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. 2024 Jul 30;150(5):350-361.
doi: 10.1161/CIRCULATIONAHA.124.069757. Epub 2024 Jun 28.

Association of Atrial Fibrillation Burden and Mortality Among Patients With Cardiac Implantable Electronic Devices

Graham Peigh  1 , Jiani Zhou  2 , Sarah C Rosemas  2 , Anthony I Roberts  2   3 , Colleen Longacre  2 , Katherine Trinh  1 , Tanvi Nayak  1 , Dana Soderlund  2 , Rod S Passman  1
Affiliations

Association of Atrial Fibrillation Burden and Mortality Among Patients With Cardiac Implantable Electronic Devices

Graham Peigh et al. Circulation. .

Abstract

Background: Current estimates of atrial fibrillation (AF)-associated mortality rely on claims- or clinical-derived diagnoses of AF, limit AF to a binary entity, or are confounded by comorbidities. The objective of the present study is to assess the association between device-recognized AF and mortality among patients with cardiac implantable electronic devices capable of sensitive and continuous atrial arrhythmia detection. Secondary outcomes include relative mortality among cohorts with no AF, paroxysmal AF, persistent AF, and permanent AF.

Methods: Using the deidentified Optum Clinformatics US claims database (2015 to 2020) linked to the Medtronic CareLink database, we identified individuals with a cardiac implantable electronic device who transmitted data ≥6 months after implantation. AF burden was assessed during the first 6 months after implantation (baseline period). Subsequent mortality, assessed from claims data, was compared between patients with and without AF, with adjustment for age, geographic region, insurance type, Charlson Comorbidity Index, and implantation year.

Results: Of 21 391 patients (age, 72.9±10.9 years; 56.3% male) analyzed, 7798 (36.5%) had device-recognized AF. During a mean of 22.4±12.9 months (median, 20.1 [12.8-29.7] months) of follow-up, the overall incidence of mortality was 13.5%. Patients with AF had higher adjusted all-cause mortality than patients without AF (hazard ratio, 1.29 [95% CI, 1.20-1.39]; P<0.001). Among those with AF, patients with nonparoxysmal AF had the greatest risk of mortality (persistent AF versus paroxysmal AF: hazard ratio, 1.36 [95% CI, 1.18-1.58]; P<.001; permanent AF versus paroxysmal AF: hazard ratio, 1.23 [95% CI, 1.14-1.34]; P<.001).

Conclusions: After adjustment for potential confounding factors, the presence of AF was associated with higher mortality in our cohort of patients with cardiac implantable electronic devices. Among those with AF, nonparoxysmal AF was associated with the greatest risk of mortality.

Keywords: atrial fibrillation; cardiac implantable electronic devices; mortality.

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Conflict of interest statement

Dr Passman received research support from the American Heart Association (No. 18SFRN34250013) and the National Institutes of Health (UG3HL165065); research support and speaker fees from Medtronic; research support from Abbott; and royalties from UpToDate. Dr Zhou, S.C. Rosemas, and Drs Soderlund and Longacre are employees and shareholders of Medtronic. A.I. Roberts is a contractor with Medtronic. Northwestern University receives fellowship support from Medtronic. The remaining authors report no conflicts.

Figures

Figure 1.
Figure 1.
Incidence of mortality through conclusion of follow-up by presence of atrial fibrillation (AF) and degree of AF burden. Presence of device-recognized AF was associated with a greater unadjusted incidence of mortality through the conclusion of follow-up. Among those with AF, the presence of persistent (PeAF) and permanent AF (PermAF) was associated with a higher unadjusted incidence of mortality compared with paroxysmal AF (pAF). There were no differences in mortality between those with PeAF and those with PermAF.
Figure 2.
Figure 2.
Adjusted HR for mortality and associated survival curves by presence of atrial fibrillation (AF). Presence of device-recognized AF was associated with a higher hazard for mortality and lower cumulative incidence of survival through the duration of follow-up. Analyses are adjusted for age, Charlson Comorbidity Index, geographic region of the patient at time of implantation, insurance type (commercial vs Medicare Advantage), and cardiac implantable electronic device implantation year. HR indicates hazard ratio.
Figure 3.
Figure 3.
Adjusted HR for mortality and associated survival curves by category of atrial fibrillation (AF). Patients with persistent (PeAF) or permanent (PermAF) AF had higher adjusted hazards of mortality and lower cumulative incidences of survival than those with paroxysmal AF (pAF). There were no differences in the adjusted hazards for mortality between those with PeAF and those with PermAF. Analyses are adjusted for age, Charlson Comorbidity Index, geographic region of the patient at time of implantation, insurance type (commercial vs Medicare Advantage), and cardiac implantable electronic device implantation year. HR indicates hazard ratio.
Figure 4.
Figure 4.
Device-specific adjusted HRs for mortality and accompanying survival curves by presence of atrial fibrillation (AF). Presence of AF was associated with a higher hazard for mortality and lower cumulative incidence of survival over time among patients with dual-chamber permanent pacemaker (PPM), implantable cardiac monitor (ICM), dual-chamber implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy–defibrillator (CRT-D) CIEDs. There was no association between presence of AF and mortality among patients with cardiac resynchronization therapy–pacemaker (CRT-P) devices. Analyses are adjusted for age, Charlson Comorbidity Index, geographic region of the patient at the time of implantation, insurance type (commercial vs Medicare Advantage), and cardiac implantable electronic device implantation year. HR indicates hazard ratio.
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