Atrial Fibrillation Burden and Clinical Outcomes in Heart Failure

Abstract Background Whether discharge heart rate for hospitalized heart failure (HF) patients with coexisted atrial fibrillation (AF) is associated with long-term clinical outcomes and whether this association differs between patients with and without beta-blockers have not been well studied. Purpose We investigated the associations between discharge heart rate and clinical outcomes in hospitalized HF patients with coexisted AF, while stratified to beta-blockers at discharge. Methods The study cohort included 1631 HF patients hospitalized primarily with AF, which was from the China PEACE Prospective Heart Failure Study. Clinical outcome was 1-year combined all-cause mortality and HF hospitalization after discharge. We analyzed association between outcome and heart rate at discharge with restricted cubic spline and Cox proportional hazard ratios (HR). Results The median age was 68 (IQR: 60- 77) years, 41.9% were women, discharge heart rate was (median (IQR)) 75 (69- 84) beats per minute (bpm), and 60.2% received beta-blockers at discharge. According to the result of restricted cubic spline plot, the relationship between discharge heart rate and clinical outcome may be nonlinear (P<0.01). Based on above result, these patients were divided into 3 groups: lowest <65 bpm, middle 65–86 bpm and highest ≥87 bpm, clinical outcomes occurred in 128 (64.32%), 624 (53.42%) and 156 (59.32%) patients in the lowest, middle, and highest groups respectively. In the Cox proportional hazard analysis, the lowest and highest groups were associated with increased risks of clinical outcome compared with the middle group (HR: 1.289, 95% confidence interval (CI): 1.056 - 1.573, p=0.013; HR: 1.276, 95% CI: 1.06 - 1.537, p=0.01, respectively). And a significant interaction between discharge heart rate and beta-blocker use was observed (P<0.001 for interaction). Stratified analysis showed the lowest group was associated with increased risks of clinical outcomes in patients with beta-blockers (HR: 1.584, 95% confidence interval (CI): 1.215–2.066, p=0.001). Conclusion There may be a U-curve relationship between discharge heart rate and clinical outcomes in hospitalized HF patients with coexisted AF. They may have the best clinical outcomes with heart rates of 65 - 86 bpm. And strict heart rate control (<65 bpm) may be avoided for patients who discharge with beta-blockers. Figure 1 Funding Acknowledgement Type of funding source: Other. Main funding source(s): This work was supported by the National Key Research and Development Program (2017YFC1310803) from the Ministry of Science and Technology of China; the CAMS Innovation Fund for Medical Science (2017-I2M-B&R-02); the 111 Project from the Ministry of Education of China (B16005).

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Plasma natriuretic peptide level is an independent determinant of major clinical outcomes in atrial fibrillation patients without heart failure: the Fushimi AF Registry

