New-onset atrial fibrillation predicts heart failure progression

Symptoms Burden as a Clinical Outcomes Assessment in Heart Failure Patients With Atrial Fibrillation

BACKGROUND

Safe and effective pharmacologic therapy for atrial fibrillation (AF) in heart failure (HF) is an unmet need. In AF clinical trials, the standard primary endpoint of time to first symptomatic AF event (TTFSE) has several disadvantages, which could theoretically be overcome by measurement of AF-specific symptoms burden during an entire follow-up period.

OBJECTIVES

The authors sought to develop and validate a method of measuring symptom burden of AF in a HF population.

METHODS

The authors constructed a patient-reported outcome instrument (AFSQ [Atrial Fibrillation Symptoms Questionnaire]) to function in the setting of AF/HF, and used it to measure symptoms throughout long-term follow-up. The AFSQ queries the presence of 10 new or worsening symptoms, equally divided between those associated with AF or HF. In a 267 patient AF/HF trial comparing 2 AF prevention treatments, the AFSQ was linked to electrocardiography documented AF to form a 2-component clinical outcome assessment (SxBAF) that was subjected to psychometric testing, anchor validation, and endpoint efficiency comparison to TTFSE.

RESULTS

SxBAF exhibited greater efficiency than time to first symptomatic event for treatment difference detection, resulting in smaller projected clinical trial sample sizes. SxBAF correlated well with device-detected AF burden (Spearman's ρ = 0.74; P < 0.0001), while permitting gradation in symptom severity. SxBAF also identified treatment group differences in cardiovascular serious adverse events and AF interventions and in recent-onset AF provided specificity for AF- or worsening HF-associated symptoms (P < 0.001 for each).

CONCLUSIONS

Measurement of symptoms burden throughout clinical trial follow-up is feasible in AF/HF and should be useful for evaluating patient-centered outcomes in AF prevention trials. (Genetically Targeted Therapy for the Prevention of Symptomatic Atrial Fibrillation in Patients With Heart Failure [GENETIC-AF]; NCT01970501).

Heart failure in older patients with atrial fibrillation: incidence and risk factors

INTRODUCTION AND OBJECTIVES

Atrial fibrillation (AF) is linked to heart failure (HF). However, little has been published on the factors that may precipitate the onset of HF in AF patients. We aimed to determine the incidence, predictors, and prognosis of incident HF in older patients with AF with no prior history of HF.

METHODS

Patients with AF older than 80 years and without prior HF were identified between 2014 and 2018.

RESULTS

A total of 5794 patients (mean age, 85.2±3.8 years; 63.2% women) were followed up for 3.7 years. Incident HF, predominantly with preserved left ventricular ejection fraction, developed in 33.3% (incidence rate, 11.5-100 people-year). Multivariate analysis identified 11 clinical risk factors for incident HF, irrespective of HF subtype: significant valvular heart disease (HR, 1.99; 95%CI, 1.73-2.28), reduced baseline left ventricular ejection fraction (HR, 1.92; 95%CI, 1.68-2.19), chronic pulmonary obstructive disease (HR, 1.59; 95%CI, 1.40-1.82), enlarged left atrium (HR 1.47, 95%CI 1.33-1.62), renal dysfunction (HR 1.36, 95%CI 1.24-1.49), malnutrition (HR, 1.33; 95%CI, 1.21-1.46), anemia (HR, 1.30; 95%CI, 1.17-1.44), permanent AF (HR, 1.15; 95%CI, 1.03-1.28), diabetes mellitus (HR, 1.13; 95%CI, 1.01-1.27), age per year (HR, 1.04; 95%CI, 1.02-1.05), and high body mass index for each kg/m2 (HR, 1.03; 95%CI, 1.02-1.04). The presence of incident HF nearly doubled the mortality risk (HR, 1.67; 95%CI, 1.53-1.81).

CONCLUSIONS

The presence of HF in this cohort was relatively frequent and nearly doubled the mortality risk. Eleven risk factors for HF were identified, expanding the scope for primary prevention among elderly patients with AF.

Association of RDW, NLR, and PLR with Atrial Fibrillation in Critical Care Patients: A Retrospective Study Based on Propensity Score Matching

Objective

Previous studies have shown inconsistent results in relation to the red cell distribution width (RDW), neutrophil to lymphocyte ratio (NLR), and platelet to lymphocyte ratio (PLR) of atrial fibrillation (AF). This retrospective study is aimed at detecting the association of RDW, NLR, and PLR with AF.

Methods

A total of 4717 critical care patients were screened from the Medical Information Mart for Intensive Care- (MIMIC-) III database. The patients were separated into the non-AF and AF groups. The imbalances between the groups were reduced using propensity score matching (PSM). ROC curves were generated to detect the diagnostic value of RDW, NLR, and PLR. Logistic regression analysis was used to detect the risk factors for AF.

