Heart failure in patients with atrial fibrillation: Insights from Polish part of the EORP-AF general long-term registry

AIMS

This study aimed to determine the impact of heart failure (HF) on clinical outcomes in patients with atrial fibrillation (AF).

METHODS AND RESULTS

We analysed data from Polish participants of the EURObservational Research Programme-AF General Long-Term Registry. The primary endpoint was all-cause death, and the secondary endpoints included hospital readmissions, cardiovascular (CV) interventions, thromboembolic and haemorrhagic events, rhythm control interventions, and other CV or non-CV diseases development during one-year follow up. Overall, 688 patients with available data on HF were included into analysis; 51% (n = 351) had HF; of these 48% (n = 168) had reduced ejection fraction (HFrEF), 22% (n = 77) mid-range EF (HFmrEF), and 30% (n = 106) preserved EF (HFpEF). Compared with patients without HF, those with HF had higher mortality rate (aHR 5.61; 95% CI 1.94-16.22, P < 0.01). Patients with HF (vs. without HF) had more often CV interventions (10% vs. 5.4%, P = 0.046) and events (14% vs. 7.1%, P = 0.02), and had less often atrial arrhythmia-related hospital admissions (6.8% vs. 15%, P < 0.01). Over follow-up, patients with HFmrEF and HFpEF had similar mortality rate versus HFrEF (aHR 0.45, 95% CI 0.13-1.57, P = 0.45 for HFmrEF and aHR 0.54, 95% CI 0.20-1.48, P = 0.54 for HFpEF). Mortality rate was similar among rhythm versus rate control group (aHR 0.34; 95% CI 0.10-1.16; P = 0.34).

CONCLUSIONS

AF patients with HF have greater mortality rate and more CV interventions/events. No statistically significant difference in long-term outcomes between patients with HFrEF, HFmrEF, and HFpEF highlights the need to develop therapeutic strategies targeting functional status and survival for patients with HF and AF.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Vascular disease in patients with atrial fibrillation. A report from Polish participants in the EORP-AF General Long-Term Registry

AIMS

This study aimed to (1) define the prevalence of vascular disease (VD; coronary (CAD) and/or peripheral artery disease (PAD)) and associated risk factors in patients with atrial fibrillation (AF); (2) establish the relationship of VD and associated treatment patterns on adverse events in AF.

METHODS

Data from 701 Polish AF patients enrolled in the EORP-AF General Long-Term Registry in the years 2013-2016 were included in this analysis. During the one-year follow-up, the occurrence of major adverse events (MAE; all-cause death, thromboembolic event, myocardial infraction) and its components was evaluated.

RESULTS

VD was recorded in 293 (44%) patients and based on multivariate logistic analysis was associated with age >75, diabetes, hypercholesterolemia, heart failure (HF). There was no significant difference in rates of MAE between patients with and without VD based on Fisher's exact test (8.8% vs 5.7%, P = .16), as well as between patients with concomitant CAD and PAD, PAD and CAD alone based on the Chi-square test (21% vs 7.5% vs 6.7%; P = .09). A higher risk of MAE was associated with HF, chronic kidney disease (in all study group), age >75, HF, diabetes (VD group),chronic obstructive pulmonary disease (non-VD group) based on the multivariate logistic analysis. Relative to patients with VD on vitamin K antagonists (VKA), those treated with non-VKA-oral anticoagulants (NOAC) had lower absolute rate of MAE according to Fisher's exact test (1.4% vs 10%, P = .02) but similar risks for thromboembolic and hemorrhagic events. The concomitant use of triple therapy was associated with increased risk of MAE as compared with those on OAC alone or dual therapy based on the Chi-square test (20% vs 4.8%, 3.2%, P = .02).

CONCLUSION

VD was prevalent in almost two-fifths of AF patients. The incidence of MAE was higher in patients with VD on VKA (vs NOAC) and on triple therapy (vs dual therapy, OAC alone) within one-year follow-up.

