Prevalence and Prognostic Implication of Atrial Fibrillation in Heart Failure Subtypes: Systematic Review and Meta-Analysis

Integrating pre-ablation and post-ablation B-type natriuretic peptide to identify high-risk population for long-term adverse events and arrhythmic recurrence in persistent atrial fibrillation

BACKGROUND

Pre-procedural and post-procedural plasma B-type natriuretic peptide (BNP) levels can predict rhythm outcomes after catheter ablation for atrial fibrillation (AF). However, the significance of long-term events remains unclear. Therefore, this study aimed to investigate the significance of integrating pre-ablation and post-ablation BNP levels on major adverse cardiovascular events (MACE) and arrhythmic recurrence in patients with persistent AF undergoing catheter ablation.

METHODS

We analysed 392 patients who underwent first catheter ablation. Patients were stratified into four subgroups based on pre-ablation plasma BNP level and its relative change after ablation (ΔBNP) using their respective median values (pre-ablation BNP: 148.0 pg/mL, ΔBNP: -52.6%): Low-Low (pre-ablation<148.0 pg/mL, ΔBNP<-52.6%), Low-High (pre-ablation<148.0 pg/mL, ΔBNP≥-52.6%), High-Low (pre-ablation≥148.0 pg/mL, ΔBNP<-52.6%) and High-High (pre-ablation≥148.0 pg/mL, ΔBNP≥-52.6%). The primary endpoint was MACE, which included all-cause death, heart failure hospitalisation and other cardiovascular hospitalisations. The secondary endpoint involved arrhythmic recurrence.

RESULTS

Of the 392 patients, 101 were classified as Low-Low, 91 as Low-High, 97 as High-Low and 103 as High-High. During a median follow-up of 5.3 (IQR: 3.2-7.2) years, 63 patients (16%) experienced MACE. Heart failure hospitalisation accounted for the majority of events (63%). The High-High subgroup showed significantly higher MACE rates than others (cumulative incidence (95% CI): 26.3% (16.2% to 35.2%), p<0.001). Low-High and High-High subgroups demonstrated a higher arrhythmic recurrence (p<0.001). After multivariate adjustment, the High-Low and High-High subgroups demonstrated progressively higher risks of MACE incidence compared with the Low-Low and Low-High subgroups. Both Low-High and High-High subgroups showed an elevated arrhythmic recurrence risk (both p<0.001).

CONCLUSIONS

Integrating pre-ablation and post-ablation BNP levels can be useful for identifying patients with persistent AF at high risk of MACE and arrhythmic recurrence during long-term follow-up.

Atrial Fibrillation Recurrence Post-Ablation Across Heart Failure Categories: A Systematic Review and Meta-analysis

Background

Previous studies have provided evidence of reduced recurrence of atrial fibrillation (AF), all-cause mortality, and heart failure (HF) hospitalizations after catheter ablation (CA) in both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). Aggregate data comparing the efficacy of AF ablation and clinical endpoints in HF with mildly reduced ejection fraction (HFmrEF) to HFrEF and HFpEF are lacking.

Methods

We conducted a systematic review and meta-analysis aimed at determining any differences in AF recurrence rate, all-cause mortality, and HF hospitalizations among patients with HFrEF, HFmrEF, and HFpEF who underwent AF ablation. A systematic search of PubMed/MEDLINE, Embase, and Cochrane Library databases was performed until October 31, 2023.

Results

A total of seven studies comprising 3,795 patients were retained: HFrEF 1,281 (33.8%), HFmrEF 870 (22.9%), and HFpEF 1,644 (43.3%). After median follow-up of 24 months, there was no significant difference in rate of AF recurrence between the three HF categories: HFrEF 40% (30-49%), HFmrEF 35% (28-43%); and HFpEF 35% (25-45%). Only two studies which included outcomes in the three HF categories were identified. Pooled hazard ratio (HR) of all-cause mortality and HF hospitalization combined after ablation or other rhythm control compared to other conservative management were: HFrEF 0.77 (0.63 - 0.94); HFmrEF 0.81 (0.55 - 1.20); and HFpEF 0.74 (0.55 - 1.00).

Conclusions

CA has similar efficacy in the long-term resolution of AF among patients with HFrEF, HFmrEF, and HFpEF. Further studies are needed to provide a robust analysis on the potential impact of CA on all-cause mortality.