Results

A total of 991 non-AF patients paired with 991 AF patients were included after PSM in this study. The RDW level in the AF group was significantly higher than that in the non-AF group (15.09 ± 1.93vs. 14.89 ± 1.91, P = 0.017). Neither NLR nor PLR showed any significant difference between the two groups (P > 0.05 for each). According to ROC curve, RDW showed a very low diagnostic value of AF (AUC = 0.5341), and the best cutoff of RDW was 14.1 (ACU = 0.5257, sensitivity = 0.658, specificity = 0.395). Logistic regression analysis showed that an elevated RDW level increased 1.308-fold (95%CI = 1.077-1.588, P = 0.007) risk of AF. Neither elevated NLR nor elevated PLR was a significant risk factor for AF (OR = 0.993, 95%CI = 0.802-1.228, P = 0.945 for NLR; OR = 0.945, 95%CI = 0.763-1.170, P = 0.603 for PLR).

Conclusions

Elevated RDW level but not NLR or PLR levels is associated with AF. RDW > 14.1 is a risk factor for AF, but its diagnostic capacity for AF is not of great value.

Life-Years Lost After Newly Diagnosed Atrial Fibrillation in Patients with Heart Failure

Objective

Prior work estimated excess death rates associated with atrial fibrillation (AF) in heart failure (HF) with hazard ratios (HR). The aim was to estimate the life-years lost after newly diagnosed AF in HF patients.

Methods

Among patients diagnosed with HF in 2008–2018 in the nationwide Danish Heart Failure Registry, we compared patients with incident AF to referents matched on age, sex, and time since HF. We estimated the marginal hazard ratio (HR) for death and marginal difference in restricted mean survival times (RMST) between AF cases and referents at 10 years after AF diagnosis. We adjusted for sex, age at AF diagnosis, clinical and lifestyle risk factors, and medications.

Results

Among 4463 AF cases and 17,792 referents (mean age 73.7 years, 29% women), the HR was 1.41 (95% CI 1.38; 1.44) but there was evidence of non-proportional hazards. The difference in RMST was −18.2 months (95% CI −16.8; −19.6) at 10 years after AF diagnosis. There were differences in life-years lost between patients diagnosed with AF >1 year and ≤1 year after HF (−25.7 months, 95% CI −23.7; −27.7 vs −10.4 months, 95% CI −8.2; −12.5, p < 0.001), women and men (−20.3 months, 95% CI −17.7; −21.9 vs −17.2 months, 95% CI −15.5; −19.0, p = 0.05), patients with low, medium, and high CHA₂DS₂-VASc (10.3 months, 95% CI −4.6; −16.1 vs −18.5 months, 95% CI −16.7; −20.4 vs 22.1, 95% CI −18.8; −22.3, p = 0.002).

Conclusion

HF patients with incident AF lost on average 1.5 life-years over 10 years after AF. Life-years lost were larger among patients diagnosed with AF >1 year after HF, women, and patients with higher CHA₂DS₂-VASc.

Temporal Association of Atrial Fibrillation With Cardiac Implanted Electronic Device Detected Heart Failure Status

OBJECTIVES

This study sought to investigate the temporal association between changes in physiologic heart failure (HF) sensors, atrial fibrillation (AF) progression, and clinical HF in patients with cardiac resynchronization therapy implantable defibrillators (CRT-D) designed to monitor AF and HF daily.

BACKGROUND

AF is a common comorbidity in HF; however, it is unclear if HF triggers AF, or vice-versa. Current implantable cardiac devices have sensors capable of quantifying HF status, which permits a greater understanding of the impact of AF on HF status and may help guide treatment.

METHODS

The MultiSENSE (Multisensor Chronic Evaluation in Ambulatory Heart Failure Patients) study collected multiple sensor data indicative of HF status in patients with CRT-D followed for up to 12 months. Patients were grouped according to their longest daily AF burden: 1) at least 24 hours of AF (HIGH AF); 2) between 6 minutes and 24 hours (MID AF); and 3) <6 minutes (NO AF). Sensor data were aligned to the first qualifying AF event or a randomly selected day for patients in the NO AF group.

RESULTS

Among 869 patients with daily AF data available, 98 patients had HIGH AF, 141 patients MID AF, and 630 patients NO AF. At baseline, history of AF, N-terminal pro hormone B-type natriuretic peptide and device-measured S3 were associated with development of AF. HeartLogic index increased before AF onset (Δ HeartLogic = 9.83 ± 2.49; P < 0.001). Multivariable time-dependent Cox regression showed an increased risk for HF events following a 24-hour AF episode compared with no 24-hour AF (hazard ratio: 1.96; 95% confidence interval: 1.03-3.74).