European Heart Journal ◽

10.1093/ehjci/ehaa946.0673 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

Y Hamatani ◽

M Iguchi ◽

Y Aono ◽

K Ishigami ◽

S Ikeda ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Clinical Outcomes ◽

Prognostic Marker ◽

Oral Anticoagulants ◽

Systemic Embolism ◽

The Mean

Abstract Background Atrial fibrillation (AF) increases the risk of death, stroke/systemic embolism and heart failure (HF). Plasma natriuretic peptide (NP) level is an important prognostic marker in HF patients. However, little is known regarding the prognostic significance of plasma NP level in AF patients without HF. Purpose The aim of this study is to investigate the relationship between plasma NP level and clinical outcomes such as all-cause death, stroke/systemic embolism and HF hospitalization during follow-up period in AF patients without HF. Methods The Fushimi AF Registry is a community-based prospective survey of AF patients in our city. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011, and follow-up data were available for 4,466 patients by the end of November 2019. From the registry, we excluded 1,220 patients without a pre-existing HF (defined as having one of the following; prior hospitalization for HF, New York Heart Association class ≥2, or left ventricular ejection fraction <40%). Among 3,246 AF patients without HF, we investigated 1,189 patients with the data of plasma BNP (n=401) or N-terminal pro-BNP (n=788) level at the enrollment. We divided the patients according to the quartile of each plasma BNP or NT-pro BNP level and compared the backgrounds and outcomes between these 4 groups stratified by plasma NP level. Results Of 1,189 patients, the mean age was 72.1±10.2 years, 454 (38%) were female and 684 (58%) were paroxysmal AF. The mean CHADS2 and CHA2DS2-VASc score were 1.6±1.1 and 2.9±1.5, respectively. Oral anticoagulants were prescribed in 671 (56%) at baseline. The median (interquartile range) BNP and N-terminal pro-BNP level were 84 (38, 176) and 500 (155, 984) pg/ml, respectively. Patients with high plasma NP level were older, and demonstrated lower prevalence of paroxysmal AF, higher CHADS2 and CHA2DS2-VASc scores and higher prevalence of chronic kidney disease and oral anticoagulants prescription (all P<0.01). A total of 165 all-cause death, 114 stroke/systemic embolism and 103 HF hospitalization occurred during the median follow-up period of 5.0 years. Kaplan-Meier curves demonstrated that higher plasma NP level was significantly associated with the incidences of all-cause death, stroke/systemic embolism and HF hospitalization in AF patients without HF (Figure 1A). Multivariable Cox regression analysis revealed that plasma NP level could stratify the risk of clinical outcomes even after adjustment by type of AF, CHA2DS2-VASc score, chronic kidney disease and oral anticoagulant prescription (Figure 1B). Conclusion Plasma NP level is a significant prognostic marker for all-cause death, stroke/systemic embolism and HF hospitalization in AF patients without HF, suggesting the importance of measuring plasma NP level in AF patients even without HF. Figure 1 Funding Acknowledgement Type of funding source: None

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Clinical Outcomes of Rivaroxaban Monotherapy in Heart Failure Patients With Atrial Fibrillation and Stable Coronary Disease: Insights From the AFIRE Trial

Circulation ◽

10.1161/circulationaha.121.055374 ◽

2021 ◽

Vol 144 (17) ◽

pp. 1449-1451

Author(s):

Yoshiyuki Yazaki ◽

Masato Nakamura ◽

Raisuke Iijima ◽

Satoshi Yasuda ◽

Koichi Kaikita ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Clinical Outcomes ◽

Coronary Disease ◽

Heart Failure Patients

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Comparison of Clinical Outcomes between Sinus Rhythm and Atrial Fibrillation in Heart Failure Patients with Cardiac Resynchronization Therapy

Journal of Arrhythmia ◽

10.4020/jhrs.27.op13_4 ◽

2011 ◽

Vol 27 (Supplement) ◽

pp. OP13_4

Author(s):

Masaru Kuroda ◽

Kazumasa Adachi ◽

Kenzou Udu ◽

Hiroki Takada ◽

Takeshi Matsuura ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Cardiac Resynchronization Therapy ◽

Sinus Rhythm ◽

Clinical Outcomes ◽

Cardiac Resynchronization ◽

Resynchronization Therapy ◽

Heart Failure Patients

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Three year clinical outcomes in a nationwide, observational, siteless clinical trial of atrial fibrillation screening—mHealth Screening to Prevent Strokes (mSToPS)

PLoS ONE ◽

10.1371/journal.pone.0258276 ◽

2021 ◽

Vol 16 (10) ◽

pp. e0258276

Author(s):

Steven R. Steinhubl ◽

Jill Waalen ◽

Anirudh Sanyal ◽

Alison M. Edwards ◽

Lauren M. Ariniello ◽

...

