Heart failure progression and mortality in atrial fibrillation patients with preserved or reduced left ventricular ejection fraction.

backgroundAtrial fibrillation (AF) worsens cardiovascular (CV) outcomes of heart failure (HF) and vice versa. The impact of rate or rhythm control strategies on HF progression and survival remains unclear.

methodsWe examined the risk of HF progression in AF patients (pts) with a prior HF event and minimal or no HF burden (NYHA class 0 or 1). They were stratified into HF with a preserved left ventricular ejection fraction (≥ 40%, pEF) or reduced EF (< 40%, rEF). HF subgroups from the Rate and Rhythm arm were compared for the primary outcome of worsening HF or death (WHFD), total mortality, cardiovascular mortality, and cardiovascular hospitalizations.

resultsFour hundred ninety-two AF pts (HFpEF = 349, HFrEF = 143) were analyzed. Baseline characteristics were generally comparable in the Rate and Rhythm arms of the two subgroups. Over a median follow-up of 4 years, HF recurred and worsened in 66.6% and 41.2% of pts by ≥ 1 and ≥ 2 NYHA classes, respectively. HF progression by even 1 NYHA class increased the mortality risk in HFpEF (hazard ratio (HR) 2.06; 95% confidence intervals (CI) 1.25-3.4; p = 0.004) and HFrEF (HR 1.9; 95% CI 0.99-3.66; p = 0.054). Cardiovascular hospitalization (CVH) increased in HFpEF (HR 3.67; 95% CI 2.56, 5.25; p < 0.0001) and HFrEF (HR 2.8; 95% CI 1.53-5.14; p = 0.0009). HF progression by 2 or more NYHA classes or death was significantly worse in pts with HFrEF with the Rate control strategy compared with the Rhythm control (HR 1.62; 95% CI 1.03-2.53; p = 0.036) but similar in pts with HFpEF (HR 0.88; 95% CI 0.64-1.21; p = 0.440).The time to first AF recurrence was longer in the Rhythm arms of both HF subgroups as compared with Rate (Figure, p < 0.05).

conclusions(1) HF progression in AF pts with a prior HF event confers significant mortality and CVH risk in both HFrEF and HFpEF populations. (2) HF progression is more pronounced with a Rate control strategy in AF pts with HFrEF, but is comparable to Rhythm control in AF pts with HFpEF. (3) A Rhythm control strategy may be desirable to reduce HF progression in pts with HFrEF and AF. Prospective clinical trials appear warranted to examine HF progression by treatment strategy in HFpEF and HFrEF populations with AF.