CONCLUSIONS

Device-measured HF indicators worsened before AF onset, whereas clinical HF deterioration only became apparent after AF occurred. Thus, the sensitivity of methods to ascertain AF and HF status appear to influence the direction of perceived causality. (Multisensor Chronic Evaluation in Ambulatory Heart Failure Patients [MultiSENSE]; NCT01128166).

Newly diagnosed atrial fibrillation and hospital utilization in heart failure: a nationwide cohort study

Aims

Atrial fibrillation (AF) constitutes a major burden to health services, but the importance of incident AF in patients with heart failure (HF) is unclear. We examined the associations between incident AF and hospital utilization in patients with HF.

Methods and results

In a nationwide matched‐cohort study of HF patients, we identified patients diagnosed with incident AF between 2008 and 2018 in the Danish Heart Failure Registry (N = 4463), and we compared them to matched referents without AF (N = 17 802). Incident AF was associated with a multivariable‐adjusted 4.8‐fold increase (95% CI 4.1–5.6) and 4.3‐fold increase (95% CI 3.9–4.8) in the cumulative incidence of inpatient and outpatient contacts within 30 days, respectively. At 1 year, the cumulative incidence ratios were 1.8 (95% CI 1.7–1.9) and 1.4 (95% CI 1.4–1.5). Incident AF was also associated with increases in the total numbers of inpatient and outpatient hospital contacts within 30 days (multivariable‐adjusted rate ratio 1.4, 95% CI 1.4–1.5, and 1.6, 95% CI 1.6–1.7, respectively). At 1 year, the ratios were 2.2 (95% CI 2.1–2.3) and 2.0 (95% CI 1.9–2.1). The multivariable‐adjusted proportion of bed‐day use among HF patients with incident AF was 10.9‐fold (95% CI 9.3–12.9) higher at 30 days and 5.3‐fold (95% CI 4.3–6.4) higher at 1 year compared with AF‐free referents.

Conclusions

Incident AF in HF is associated with earlier hospital contact, more hospital contacts, and more hospital bed‐days. More evidence on interventions that may prevent the risk and subsequent burden of AF in HF is urgently needed.

Atrial fibrillation in the elderly population: Challenges and management considerations

IMPORTANCE

Atrial fibrillation is the most clinically significant arrhythmia in humans when viewed both from a global and also a national perspective. In the United States, approximately 2.7-6.1 million people are estimated to have atrial fibrillation. With the aging of the population, this prevalence is on an increasing trend and remains an obstacle to cardiovascular health despite significant advancements specific to cardiovascular disease management.

OBSERVATION

In this specific group of patients, healthcare utilization is a concern from the public health perspective. Unfortunately, misconceptions dominate clinical decision making; for instance, the avoidance of safe and effective anticoagulation strategies in patients at the highest risk for embolic strokes continues to be widespread in clinical practice and is often based on a skewed assessment of risk versus benefit. Also, when there are contraindications to standard interventions for atrial fibrillation, a clear and nuanced understanding of second- and third-line interventions with proven benefit is often lacking.

CONCLUSIONS AND RELEVANCE

An individualized approach should be followed by physicians when managing atrial fibrillation in the elderly patient, taking into consideration the risk of complications, particularly the embolic stroke and the availability of treatment options for stroke prevention whether through pharmacological anticoagulation or left atrial appendage occluding devices. The following review sets out to clarify these issues.

Cost-Utility of Catheter Ablation for Atrial Fibrillation in Patients with Heart Failure: An Economic Evaluation

Background Recent trials comparing catheter ablation to medical therapy in patients with heart failure (HF) with symptomatic atrial fibrillation despite first-line management have demonstrated a reduction in adverse outcomes. We performed an economic evaluation to estimate the cost-utility of catheter ablation as second line therapy in patients with HF with reduced ejection fraction. Methods and Results A Markov model with health states of alive, dead, and alive with amiodarone toxicity was constructed, using the perspective of the Canadian healthcare payer. Patients in the alive states were at risk of HF and non-HF hospitalizations. Parameters were obtained from randomized trials and Alberta health system data for costs and outcomes. A lifetime time horizon was adopted, with discounting at 3.0% annually. Probabilistic and 1-way sensitivity analyses were performed. Costs are reported in 2018 Canadian dollars. A patient treated with catheter ablation experienced lifetime costs of $64 960 and 5.63 quality-adjusted life-years (QALY), compared with $49 865 and 5.18 QALYs for medical treatment. The incremental cost-effectiveness ratio was $35 360/QALY (95% CI, $21 518-77 419), with a 90% chance of being cost-effective at a willingness-to-pay threshold of $50 000/QALY. A minimum mortality reduction of 28%, or a minimum duration of benefit of >1 to 2 years was required for catheter ablation to be attractive at this threshold. Conclusions Catheter ablation is likely to be cost-effective as a second line intervention for patients with HF with symptomatic atrial fibrillation, with incremental cost-effectiveness ratio $35 360/QALY, as long as over half of the relative mortality benefit observed in extant trials is borne out in future studies.