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Atrial Fibrillation ◽

Clinical Outcomes ◽

Clinical Event ◽

Newly Diagnosed ◽

Clinical Events ◽

High Event ◽

Asymptomatic Individuals ◽

New Diagnosis

Background Atrial fibrillation (AF) is common, often without symptoms, and is an independent risk factor for mortality, stroke and heart failure. It is unknown if screening asymptomatic individuals for AF can improve clinical outcomes. Methods mSToPS was a pragmatic, direct-to-participant trial that randomized individuals from a single US-wide health plan to either immediate or delayed screening using a continuous-recording ECG patch to be worn for two weeks and 2 occasions, ~3 months apart, to potentially detect undiagnosed AF. The 3-year outcomes component of the trial was designed to compare clinical outcomes in the combined cohort of 1718 individuals who underwent monitoring and 3371 matched observational controls. The prespecified primary outcome was the time to first event of the combined endpoint of death, stroke, systemic embolism, or myocardial infarction among individuals with a new AF diagnosis, which was hypothesized to be the same in the two cohorts but was not realized. Results Over the 3 years following the initiation of screening (mean follow-up 29 months), AF was newly diagnosed in 11.4% (n = 196) of screened participants versus 7.7% (n = 261) of observational controls (p<0.01). Among the screened cohort with incident AF, one-third were diagnosed through screening. For all individuals whose AF was first diagnosed clinically, a clinical event was common in the 4 weeks surrounding that diagnosis: 6.6% experienced a stroke,10.2% were newly diagnosed with heart failure, 9.2% had a myocardial infarction, and 1.5% systemic emboli. Cumulatively, 42.9% were hospitalized. For those diagnosed via screening, none experienced a stroke, myocardial infarction or systemic emboli in the period surrounding their AF diagnosis, and only 1 person (2.3%) had a new diagnosis of heart failure. Incidence rate of the prespecified combined primary endpoint was 3.6 per 100 person-years among the actively monitored cohort and 4.5 per 100 person-years in the observational controls. Conclusions At 3 years, screening for AF was associated with a lower rate of clinical events and improved outcomes relative to a matched cohort, although the influence of earlier diagnosis of AF via screening on this finding is unclear. These observational data, including the high event rate surrounding a new clinical diagnosis of AF, support the need for randomized trials to determine whether screening for AF will yield a meaningful protection from strokes and other clinical events. Trail registration The mHealth Screening To Prevent Strokes (mSToPS) Trial is registered on ClinicalTrials.gov with the identifier NCT02506244.

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Renal function and outcomes in atrial fibrillation patients after catheter ablation

PLoS ONE ◽

10.1371/journal.pone.0241449 ◽

2020 ◽

Vol 15 (11) ◽

pp. e0241449

Author(s):

Tetsuma Kawaji ◽

Satoshi Shizuta ◽

Takanori Aizawa ◽

Shintaro Yamagami ◽

Yasuaki Takeji ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Renal Function ◽

Catheter Ablation ◽

Clinical Outcomes ◽

Cox Model ◽

Strong Predictor ◽

Multivariable Analysis ◽

Heart Failure Hospitalization

Background Atrial fibrillation (AF) and renal failure coexist and interact. However, scarce data about association between renal function and clinical outcomes in patients undergoing catheter ablation for AF are available. We sought to evaluate long-term renal function and clinical outcomes after AF ablation. Methods We enrolled 791 non-dialysis patients undergoing catheter ablation for AF, and evaluated the incidence of worsening renal function (WRF) after the procedure, defined as >30% decline in estimate glomerular filtration rate. Results Mean follow-up duration was 5.1±2.5 years. Five hundreds and twenty-six patients (66.5%) were free from recurrent atrial arrhythmias without any antiarrhythmic drugs at the time of final follow-up. Cumulative incidence of WRF was 13.2% at 5-year after procedure, which was significantly higher in patients with recurrent AF compared to those without (21.6% versus 8.7%, P<0.001). In the multivariable analysis, recurrent AF was an independent risk factor for WRF (adjusted hazard ratio [HR] 1.89, 95% confidence interval 1.27–2.81, P = 0.002), along with congestive heart failure, diabetes, and eGFR <60 ml/min/1.73m2 at baseline. Patients with WRF had significantly higher 5-year incidences of all-cause death, cardiovascular death, heart failure hospitalization, ischemic stroke, and major bleeding compared to those without WRF. After adjustment of baseline differences in the multivariate Cox model, the excessive risks of WRF for all-cause death and heart failure hospitalization remained significant (adjusted HR 3.46, P = 0.002; adjusted HR 3.67, P<0.001). Conclusions In AF patients undergoing catheter ablation for AF, arrhythmia recurrence was associated with WRF during follow-up, which was a strong predictor of adverse clinical outcomes.

