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Observational Study
. 2024 Aug 30;26(9):euae218.
doi: 10.1093/europace/euae218.

Clinical impact of atrial fibrillation progression in patients with heart failure with preserved ejection fraction: A report from the CHART-2 Study

Tomohiro Ito  1 , Takashi Noda  1 , Kotaro Nochioka  1 , Takashi Shiroto  1 , Nobuhiko Yamamoto  1 , Hiroyuki Sato  1 , Takahiko Chiba  1 , Yuhi Hasebe  1 , Makoto Nakano  1 , Hiroyuki Takahama  1 , Jun Takahashi  1 , Satoshi Miyata  2 , Hiroaki Shimokawa  1   3 , Satoshi Yasuda  1
Affiliations
Observational Study

Clinical impact of atrial fibrillation progression in patients with heart failure with preserved ejection fraction: A report from the CHART-2 Study

Tomohiro Ito et al. Europace. .

Abstract

Aims: Atrial fibrillation (AF) frequently coexists with heart failure with preserved ejection fraction (HFpEF), and clinical outcomes of patients with AF vary depending on its subtype. While AF progression characterized by the transition from paroxysmal AF to persistent AF is sometimes observed, the incidence and clinical impact of AF progression in patients with HFpEF remain to be explored.

Methods and results: We enrolled patients with HFpEF and paroxysmal AF from the Chronic Heart Failure Analysis and Registry in the Tohoku District-2 (CHART-2) Study. AF progression was defined as the transition from paroxysmal AF to persistent AF. A total of 718 patients (median age: 72 years, 36% were female) were enrolled. For a median follow-up of 6.0 years (interquartile range: 3.0-10.2 years), AF progression occurred in 105 patients (14.6%), with a cumulative incidence of 16.7% at 10 years. In the multivariable Cox proportional hazards model, previous hospitalization for heart failure [hazard ratio (HR) 1.74, 95% confidence interval (CI) 1.16-2.60; P = 0.007] and left atrial diameter (per 5-mm increase) (HR 1.37, 95% CI 1.20-1.55; P < 0.001) were significantly associated with AF progression. Furthermore, AF progression was significantly linked to worsening heart failure (adjusted HR 1.68, 95% CI 1.18-2.40; P = 0.004). Notably, 27 cases (26%) of worsening heart failure occurred within 1 year following AF progression.

Conclusion: In patients with HFpEF, AF progression is significantly associated with adverse outcomes, particularly worsening heart failure. An increased risk is observed in the early phases following progression to persistent AF.

Registration: Clinical Trials.gov Identifier: NCT00418041.

Keywords: Atrial fibrillation; Heart failure with preserved ejection fraction; Prognosis; Progression.

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Conflict of interest statement

Conflict of interest: H.S. has received lecture fees from Bayer Yakuhin (Osaka, Japan) and Daiichi Sankyo (Tokyo, Japan). S.Y. has received lecture fees from Bristol-Meyers (Tokyo, Japan), Bayer Yakuhin (Osaka, Japan) and Daiichi Sankyo (Tokyo, Japan). T.N. has recieved Grants-in-Aid for Scientific Research (22K08092) from the Ministry of Education, Culture, Sports, Science, and Technology of Japan and personal fees from Bayer Yakuhin (Osaka, Japan), Medtronic Japan (Tokyo, Japan), and Biotronik Japan (Tokyo, Japan). The remaining authors have no conflicts of interest to be disclosed.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
Study flowchart. A total of 718 patients with stage C/D heart failure and paroxysmal AF were included in the analysis. AF, atrial fibrillation; LVEF, left ventricular ejection fraction.
Figure 2
Figure 2
Cumulative incidence rate of AF progression. The cumulative incidence rate of AF progression was calculated for 718 patients. Incidence rates were calculated with all-cause mortality as a competing risk.
Figure 3
Figure 3
Cumulative incidence rate of worsening heart failure subsequent to AF progression. Incidence rates were calculated with all-cause mortality as a competing risk.
Figure 4
Figure 4
Landmark analysis of cumulative incidence rate of worsening heart failure every 3 years. The landmark analysis depicts the incidence of worsening heart failure at each 3-year observation period. Patients with AF progression showed a significantly higher incidence of worsening heart failure compared to those without AF progression. Hazard ratios for AF progression adjusted for age (≥75 years) and sex remained consistent across the observation periods. Hazard ratios were calculated with all-cause mortality as a competing risk.
Figure 5
Figure 5
Annual incidence rate of worsening heart failure following AF progression. The annual incidence of worsening heart failure was most frequent in the first year (25.8% per year), followed by a subsequent decrease in the second year (8.8% per year). These rates were calculated with all-cause mortality considered as a competing risk.
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References

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