Comorbidities Associated with One-Year Mortality in Patients with Atrial Fibrillation and Heart Failure

BACKGROUND

Heart failure (HF) and atrial fibrillation (AF) commonly coexist and patients with both diseases have a worse prognosis than those with HF or AF alone. The objective of our study was to identify the factors associated with one-year mortality in patients with HF and AF, depending on the left ventricular ejection fraction (LVEF).

METHODS

We included 727 patients with HF and AF consecutively admitted in a clinical emergency hospital between January 2018 and December 2019. The inclusion criteria were age of more than 18 years, diagnosis of chronic HF and AF (paroxysmal, persistent, permanent), and signed informed consent. The exclusion criteria were the absence of echocardiographic data, a suboptimal ultrasound view, and other cardiac rhythms than AF. The patients were divided into 3 groups: group 1 (337 patients with AF and HF with reduced ejection fraction (HFrEF)), group 2 (112 patients with AF and HF with mid-range ejection fraction (HFmrEF)), and group 3 (278 patients with AF and HF with preserved ejection fraction (HFpEF)).

RESULTS

The one-year mortality rates were 36.49% in group 1, 27.67% in group 2, and 27.69% in group 3. The factors that increased one-year mortality were chronic kidney disease (OR 2.35, 95% CI 1.45-3.83), coronary artery disease (OR 1.67, 95% CI 1.06-2.62), and diabetes (OR 1.66, 95% CI 1.05-2.67) in patients with HFrEF; and hypertension in patients with HFpEF (OR 2.45, 95% CI 1.36-4.39).

CONCLUSIONS

One-year mortality in patients with HF and AF is influenced by different factors, depending on the LVEF.

Effects of Atrial Fibrillation on Heart Failure Outcomes and NT-proBNP Levels in the GUIDE-IT Trial

Objective

To evaluate effects of atrial fibrillation (AF) on cardiac biomarkers and outcomes in a trial population of patients with heart failure (HF) with reduced ejection fraction treated with optimal guideline-directed medical therapy.

Methods

We performed a secondary analysis of 894 patients in the Guiding Evidence-Based Therapy Using Biomarker-Intensified Treatment in Heart Failure (GUIDE-IT) trial (January 2013–July 2016). Patients were stratified by AF status and compared with regard to guideline-directed medical therapy use, longitudinal levels of N-terminal pro–B type natriuretic peptide (NT-proBNP), and outcomes including HF hospitalization and mortality.

Results

After adjustment, AF was associated with a significant increase in the risk of HF hospitalization or cardiovascular death (hazard ratio, 1.28; 95% CI, 1.02 to 1.61; P=0.04) and HF hospitalization (hazard ratio, 1.31; 95% CI, 1.02 to 1.68; P=.03) but with no difference in mortality during a median 15 months of follow-up. There were no significant differences in medication treatment between those with and those without AF. At 90 days, a higher proportion of patients with AF (89.4% vs 81.5%; P=.002) had an NT-proBNP level above 1000 pg/mL (to convert NT-proBNP values to pmol/L, multiply by 0.1182), and AF patients had higher NT-proBNP levels at all time points through 2 years of follow-up.

Conclusion

Among patients with HF with reduced ejection fraction, prevalent AF was associated with higher NT-proBNP concentrations through 2 years of follow-up and higher risk for HF hospitalization despite no substantial differences in medical therapy.

Impact of the Temporal Relationship Between Atrial Fibrillation and Heart Failure on Prognosis After Ablation

BACKGROUND

The purpose of this study was to elucidate the effect of the temporal relationship between atrial fibrillation (AF) and heart failure (HF) on clinical outcomes after catheter ablation.

METHODS AND RESULTS

We included 129 consecutive patients with AF and HF who underwent catheter ablation in hospital from December 2014 to September 2017. The patients were divided into 2 groups based on the temporal relationship between AF and HF. Group 1 consisted of 42 patients with AF following HF while Group 2 consisted of 87 patients with AF preceding HF or those who developed both of them simultaneously at the timing of first visit to a doctor. The primary endpoint was a composite of death and hospitalization due to HF during a 2-year follow-up. AF recurrence was more common in Group 1 (45% vs. 23%; hazard ratio [HR], 2.49; 95% confidence interval [CI], 1.25-4.94; P=0.009). Death and HF hospitalization were more frequent in Group 1 (19 [45%], 6 [7%] patients, respectively, P<0.0001). After adjustment for several covariates, patients in Group 1 were independently associated with poorer outcomes after AF ablation (HR, 8.66; 95% CI, 2.942-5.5; P<0.0001).