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Management and clinical outcome of patients with atrial fibrillation stratified by the 4S-AF scheme for structured characterization of atrial fibrillation: data from CODE-AF registry

European Heart Journal ◽

10.1093/eurheartj/ehab724.0445 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

S.R Lee ◽

K.M Park ◽

B Joung ◽

E.K Choi ◽

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Clinical Outcomes ◽

Stroke Prevention ◽

Left Atrial ◽

Rhythm Control ◽

Prevention Strategies ◽

Group A ◽

Group B

Abstract Background Recently, 4S-AF scheme consisting of four essential domains requiring for integrated management of atrial fibrillation (AF), including stroke prevention, symptom severity, severity of AF burden, and substrate for AF, has been proposed for the structured characterization of AF. Purpose To classify patients with AF applying 4S-AF scheme, evaluate how rhythm control and stroke prevention strategies were applied according to the 4S-AF scheme, and analyze the association between 4S-AF scheme score and the risk of clinical outcome, composite of stroke and admission for heart failure in patients with AF. Methods Using the data from the COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation (CODE-AF) registry from June 2015 to October 2020, we identified patients with AF who had information about 4S. The 4S-AF scheme score was calculated by stroke risk (truly low risk patients = 0; otherwise = 1), symptom severity (no symptom = 1; presence of symptom = 1), severity of AF burden (paroxysmal = 0, persistent = 1, and long-persistent to permanent = 2), substrate for AF (add 1 if >75 years; no comorbidity=1, 1 comorbidity = 1, 2 or more comorbidities = 2; left atrial anteroposterior diameter <40mm = 0, 40 to <50mm = 1, and ≥50mm = 2). Treatment strategies, including rhythm control and anticoagulation, were analyzed according to the 4S-AF scheme score. The risk for a composite of stroke and admission for heart failure was evaluated according to the 4S-AF scheme score during follow-up. Results Among 8199 patients with AF, the 4S-AF scheme scores of 0, 1, 2, 3, 4, 5, and ≥6 were 2.5%, 5.6%, 9%, 17.1%, 20.1%, 17.6%, and 28%, respectively. Patients with higher scores were tended to be older, had higher CHA2DS2-VASc score, included less proportion of paroxysmal AF, and showed larger left atrial size (Table). According to 4S-AF scheme, physicians preferred to apply a rhythm control strategy through both performing catheter ablation and prescribing antiarrhythmic agents in patients with lower 4S-AF scheme score (Figure). Oral anticoagulation rates were higher in patients with higher 4S-AF scheme score owing to higher CHA2DS2-VASc scores of these patients (Figure). The incidence rates of composite clinical outcomes were increased with increasing in 4S-AF scheme score (Figure). When grouping 4S-AF scheme score 0 and 1 as group A, 2 to 4 as group B, 5 as group C, and 6 as group D, group B, C, and D were associated with a higher risk of the composite clinical outcomes by 3.4, 7.9 and 11.5-fold compared to group A, respectively (Figure). Conclusions The 4S-AF scheme score was well-associated with the risk of stroke and admission for heart failure in patients with AF. Although the 4S-AF scheme might be already reflected in clinical practice when physicians determined the rhythm control and stroke prevention strategies for their AF patients, more systematic approach should be utilized for better clinical outcomes in patients with AF. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported by a research grant from the Korean Healthcare Technology R&D project funded by the Ministry of Health & Welfare (HI15C1200, HC19C0130).

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Progrostic impact of a pre-existing heart failure with preserved ejection fraction in patients with acute pulmonary embolism or paroxysmal atrial fibrillation

European Journal of Preventive Cardiology ◽

10.1093/eurjpc/zwab061.017 ◽

2021 ◽

Vol 28 (Supplement_1) ◽

Author(s):

