Under-recognition of heart failure in patients with atrial fibrillation and the impact of gender: a UK population-based cohort study

Abstract

Background: Patients with atrial fibrillation (AF) complicated by heart failure (HF) have a poor prognosis. We investigated whether long term loop-diuretic therapy in patients with AF and no known diagnosis of HF, as a potential surrogate marker of undiagnosed HF, is also associated with worse outcomes.

Methods: Adults with incident AF were identified from UK primary and secondary care records between 2004 and 2016. Repeat prescriptions for loop diuretics, without a diagnosis of HF or documented non-cardiac indication, were classified as 'isolated' loop diuretic use.

Results: Amongst 124,256 people with incident AF (median 76 years, 47% women), 22,001 (17.7%) had a diagnosis of HF, and 22,325 (18.0%) had isolated loop diuretic use. During 2.9 (LQ-UQ 1-6) years' follow-up, 12,182 patients were diagnosed with HF (incidence rate 3.2 [95% CI 3.1-3.3]/100 person-years). Of these, 3999 (32.8%) had prior isolated loop diuretic use, including 31% of patients diagnosed with HF following an emergency hospitalisation. The median time from AF to HF diagnosis was 3.6 (1.2-7.7) years in men versus 5.1 (1.8-9.9) years in women (p = 0.0001). In adjusted models, patients with isolated loop diuretic use had higher mortality (HR 1.42 [95% CI 1.37-1.47], p < 0.0005) and risk of HF hospitalisation (HR 1.60 [95% CI 1.42-1.80], p < 0.0005) than patients with no HF or loop diuretic use, and comparably poor survival to patients with diagnosed HF.

Conclusions: Loop diuretics are commonly prescribed to patients with AF and may indicate increased cardiovascular risk. Targeted evaluation of these patients may allow earlier HF diagnosis, timely intervention, and better outcomes, particularly amongst women with AF, in whom HF appears to be under-recognised and diagnosed later than in men.

Keywords: Atrial fibrillation; Epidemiology; Heart failure; Loop diuretics.

Fig. 1

Participant flow diagram. Isolated loop-diuretic use refers to loop-diuretic use for a presumed cardiac indication and in the absence of a diagnosis of heart failure. Percentages represent the proportion of the final study cohort (n = 124,256)

Fig. 2

Prevalence of diagnosed heart failure and isolated loop-diuretic use by age at AF diagnosis. Includes heart failure recorded any time before, and up to 3 months after, the first record of AF

Fig. 3

Cumulative incidence of diagnosed heart failure and isolated loop-diuretic use. A Total population. B Stratified by gender. Diagnosed heart failure represented by a solid line, diagnosed heart failure and isolated loop-diuretic use combined represented by a dashed line

Fig. 4

Left panel: Rates of unplanned (emergency) hospitalisation for heart failure per 100 person-years of follow-up. Right panel: Survival after AF diagnosis, according to baseline heart failure status. AF, atrial fibrillation; HF, heart failure; IRR, incidence rate ratio; LD, loop-diuretic (refers to loop-diuretic use for a presumed cardiac indication). Asterisk (*) indicates the number of patients at risk for each baseline group, after 100-day censor period. † indicates data adjusted for age, gender, systolic blood pressure, BMI, smoking status, and comorbidities (COPD, diabetes, hypertension, previous MI, previous stroke/TIA) and medication use at AF diagnosis (ACEI/ARB, beta-blocker, MRA, digoxin, anticoagulant, antiplatelet, antiarrhythmic drug, non-dihydropyridine CCB, and statin use)