CONCLUSIONS

Adverse clinical outcomes of death, HF hospitalization and AF recurrence were more frequent in patients with AF following HF than in those with AF preceding HF.

Heart Failure in Atrial Fibrillation - An Update on Clinical and Echocardiographic Implications

Atrial fibrillation (AF) is the most common sustained arrhythmia in adults and has unfavorable consequences such as stroke, heart failure (HF), and death. HF is the most common adverse event following AF and the leading cause of death. Therefore, identifying the association between AF and HF is important to establish risk stratification for HF in AF. Recent studies suggested that left atrial and ventricular fibrosis is an important link between AF and HF, and the prognostic impact may differ with respect to HF subtype, stratified with left ventricular ejection fraction (EF). Mortality risk in patients with concurrent AF and HF with reduced EF (HFrEF) appears slightly higher compared with those with concurrent AF and HF with preserved EF (HFpEF). On the other hand, the prognostic impact of HF in AF is similar between HFrEF and HFpEF. Further, left atrial size, as well as left atrial and left ventricular functional assessment, are reported to be useful for the prediction of HF in AF, incremental to the conventional risk factors. In this review, we focus on the epidemiological, pathophysiological, and prognostic associations between AF and HF, and review the clinical and echocardiographic predictors for HF in AF.

Atrial fibrillation in acute heart failure: A position statement from the Acute Cardiovascular Care Association and European Heart Rhythm Association of the European Society of Cardiology

Atrial fibrillation and acute heart failure frequently co-exist and can exacerbate each other. Their combination leads to increased morbidity and mortality. However, the prevalence and significance, as well as the treatment, of atrial fibrillation in acute heart failure are not well studied. Management of atrial fibrillation in acute heart failure requires a multidisciplinary team approach. Treatment of underlying disease(s), identification and treatment of potentially correctable causes and precipitating factors and anticoagulation are crucial. In this article, current evidence on atrial fibrillation in the setting of acute heart failure is summarised. The recommendations on management of atrial fibrillation in the prehospital stage, the treatment of reversible causes, when and how to use rate or rhythm control, maintenance of sinus rhythm, catheter ablation and pacing, anticoagulation, as well as measures on prevention of atrial fibrillation are provided.

A Nurse-led Approach to Improving Cardiac Lifestyle Modification in an Atrial Fibrillation Population

Atrial fibrillation (AF) is a major public health problem and the most common cardiac arrhythmia encountered in clinical practice at this time. AF is associated with numerous symptoms such as palpitations, shortness of breath, and fatigue, which can significantly reduce health-related quality of life and result in serious adverse cardiac outcomes. In light of this, the aim of the present pilot study was to test the feasibility of implementing a mobile health (mHealth) lifestyle intervention titled "Atrial Fibrillation and Cardiac Health: Targeting Improving Outcomes via a Nurse-Led Intervention (ACTION)," with the goal of improving cardiac health measures, AF symptom recognition, and self-management. As part of this study, participants self-identified cardiac health goals at enrollment. The nurse used web-based resources from the American Heart Association (Dallas, TX, USA), which included the Life's Simple 7® My Life Check® assessment, to quantify current lifestyle behavior change needs. Furthermore, on the My AFib Experience™ website (American Heart Association, Dallas, TX, USA), the patient used a symptom tracker tool to capture the date, time, frequency, and type of AF symptoms, and these data were subsequently reviewed by the cardiac nurse. Throughout the six-month intervention period, the cardiac nurse used a motivational interviewing approach to support participants' cardiac health goals. Ultimately, the ACTION intervention was tested in 53 individuals with AF (mean age: 59 ± 11 years; 76% male). Participants were predominantly overweight/obese (79%), had a history of hypertension (62%) or hyperlipidemia (61%), and reported being physically inactive/not preforming any type of regular exercise (52%). The majority (88%) of the participants had one or more Life's Simple 7® measures that could be improved. Most of the participants (98%) liked having a dedicated nurse to work with them on a biweekly basis via the mHealth portal. The most commonly self-reported symptoms were palpitations, fatigue/exercise intolerance, and dyspnea. Seventy percent of the participants had an improvement in their weight and blood pressure as documented within the electronic health record as well as a corresponding improvement in their Life's Simple 7® score at six months. On average, there was a three-pound (1.36-kg) decrease in weight and a 5-mmHg decrease in systolic blood pressure between baseline and at six months. In conclusion, this pilot work provides initial evidence regarding the feasibility of implementing the ACTION intervention and supports testing the ACTION intervention in a larger cohort of AF patients to inform existing AF guidelines and build an evidence base for reducing AF burden through lifestyle modification.

Bucindolol for the Maintenance of Sinus Rhythm in a Genotype-Defined HF Population: The GENETIC-AF Trial

OBJECTIVES

The purpose of this study was to compare the effectiveness of bucindolol with that of metoprolol succinate for the maintenance of sinus rhythm in a genetically defined heart failure (HF) population with atrial fibrillation (AF).

