Secondary prevention and outcomes in outpatients with coronary artery disease, atrial fibrillation or heart failure: a focus on disease overlap.

Objective: To assess secondary prevention and outcomes in patients with chronic coronary artery disease (CAD), atrial fibrillation (AF) and heart failure (HF), focusing on disease overlap. Methods: We analysed the data of 10 517 outpatients with a diagnosis of CAD, AF and/or HF included in a prospective cohort study. Follow-up (median 3.2 years) was achieved in 10 478 (99.6%) patients. Seven mutually exclusive patient groups were formed: CAD alone (n=4303), AF alone (n=2604), CAD+AF (n=700), HF alone (n=513), HF+CAD (n=728), HF+AF (n=1087) and HF+CAD+AF (n=582). Results: Patients with disease overlaps represented 29.4% of the total population. The level of secondary prevention was high in all subgroups and in accordance with European class I - level A guidelines. Among patients with CAD, 99% received an antithrombotic and 91% received a statin. Among patients with AF, 81.7% were treated with an anticoagulant if indicated. Among HF patients with left ventricular ejection fraction <40%, 90.9% received a renin-angiotensin system antagonist and 91% a beta-blocker. Three-year all cause/cardiovascular mortality rates were: 6.4%/2%, 9.7%/3.3%, 15.6%/6.7%, 19.2%/9.4%, 24.3%/13.6%, 28%/15.7% and 35.4%/24.8%, for patients with CAD alone, AF alone, CAD+AF, HF alone, HF+CAD, HF+AF and HF+CAD+AF, respectively. In all groups with HF, observed all-cause mortality was higher (p<0.0001) than expected mortality for age-matched, gender-matched and geography-matched persons. In contrast, observed mortality was lower than expected for patients with CAD alone and AF alone (p<0.0001). Conclusions: In a context of adequate secondary prevention, overlap between diseases is a frequent and high-risk situation with incremental increases in mortality. These patients deserve specific attention.