bleeding occurred in 10.5%, 3.3% and 2.1% of patients, respectively. When analyzed as time-dependent variables, IS/SE, major bleeding and hospitalization for decompensated HF were all strongly associated with mortality. The independent predictors of incident HF were age, women, hypertension, diabetes mellitus, coronary artery disease and a previous history of HF. A sensitivity analysis in patients without history of HF at inclusion revealed that incident HF remained the most frequent adverse event, occurring in 5.3% of patients, compared to IS/SE (1.7%) and major bleeding (2.5%).

Conclusion: HF is a common residual cardiovascular adverse event occurring in AF outpatients and is associated with a very high mortality. Since modifiable risk factors are associated with incident HF, upstream intensive management of these risk factors would be of interest.

Keywords: atrial fibrillation; bleeding; heart failure; stroke.

Figure 1

Incident events during follow-up. Cumulative incidence functions (death as the competing event) are shown. (A) Overall study population (n = 4951 with follow-up). (B) Patients without HF at inclusion (n = 3288 with follow-up). (C) Patients with HF at inclusion (n = 1663 with follow-up). HF, heart failure.

Figure 2

Impact of incident events on subsequent mortality during the follow-up period. Ischemic stroke/systemic embolism (IS/SE), major bleeding, and hospitalization for heart failure (HF) were analyzed as time-dependent variables. HR, hazard ratio; CI, confidence interval.