N Tufano

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Pulmonary Embolism ◽

Ejection Fraction ◽

Clinical Outcomes ◽

Acute Pulmonary Embolism ◽

Older Age ◽

Lower Percentage ◽

Preserved Ejection Fraction ◽

Acute Pe

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf none Introduction heart failure with preserved ejection fraction (HFpEF) is a growing public health problem. Its prevalence among heart failure patients increases over time, accounting for at least 50 % of all hospital admissions for HF. Nevertheless, no single guideline exists for diagnosis or treatment for HFpEF, and older age or comorbidities are additional factors that confuse etiology and complicate prognosis. Moreover, there are few data regarding the consequences of HFpEF on other recurrent pathologies. Aims to assess the prognostic impact of a pre-existing HFpEF on patients ospidalized for intercurrent episodes of atrial fibrillation (AF) or acute pulmonary embolism (PE) Methods We performed a retrospective evaluation of 194 patients, consecutively hospitalized in our unit of Cardiology with a diagnosis of paroxysmal AF or acute PE, from April 2017 to October 2020. We recruited exclusively patients with normal cardiac function and HFpEF patients. Heart failure with reduced FEVS patients were excluded from the study. We have described for each patient the demographic and clinical characteristics, comorbidities, instrumental test results and clinical outcomes. In order to assess, for each group, the relationship between patient characteristics and clinical outcomes, the Chi-square test or alternatively the Pearson-Spearman correlation coefficients were calculated. Results the 194 patients studied had an average age of 73,7 years (min. 27, max 94). 59 AF patients had pre-existing HFpEF, whereas AF patients without HF were 67. Patients with pre-existing HFpEF and newly-onset AF had a more advanced age (76,7 y vs 72,9 y), and greater comorbidity (meanly 4 vs 3) rather than AF patients without HFpEF. Moreover, percentage of converting arrhythmia were significantly higher in AF patients without HFpEF. . Patients with acute PE and pre-existing HFpEF were 38, whereas PE patients without HF were 30. Acute PE patients with pre-existing HFpEF had older age, a prevalence for femal sex, more comorbidities, an average longer hospitalizations, but no significantly different rates of severe complications (ictus, hemorrhagies, needs for ventilation, pulmonary infarction or deaths) rather than PE patients without HFpEF. Conclusions the patients with AF or PE and concomitant HFpEF that were hospitalized from April 2017 to October 2020, showed an average longer hospitalization, a lower percentage of converting arrhythmia, probably due to the older age and the greater comorbidity.

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P783Guideline-directed therapy at discharge is important in patients with heart failure and atrial fibrillation

European Heart Journal ◽

10.1093/eurheartj/ehz747.0383 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

B S Yoo ◽

M S Ahn ◽

S J Lee ◽

J W Son ◽

J Y Kim ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Ejection Fraction ◽

Beneficial Effect ◽

Clinical Outcomes ◽

Guideline Adherence ◽

Angiotensin Receptor Blockers ◽

Composite Endpoint ◽

Converting Enzyme Inhibitors ◽

Reduced Ejection Fraction

Abstract Background There are limited and conflicting data regarding the prognostic implication of guideline-directed therapy, especially in heart failure (HF) patients with atrial fibrillation (AF). Thus, this study evaluated the relationship between guideline adherence to recommended therapy at discharge and relevant 60-day clinical outcomes in acute HF patients with AF having reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). Methods and results Of 5,625 acute HF patients in the Korean Acute Heart Failure Registry, 2,071 with documented AF (HFrEF, n=986; HFpEF, n=1,085) were separately analysed. A guideline adherence score was calculated for the prescription of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists, and anticoagulants. In HFrEF patients with AF, there was significant trend of increase in mortality (p for trend <0.001) and composite endpoint (p for trend = 0.002) according to guideline adherence. Poor adherence was associated with a significantly high risk of mortality (hazard ratio [HR], 4.75; 95% confidence interval [95% CI], 1.77–12.74) and composite endpoint (HR, 2.36; 95% CI, 1.33–4.18). In HFpEF patients with AF, there was a significant increasing trend for rehospitalization (p for trend = 0.04) and composite endpoint (p for trend = 0.03). However, the beneficial effect of good guideline adherence was statistically non-significant for all clinical outcomes Conclusion Better adherence to guidelines was associated with a better 60-day prognosis in both HFrEF and HFpEF patients with AF. However, the beneficial effect of guideline adherence was more pronounced in HFrEF patients with AF.

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