BACKGROUND

Bucindolol is a beta-blocker whose unique pharmacologic properties provide greater benefit in HF patients with reduced ejection fraction (HFrEF) who have the beta₁-adrenergic receptor (ADRB1) Arg389Arg genotype.

METHODS

A total of 267 HFrEF patients with a left ventricular ejection fraction (LVEF) <0.50, symptomatic AF, and the ADRB1 Arg389Arg genotype were randomized 1:1 to receive bucindolol or metoprolol therapy and were up-titrated to target doses. The primary endpoint of AF or atrial flutter (AFL) or all-cause mortality (ACM) was evaluated by electrocardiogram (ECG) during a 24-week period.

RESULTS

The hazard ratio (HR) for the primary endpoint was 1.01 (95% confidence interval [CI]: 0.71 to 1.42), but trends for bucindolol benefit were observed in several subgroups. Precision therapeutic phenotyping revealed that a differential response to bucindolol was associated with the interval of time from the initial diagnoses of AF and HF to randomization and with the onset of AF relative to that of the initial HF diagnosis. In a cohort whose first AF and HF diagnoses were <12 years prior to randomization, in which AF onset did not precede HF by more than 2 years (n = 196), the HR was 0.54 (95% CI: 0.33 to 0.87; p = 0.011).

CONCLUSIONS

Pharmacogenetically guided bucindolol therapy did not reduce the recurrence of AF/AFL or ACM compared to that of metoprolol therapy in HFrEF patients, but populations were identified who merited further investigation in future phase 3 trials.

The interplay between atrial fibrillation and heart failure on long-term mortality and length of stay: Insights from the, United Kingdom ACALM registry

BACKGROUND

There is concern that the development of heart failure and atrial fibrillation has a detrimental influence on clinical outcomes. The aim of this study was to assess all-cause mortality and length of hospital stay in patients with chronic and new-onset concomitant AF and HF.

METHODS

Using the ACALM registry, we analysed adults hospitalised between 2000 and 2013 with AF and HF and assessed prevalence, mortality and length of hospital stay. Patients with HF and/or AF at baseline (study-entry) were compared with patients who developed new-onset disease during follow-up.

RESULTS

Of 929,552 patients, 31,695 (3.4%) were in AF without HF, 20,768 (2.2%) had HF in sinus rhythm, and 10,992 (1.2%) had HF in AF. Patients with HF in AF had the greatest all-cause mortality (70.8%), followed by HF in sinus rhythm (64.1%) and AF alone (45.1%, p<0.0001). Patients that developed new-onset AF, HF or both had significantly worse mortality (58.5%, 70.7% and 74.8% respectively) compared to those already with the condition at baseline (48.5%, 63.7% and 67.2% respectively, p<0.0001). Patients with HF in AF had the longest length of hospital stay (9.41days, 95% CI 8.90-9.92), followed by HF in sinus rhythm (7.67, 95% CI 7.34-8.00) and AF alone (6.05, 95% CI 5.78-6.31).

CONCLUSIONS

Patients with HF in AF are at a greater risk of mortality and longer hospital stay compared to patients without the combination. New-onset AF or HF is associated with significantly worse prognosis than long-standing disease.

A genotype-directed comparative effectiveness trial of Bucindolol and metoprolol succinate for prevention of symptomatic atrial fibrillation/atrial flutter in patients with heart failure: Rationale and design of the GENETIC-AF trial

BACKGROUND

Few therapies are available for the safe and effective treatment of atrial fibrillation (AF) in patients with heart failure. Bucindolol is a non-selective beta-blocker with mild vasodilator activity previously found to have accentuated antiarrhythmic effects and increased efficacy for preventing heart failure events in patients homozygous for the major allele of the ADRB1 Arg389Gly polymorphism (ADRB1 Arg389Arg genotype). The safety and efficacy of bucindolol for the prevention of AF or atrial flutter (AFL) in these patients has not been proven in randomized trials.

METHODS/DESIGN

The Genotype-Directed Comparative Effectiveness Trial of Bucindolol and Metoprolol Succinate for Prevention of Symptomatic Atrial Fibrillation/Atrial Flutter in Patients with Heart Failure (GENETIC-AF) trial is a multicenter, randomized, double-blinded "seamless" phase 2B/3 trial of bucindolol hydrochloride versus metoprolol succinate, for the prevention of symptomatic AF/AFL in patients with reduced ejection fraction heart failure (HFrEF). Patients with pre-existing HFrEF and recent history of symptomatic AF are eligible for enrollment and genotype screening, and if they are ADRB1 Arg389Arg, eligible for randomization. A total of approximately 200 patients will comprise the phase 2B component and if pre-trial assumptions are met, 620 patients will be randomized at approximately 135 sites to form the Phase 3 population. The primary endpoint is the time to recurrence of symptomatic AF/AFL or mortality over a 24-week follow-up period, and the trial will continue until 330 primary endpoints have occurred.