Clinical outcomes of patients with heart failure and atrial fibrillation: Experience from an outpatient heart failure clinic in Colombia

BACKGROUND

Heart failure (HF) can coexist with atrial fibrillation in up to 60 % of cases, increasing rates of hospitalizations and death. This study analyzed the clinical characteristics, treatment, hospitalization, and mortality of patients with HF and atrial fibrillation based on left ventricular ejection fraction (LVEF).

METHODS

A retrospective cohort study included patients from an outpatient HF clinic at Medellín (Colombia) between 2020-2022. Patients were classified into two groups according to LVEF: reduced (LVEF≤40 %) and mildly reduced or preserved ejection fraction (LVEF>40 %). The evaluated outcomes were hospitalization and mortality during follow-up. Values for B-type natriuretic peptide (BNP), LVEF and functional class according to the New York Heart Association (NYHA) were also analyzed at admission and during the last follow-up visit.

RESULTS

The study included 185 patients, with 51.9% being male. The median age of the participants was 80 years (interquartile range [IQR] 74 - 86). There was an overall improvement in the NYHA functional class, BNP levels, and LVEF compared with the baseline values, irrespective of left systolic function. Atrial fibrillation ablation was performed in 3.2 % of patients, and cardiac device implantation with atrioventricular node ablation in 29 %. No statistically significant differences were found in terms of hospitalization and mortality regarding left systolic function.

CONCLUSION

Compressive optimal treatment for patients with HF and atrial fibrillation requires pharmacological treatment, ablation strategies, cardiac devices, cardiovascular rehabilitation and close follow-up. In this cohort, hospitalization and mortality rates were similar according to LVEF categories and there was improvement in NYHA functional class and BNP level.

All-Cause Mortality of Atrial Fibrillation and Heart Failure in the Same Patient: Does the Order Matter?

INTRODUCTION

Atrial fibrillation (AF) and heart failure (HF) often coexist due to the common elements of the pathomechanism they share. The potential significance of the order these entities present in the same patient is ill-defined. Herein, we report our results from a nationwide database on the occurrence of various sequences AF and HF may present, the time delays between the two conditions and all-cause mortality associated with different scenarios.

METHODS

Patients diagnosed with both AF and HF between 2015 and 2021 were enrolled from the Hungarian National Health Insurance Fund (NHIF) database. The order the two entities followed each other, and the time delay in between were registered. Median survival rates were calculated in AF → HF; HF → AF and simultaneous scenarios.

RESULTS

A total of 109,075 patients were enrolled: 29,937 with AF → HF, 38,171 with HF → AF, and 40,967 diagnosed simultaneously. Time delays between AF → HF and HF → AF were 6 and 10 months, respectively. The median survival was 46 months in the AF → HF, 38 months in the HF → AF, and 21 months in the simultaneous group. Patients with HF → AF, and with simultaneous presentations had 5% and 16% greater mortality risk as compared to the AF → HF sequence, with hazard ratios (95% confidence intervals) of 0.95 (0.93-0.97) and 0.84 (0.82-0.85), respectively (P < 0.0001).

CONCLUSIONS

HF occurred significantly earlier after the diagnosis of AF than vice versa. Patients diagnosed simultaneously had the worst, while the AF → HF sequence had the best prognosis. These data should have implications for the intensification of monitoring and therapy in different scenarios.

Conventional and Novel Inflammatory Biomarkers in Chronic Heart Failure Patients with Atrial Fibrillation

(1) Background and Objectives: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased morbidity and mortality both in the general population and heart failure patients. Inflammation may promote the initiation, maintenance and perpetuation of AF, but the impact of inflammatory molecular signaling on the association between AF and heart failure remains elusive. (2) Materials and Methods: In 111 patients with chronic stable heart failure, baseline values of conventional (IL-6 and hsCRP) and selected novel inflammatory biomarkers (IL-10, IL-6/IL-10 ratio, orosomucoid and endocan) were determined. Inflammatory biomarkers were compared with respect to the presenting cardiac rhythm. (3) Results: Patients aged below 75 years with AF had significantly higher values of IL-6 and IL-6/IL-10 ratio; IL-6 levels were a significant predictor of AF in both univariate (OR 1.175; 95%CI 1.013-1.363; p = 0.034) and multivariate logistic regression analysis when accounting for other inflammatory biomarkers (OR 1.327; 95% CI 1.068-1.650; p = 0.011). Conversely, there was no association between other novel inflammatory biomarkers and AF. (4) Conclusions: IL-6 levels and the IL-6/IL-10 ratio are associated with AF in patients with chronic stable heart failure under the age of 75 years, suggesting that inflammatory molecular signaling may play a role in the development of AF in the heart failure population.

