Impact of atrial fibrillation on 1-year outcome in patients with implantable cardioverter defibrillator or cardiac resynchronization therapy with defibrillator: results from the German DEVICE Registry

Abstract

Background: Atrial fibrillation (AF) is a cardiac arrhythmia frequently documented in patients requiring implantable cardioverter defibrillators (ICDs) and/or cardiac resynchronization therapy with defibrillator (CRT-D). Patients with diagnosed AF at the point of ICD or CRT-D implantation may have an impaired follow-up outcome.

Methods: The German DEVICE I-II registry is a nationwide prospective multicentre database of patients implanted with ICD and CRT-D with clinical follow-up data. We analysed a 1-year follow up of implanted patients with AF and with sinus rhythm (SR).

Results: A total of 4,929 ICD/CRT patients are included in the present analysis: 946 (19.2%) were in AF and 3,983 (80.8%) were SR at time of device implantation. AF patients had a significantly more comorbid profile including older age {72 [interquartile range (IQR), 66-77] vs. 66 (IQR, 56-73) years; P<0.001}, and higher rate of patients with left ventricular ejection fraction <30% (68.2% vs. 61.0%; P<0.001), peripheral artery disease (4.5% vs. 2.7%; P=0.002), diabetes (33.6% vs. 25.5%; P<0.001), hypertension (58.4% vs. 51.1%; P<0.001) and renal failure (22.6% vs. 15.3%; P<0.001). The intra-hospital complication rate was 4.3% in the AF and 3.6% in the SR group (P=0.38). In 1-year follow-up AF patients experienced a significantly higher rate of defibrillator shocks (25% vs. 15.3%; P<0.001). One-year estimated mortality was 10.8% in the AF and 5.9% in the SR group (P<0.001), while estimated 1-year major adverse cardiac and cerebrovascular events (MACCE) rate was 11.2% vs. 7.0% (P<0.001). The effects of AF on electrical shocks and mortality persisted after adjusting for age, sex, advanced New York Heart Association (NYHA) class, severely impaired left ventricular ejection fraction (LVEF), coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), chronic renal failure (CRF), QRS duration, and type of indication for electronic device implantation.

Conclusions: Our clinical data on an extended cohort of contemporary patients confirm the significant impact of AF, and its associated comorbidities, upon mortality and major adverse events after implantation of ICD/CRT.

Keywords: Implantable cardioverter defibrillators (ICDs); atrial fibrillation (AF); cardiac resynchronization therapy with defibrillator (CRT-D); follow-up; registry.

Figure 1

Kaplan-Meier estimate representing survival over the first 365 days after implantation of ICD or CRT-D. ICD, implantable cardioverter defibrillator; CRT-D, cardiac resynchronization therapy with defibrillator.

Figure 2

Hazard ratios for mortality adjusted for age (linear), sex, NYHA III+, EF ≤30%, secondary prevention, QRS >120 ms, CHD, diabetes, chronic kidney disease, COPD in all patients (top), patients implanted with ICD (middle) and patients implanted with CRT-D (bottom). Odds ratios of ICD-Shock within 365 days in survivors, adjusted for age (linear), sex, known EF ≤30%, secondary prevention, QRS >120 ms, CHD in all patients (top), patients implanted with ICD (middle) and patients implanted with CRT-D (bottom). ICD, implantable cardioverter defibrillator; CRT-D, cardiac resynchronization therapy with defibrillator; CI, confidence interval; NYHA, New York Heart Association; EF, ejection fraction; CHD, coronary heart disease; COPD, chronic obstructive pulmonary disease.