CONCLUSIONS

GENETIC-AF is the first randomized trial of pharmacogenetic guided rhythm control, and will test the safety and efficacy of bucindolol compared with metoprolol succinate for the prevention of recurrent symptomatic AF/AFL in patients with HFrEF and an ADRB1 Arg389Arg genotype. (ClinicalTrials.govNCT01970501).

How to manage various arrhythmias and sudden cardiac death in the cardiovascular intensive care

In the clinical practice of cardiovascular critical care, we often observe a variety of arrhythmias in the patients either with (secondary) or without (idiopathic) underlying heart diseases. In this manuscript, the clinical background and management of various arrhythmias treated in the CCU/ICU will be reviewed. The mechanism and background of lethal ventricular tachyarrhythmias vary as time elapses after the onset of MI that should be carefully considered to select a most suitable therapy. In the category of non-ischemic cardiomyopathy, several diseases are known to be complicated by the various ventricular tachyarrhythmias with some specific mechanisms. According to the large-scale registry data, the most common arrhythmia is atrioventricular block. It is essential for the decision of permanent pacemaker indication to rule out the presence of transient causes such as ischemia and electrolyte abnormalities. The prevalence of atrial fibrillation (AF) is very high in the patients with heart failure (HF) and myocardial infarction (MI). AF and HF have a reciprocal causal relationship; thus, both are associated with the poor prognosis. Paroxysmal AF occurs in 5 to 20% during the acute phase of MI and triggered by several specific factors including pump failure, atrial ischemia, and autonomic instability. After the total management of patients with various arrhythmias and basic heart diseases, the risk of sudden cardiac death should be stratified for each patient to assess the individual need for preventive therapies. Finally, it is recommended that the modalities of the treatment and prophylaxis should be selected on a case-by-case basis in the scene of critical care.

Subclinical atrial fibrillation in patients with recent transient ischemic attack

BACKGROUND

Atrial fibrillation (AF) is a major risk factor of stroke, but the association between AF and transient ischemic attack (TIA) is less clear. Despite this, patients with TIA are included in stroke trials.

AIMS

To determine the 1-year incidence of AF in TIA patients using an insertable cardiac monitor (ICM); second, to determine factors associated with incident AF in these patients.

METHODS

Prospective cohort study of patients with TIA with normal standard electrocardiogram (ECG) and 72-hour Holter monitoring (HM). Exclusion criteria were as follows: age < 18 or > 81 years; prior AF/stroke; ongoing oral anticoagulation therapy or contraindication for it; significant carotid artery stenosis; uncertain TIA diagnosis. Eligible patients received an ICM and were followed for 12 months.

RESULTS

From November 2013 to October 2015, 809 patients were diagnosed with TIA. In total, 235 patients were eligible. Nine (3.8%) of these had AF on standard ECG or HM. Of the remaining patients, 121 refused ICM implantation. In total, 105 patients (median age 65.4 years [range 27.1-80.8], 46% males) received an ICM, which revealed AF in 7 (6.7%). Factors associated with new-onset AF were a history of recurrent TIA (odds ratio [OR] 11.5, 95% confidence interval [CI] 2.1-63.6) and heart failure (OR 12.7, 95% CI 1.71-96.83).

CONCLUSIONS

The 1-year incidence of AF in TIA patients with normal ECG and HM was 6.7% using an ICM. Factors associated with development of AF were recurrent TIA and heart failure.

Anticoagulation in atrial fibrillation and chronic heart failure: the risk and drug of choice

PURPOSE OF REVIEW

This review seeks to provide an evidence-based update on the issue of atrial fibrillation and chronic heart failure with an emphasis on anticoagulation and the expanding use of the novel oral anticoagulants (NOACs).

RECENT FINDINGS

There is an increasing appreciation of the important reciprocal relationship between atrial fibrillation and heart failure and the negative prognostic impact that each condition has on the other. There are now four NOACs approved for stroke prevention in atrial fibrillation. There are increasing data to support their use in atrial fibrillation with heart failure, including in patients with nonmechanical or rheumatic valvular disease, and to facilitate direct current cardioversion. The choice of NOAC is heavily dependent on individual patient characteristics.

SUMMARY

The use of and indications for NOACs for patients with heart failure and atrial fibrillation are rapidly increasing.

Peripheral arterial disease and atrial fibrillation and risk of stroke, heart failure hospitalization and cardiovascular death: A nationwide cohort study

BACKGROUND

Peripheral arterial disease (PAD) and atrial fibrillation (AF) share several comorbidities and contribute to similar cardiovascular (CV) outcomes. Only few studies have evaluated the correlation between PAD, AF, and their interaction effects on CV outcomes.