Atrial fibrillation type and long-term clinical outcomes in hospitalized patients with heart failure: insight from JROADHF

AIMS

Atrial fibrillation (AF) type (paroxysmal, persistent, or permanent) is important in determining therapeutic management; however, clinical outcomes by AF type are largely unknown for hospitalized patients with heart failure (HF).

METHODS AND RESULTS

The Japanese Registry Of Acute Decompensated Heart Failure is a retrospective, multicenter, and nationwide registry of patients hospitalized for acute HF in Japan. Follow-up data were collected up to 5 years after hospitalization. Patients were divided based on diagnosis and AF type into 3 groups [without AF, paroxysmal AF, and sustained AF (defined as a composite of persistent and permanent AF)], and compared the backgrounds and outcomes between the groups. Of 12 895 hospitalized HF patients [mean age: 78 ± 13 years, female: 6077 (47%), and mean left ventricular ejection fraction: 47 ± 17%], 1725 had paroxysmal AF, and 3672 had sustained AF. Compared with patients without AF, sustained AF had a higher risk of the primary composite endpoint of cardiovascular (CV) death or HF hospitalization [hazard ratio (HR): 1.09, 95% confidence interval (CI): 1.01-1.17; P = 0.03], mainly driven by HF hospitalization [HR: 1.16, 95% CI: 1.06-1.26; P < 0.001], whereas the corresponding risk for the primary endpoint in patients with paroxysmal AF was not elevated (HR: 1.03, 95% CI: 0.94-1.13; P = 0.53) after adjustment by multivariable Cox regression analysis. These results were consistent among the subgroups of patients with reduced or preserved ejection fraction (interaction P = 0.74).

CONCLUSION

Among hospitalized patients with HF, sustained AF, but not paroxysmal AF, was significantly associated with a higher risk for CV death or HF hospitalization, indicating the importance of accounting for AF type in HF patients.

Heart Failure-Related Death in Subjects With Atrial Fibrillation in the United States, 1999 to 2020

BACKGROUND

Population-based data on heart failure (HF)-related death in patients with atrial fibrillation (AF) are lacking. We assessed HF-related death in people with AF in the United States over the past 21 years and examined differences by age, sex, race, ethnicity, urbanization, and census region.

METHODS AND RESULTS

Data were extracted from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research to determine trends in age-adjusted mortality rates per 100 000 people, due to HF-related death among subjects with AF aged ≥15 years. To calculate nationwide annual trends, we assessed the average annual percent change (AAPC) and annual percent change with relative 95% CIs using joinpoint regression. Between 1999 and 2020, 916 685 HF-related deaths (396 205 men and 520 480 women) occurred among US adults having a concomitant AF. The overall age-adjusted mortality rates increased (AAPC: +4.1% [95% CI, 3.8-4.4]; P<0.001), especially after 2011 (annual percent change, +6.8% [95% CI, 6.2-7.4]; P<0.001) in men (AAPC, +4.8% [95% CI, 4.4-5.1]; P<0.001), in White subjects (AAPC: +4.2% [95% CI, 3.9 to 4.6]; P<0.001) and in subjects aged <65 years (AAPC: +7.5% [95% CI, 6.7-8.4]; P<0.001). The higher percentage of deaths were registered in the South (32.8%). During the first year of the COVID-19 pandemic, a significant excess in HF-related deaths among patients with AF aged >65 years was observed.

CONCLUSIONS

A worrying increase in the HF-related mortality rate among patients with AF has been observed in the United States over the past 2 decades.

