Impact of atrial fibrillation in patients with heart failure and reduced, mid-range or preserved ejection fraction

Mi Kyoung Son, Jin Joo Park, Nam-Kyoo Lim, Won-Ho Kim, Dong-Ju Choi, Mi Kyoung Son, Jin Joo Park, Nam-Kyoo Lim, Won-Ho Kim, Dong-Ju Choi

Abstract

Objective: To determine the prognostic value of atrial fibrillation (AF) in patients with heart failure (HF) and preserved, mid-range or reduced ejection fraction (EF).

Methods: Patients hospitalised for acute HF were enrolled in the Korean Acute Heart Failure registry, a prospective, observational, multicentre cohort study, between March 2011 and February 2014. HF types were defined as reduced EF (HFrEF, LVEF <40%), mid-range EF (HFmrEF, LVEF 40%-49%) or preserved EF (HFpEF, LVEF ≥50%).

Results: Of 5414 patients enrolled, HFrEF, HFmrEF and HFpEF were seen in 3182 (58.8%), 875 (16.2%) and 1357 (25.1%) patients, respectively. The prevalence of AF significantly increased with increasing EF (HFrEF 28.9%, HFmrEF 39.8%, HFpEF 45.2%; p for trend <0.001). During follow-up (median, 4.03 years; IQR, 1.39-5.58 years), 2806 (51.8%) patients died. The adjusted HR of AF for all-cause death was 1.06 (0.93-1.21) in the HFrEF, 1.10 (0.87-1.39) in the HFmrEF and 1.22 (1.02-1.46) in the HFpEF groups. The HR for the composite of all-cause death or readmission was 0.97 (0.87-1.07), 1.14 (0.93-1.38) and 1.03 (0.88-1.19) in the HFrEF, HFmrEF and HFpEF groups, respectively, and the HR for stroke was 1.53 (1.03-2.29), 1.04 (0.57-1.91) and 1.90 (1.13-3.20), respectively. Similar results were observed after propensity score matching analysis.

Conclusions: AF was more common with increasing EF. AF was seen to be associated with increased mortality only in patients with HFpEF and was associated with an increased risk of stroke in patients with HFrEF or HFpEF.

Trial registration number: NCT01389843.

Keywords: atrial fibrillation; epidemiology; heart failure with preserved ejection fraction; heart failure with reduced ejection fraction; stroke.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Study population flow chart. HFmrEF, heart failure with mid-range ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction.
Figure 2
Figure 2
Prevalence of AF in patients with HFrEF, HFmrEF and HFpEF according to age and sex; p value for trend. AF, atrial fibrillation; HFmrEF, heart failure with mid-range ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction.
Figure 3
Figure 3
Kaplan-Meier curves for unmatched cohort. Data are stratified by the three ejection fraction groups and the presence or absence of AF for (A) all-cause mortality, (B) all-cause mortality or rehospitalisation, (C) CVD mortality and (D) stroke. AF, atrial fibrillation; CVD, cardiovascular disease; HFmrEF, heart failure with mid-range ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction.
Figure 4
Figure 4
Multivariable HR for adverse outcomes associated with AF, according to EF groups: A. unmatched cohort and B. propensity score matched cohort. AF, atrial fibrillation; CVD, cardiovascular disease; EF, ejection fraction; HFmrEF, heart failure with mid-range ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction.

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