METHODS

We included 597,164 adults from Taiwan's National Health Insurance Research Database to conduct a cohort study to assess whether PAD was an independent risk factor of AF and vice versa. We also examined if PAD and AF increased the incident stroke, heart failure hospitalization and CV death.

RESULTS

People with PAD had a significant higher risk of incident AF than those without PAD [adjusted hazard ratio (HR): 1.29, 95% confidence interval (CI): 1.17-1.42]. Meanwhile, people with AF did not have an increased risk of incident PAD compared to those without AF (adjusted HR: 1.00, 95% CI: 0.89-1.11). Both AF and PAD increased the risk of stroke [adjusted HR being 1.29 (95% CI: 1.17-1.43) and 1.41 (95% CI: 1.35-1.47), respectively], heart failure hospitalization [adjusted HR being 1.96 (95% CI: 1.77-2.17) and 1.35 (95% CI: 1.28-1.42), respectively], and CV death [adjusted HR being 3.33 (95% CI: 2.58-4.30) and 2.08 (95% CI: 1.80-2.41), respectively]. However, we found no interaction effects of AF and PAD on these outcomes.

CONCLUSIONS

PAD is an independent risk factor of incident AF but not vice versa. Both PAD and AF are independent risk factors for stroke, heart failure hospitalization, and CV death.

The Stress-Response MAP Kinase Signaling in Cardiac Arrhythmias

Stress-response kinases, the mitogen-activated protein kinases (MAPKs) are activated in response to the challenge of a myriad of stressors. c-Jun N-terminal kinase (JNK), extracellular signal-regulated kinases (ERKs), and p38 MAPKs are the predominant members of the MAPK family in the heart. Extensive studies have revealed critical roles of activated MAPKs in the processes of cardiac injury and heart failure and many other cardiovascular diseases. Recently, emerging evidence suggests that MAPKs also promote the development of cardiac arrhythmias. Thus, understanding the functional impact of MAPKs in the heart could shed new light on the development of novel therapeutic approaches to improve cardiac function and prevent arrhythmia development in the patients. This review will summarize the recent findings on the role of MAPKs in cardiac remodeling and arrhythmia development and point to the critical need of future studies to further elucidate the fundamental mechanisms of MAPK activation and arrhythmia development in the heart.

Biological significance of miR-126 expression in atrial fibrillation and heart failure

We investigated the biological significance of microRNA-126 (miR-126) expression in patients with atrial fibrillation (AF) and/or heart failure (HF) to examine the possible mechanism of miR-126-dependent AF and development of HF. A total of 103 patients were divided into three groups: AF group (18 men and 17 women, mean age: 65.62±12.72 years), HF group (17 men and 15 women, mean age: 63.95±19.71 years), and HF-AF group (20 men and 16 women, mean age: 66.56±14.37 years). Quantitative real-time PCR was used to measure relative miR-126 expression as calculated by the 2-ΔΔCt method. miR-126 was frequently downregulated in the 3 patient groups compared with controls. This reduction was significantly lower in permanent and persistent AF patients than in those with paroxysmal AF (P<0.05, t-test). Moreover, miR-126 expression was markedly lower in the HF-AF group compared with the AF and HF groups. The 3 patient groups had higher N-terminal prohormone brain natriuretic peptide (NT-proBNP) levels, lower left ventricular ejection fraction (LVEF), larger left atrial diameter, and higher cardiothoracic ratio compared with controls. There were significant differences in NT-proBNP levels and LVEF among the AF, HF, and HF-AF groups. Pearson correlation analysis showed that relative miR-126 expression was positively associated with LVEF, logarithm of NT-proBNP, left atrial diameter, cardiothoracic ratio, and age in HF-AF patients. Multiple linear regression analysis showed that miR-126 expression was positively correlated with LVEF, but negatively correlated with the logarithm of NT-pro BNP and the cardiothoracic ratio (all P<0.05). Serum miR-126 levels could serve as a potential candidate biomarker for evaluating the severity of AF and HF. However, to confirm these results, future studies with a larger and diverse patient population are necessary.

[Update on therapy of chronic heart failure. Innovations and studies from last year]

Chronic heart failure is one of the most common chronic diseases worldwide with increasing prevalence and incidence. Due to the high morbidity and mortality a standardized and evidence-based therapy is crucial. The present review article gives an overview about the innovations in 2014 based on the current guidelines of the European Society of Cardiology. First, improvements in established medication regimens regarding beta blockers and mineralocorticoid receptor antagonists as well as treatment options for heart rate reduction will be explained. Second, new pharmacological developments, such as angiotensin receptor neprilysin inhibition will be discussed. Finally, new insights into common comorbidities of patients with chronic heart failure, such as atrial fibrillation and hyperkalemia will be presented.