SEA 2024 Standards for Global Control of Vascular Risk

One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to the knowledge, prevention and treatment of vascular diseases, which are the leading cause of death in Spain and entail a high degree of disability and health expenditure. Atherosclerosis is a multifactorial disease and its prevention requires a global approach that takes into account the associated risk factors. This document summarises the current evidence and includes recommendations for patients with established vascular disease or at high vascular risk: it reviews the symptoms and signs to evaluate, the laboratory and imaging procedures to request routinely or in special situations, and includes the estimation of vascular risk, diagnostic criteria for entities that are vascular risk factors, and general and specific recommendations for their treatment. Finally, it presents aspects that are not usually referenced in the literature, such as the organisation of a vascular risk consultation.

Atrial fibrillation and risk of adverse outcomes in heart failure with reduced, mildly reduced, and preserved ejection fraction: A systematic review and meta-analysis

INTRODUCTION

Heart failure (HF) and atrial fibrillation (AF) frequently co-exist. Contemporary classification of HF categorizes it into HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF). Aggregate data comparing the risk profile of AF between these three HF categories are lacking.

METHODS

We conducted a systematic review and meta-analysis aimed at determining any significant differences in AF-associated all-cause mortality, HF hospitalizations, cardiovascular mortality (CV), and stroke between HFrEF, HFmrEF, and HFpEF. A systematic search of PubMed, EMBASE, and Cochrane Library databases until February 28, 2023. Data were combined using DerSimonian-Laird random effects model.

RESULTS

A total of 22 studies comprising 248 323 patients were retained: HFrEF 123 331 (49.7%), HFmrEF 40 995 (16.5%), and HFpEF 83 997 (33.8%). Pooled baseline AF prevalence was 36% total population, 30% HFrEF, 36% HFmrEF, and 42% HFpEF. AF was associated with a higher risk of all-cause mortality in the total population with pooled hazard ratio (HR) = 1.13 (95% confidence interval [CI] = 1.07-1.21), HFmrEF (HR = 1.25, 95% CI = 1.05-1.50) and HFpEF (HR = 1.16, 95% CI = 1.09-1.24), but not HFrEF (HR = 1.03, 95% CI = 0.93-1.14). AF was associated with a higher risk of HF hospitalizations in the total population (HR = 1.29, 95% CI = 1.14-1.46), HFmrEF (HR = 1.64, 95% CI = 1.20-2.24), and HFpEF (HR = 1.46, 95% CI = 1.17-1.83), but not HFrEF (HR = 1.01, 95% CI = 0.87-1.18). AF was only associated with CV in the HFpEF subcategory but was associated with stroke in all three HF subtypes.

CONCLUSIONS

AF appears to be associated with a higher risk of all-cause mortality and HF hospitalization in HFmrEF and HFpEF. With these findings, the paucity of data and treatment guidelines on AF in the HFmrEF subgroup becomes even more significant and warrant further investigations.

Increased Risk for Atrial Alternans in Rabbit Heart Failure: The Role of Ca2+/Calmodulin-Dependent Kinase II and Inositol-1,4,5-trisphosphate Signaling

Heart failure (HF) increases the probability of cardiac arrhythmias, including atrial fibrillation (AF), but the mechanisms linking HF to AF are poorly understood. We investigated disturbances in Ca2+ signaling and electrophysiology in rabbit atrial myocytes from normal and failing hearts and identified mechanisms that contribute to the higher risk of atrial arrhythmias in HF. Ca2+ transient (CaT) alternans-beat-to-beat alternations in CaT amplitude-served as indicator of increased arrhythmogenicity. We demonstrate that HF atrial myocytes were more prone to alternans despite no change in action potentials duration and only moderate decrease of L-type Ca2+ current. Ca2+/calmodulin-dependent kinase II (CaMKII) inhibition suppressed CaT alternans. Activation of IP3 signaling by endothelin-1 (ET-1) and angiotensin II (Ang II) resulted in acute, but transient reduction of CaT amplitude and sarcoplasmic reticulum (SR) Ca2+ load, and lowered the alternans risk. However, prolonged exposure to ET-1 and Ang II enhanced SR Ca2+ release and increased the degree of alternans. Inhibition of IP3 receptors prevented the transient ET-1 and Ang II effects and by itself increased the degree of CaT alternans. Our data suggest that activation of CaMKII and IP3 signaling contribute to atrial arrhythmogenesis in HF.