Temporal relationship and prognostic significance of atrial fibrillation in heart failure patients with preserved ejection fraction: a community-based study

Abstract

Background: In patients with heart failure and preserved ejection fraction (HFpEF), atrial fibrillation (AF) may predate, concur with, or develop after HFpEF diagnosis. We sought to define the temporal relationship between AF and HFpEF, to identify factors associated with AF, and to determine the prognostic impact of prevalent and incident AF in HFpEF.

Method and results: From 1983 to 2010, 939 Olmsted County, Minnesota, residents (age, 77±12 years; 61% female) newly diagnosed with HFpEF (EF ≥0.50) were evaluated. Baseline rhythm classification included prior AF (>3 months before HFpEF diagnosis), concurrent AF (±3 months), or sinus rhythm. Incident AF (>3 months after HFpEF diagnosis) and all-cause mortality were ascertained through February 2012. Prior AF (29%) and concurrent AF (23%) were associated with older age, higher brain-type natriuretic peptide, and larger left atrial volume index at HFpEF diagnosis compared with sinus rhythm. Of HFpEF patients in sinus rhythm at diagnosis, 32% developed AF over a median follow-up of 3.7 years (interquartile range, 1.5-6.7 years; 69 events per 1000 person-years). Age and diastolic dysfunction were positively and statin use was inversely associated with incident AF. With no AF used as the referent, prior or concurrent AF (combined hazard ratio, 1.3; 95% confidence interval, 1.0-1.6; P=0.03) and incident AF, modeled as a time-dependent covariate (hazard ratio, 2.1; 95% confidence interval, 1.4-3.0; P<0.001), were independently associated with death after adjustment for pertinent covariates.

Conclusions: AF occurs in two thirds of HFpEF patients at some point in the natural history and confers a poor prognosis. Further study is required to determine whether intervention for AF may improve outcomes or if statin use can prevent AF in HFpEF.

Keywords: atrial fibrillation; heart failure, diastolic; population; prognosis.

Conflict of interest statement

Conflict of Interest Disclosures: None.

Figures

Figure 1

Time between diagnosis of AF and HFpEF (truncated at ±30 years of HFpEF diagnosis). Zero represents HFpEF diagnosis (baseline).

Figure 2

Cumulative incidence of AF adjusting for death as a competing risk (dashed line) and cumulative incidence of death (solid line) among HFpEF patients presenting in sinus rhythm and no prior history of AF (truncated at 15 years after HFpEF diagnosis).

Figure 3

Kaplan-Meier survival analysis according to rhythm status at baseline. Survival curves shown for patients with prevalent AF (dashed line) and sinus rhythm (solid line) at HFpEF diagnosis. Median survival by group shown (vertical line). Numbers given below figure are survival rates (%) and number of patients at risk (in parentheses) at each 5-year interval, truncated at 15 years after HFpEF diagnosis.