Clinical characteristics and risk profile of patients with atrial fibrillation with mid-range ejection fraction, insights from the Polish part of EORP-AF Long-Term General Registry

Background

Atrial fibrillation (AF) comprises a wide range of patients (pts), from those with preserved to those with reduced left ventricular ejection fraction (LVEF). According to 2016 ESC guidelines, pts with LVEF in the range of 40–49% represent a “grey area”, which is defined as heart failure with mid-range ejection fraction (HFmrEF). Not much is known about the clinical characteristics of AF pts with mid-range ejection fraction.

Purpose

To determine the potential differences in the clinical characteristics, risk profile, and the outcomes of AF with moderate systolic dysfunction, measured by LVEF.

Methods

The EURObservational Research Programme on AF (EORP-AF) Long-Term General Registry analyzed consecutive AF patients who have presented to cardiologists in 250 centers from 27 European countries, including 25 centers from Poland. We analyzed data collected at baseline and at a 1-year follow-up visit from 568 Polish patients included in 25 Polish centers in the years 2013–2016. Pts were divided into three groups based on LVEF: the preserved LVEF (pEF) group (LVEF ≥50%), the mid-range LVEF (mrEF) group (40–49%), and the reduced LVEF (rEF) group (&lt;40%).

Results

117/568 pts with rEF represented 20,6%, 105/568 mrEF 18,5% and 346/568 pEF 60,9% of the whole analyzed group. With regard to the most typical risk factors, the mrEF population appeared between rEF and pEF, presenting a moderate risk profile with the exception of hypertension, which was the most common in the mrEF group. While permanent AF was the most common in the rEF group and paroxysmal in the pEF pts, pts with mrEF had a higher rate of long-lasting persistent AF. Taking into account the risk factors profile, surprisingly, pts with AF and mrEF more often presented with dyspnea/shortnes of breath (mrEF 38,1% vs. rEF 18,8% vs. pEF 22,5%; p=0,001) and fatigue (mrEF 38,1% vs. rEF 23,9% vs. pEF 25,4%; p=0,025). AF pts with mrEF also had the highest thrombo-embolic risk estimated with the CHA2DS2-VASc score (mrEF 4 [2–5], n=105; rEF 3 [2–5], n=117, pEF 3 [2–4], n=346, p=0.005). However, this did not translate into the highest number of thromboembolic events after one year which did not significantly differ (mrEF 10.5%, rEF 15.4%, pEF 11.3%, p=0.30) between the three groups.

Conclusions

The risk factor profile of AF pts with mrEF was milder than for those with rEF and more severe than for pEF pts. AF pts with mrEF more often presented HF symptoms. Their estimated thrombo-embolic risk was higher but the number of events in the one year follow-up did not significantly differ between groups.

Funding Acknowledgement

Type of funding source: None

P738 Association of galectin-3 and soluble ST2, and their changes, with echocardiographic parameters and development of heart failure after ST-segment elevation myocardial infarction

Background

The occurrence of HF (heart failure) with preserved ejection fraction (HFpEF) has risen significantly over the past decade. Galectin-3 (Gal-3) and soluble ST2 (sST2) are involved in inflammatory processes and fibrosis and might be useful in estimation of the risk of HFpEF development after myocardial infarction (MI).Purpose: To investigate the association of Gal-3 and sST2, and their follow-up changeswith echocardiographic parameters of systolic and diastolic dysfunctionin patients (pts) with ST-segment elevation MI (STEMI) treated with primary percutaneous coronary intervention (pPCI). Methods:A prospective, observational study, BIOSTRAT (NCT03735719), enrolled 117 pts. Gal-3 and sST2 serum collection and echocardiography were performed twice (during index hospitalization and on a control visit at one-year follow-up). Assessedat baseline and at one-year echocardiographic indices included left ventricular ejection fraction (LVEF), atrial and ventricular size, LV posterior wall and septal thickness, LV hypertrophy based on LV mass index, mitral inflow velocities, and early diastolic tissue velocities at the lateral and medial mitral annulus. Results:Mean baseline concentrations of Gal-3 and sST2 (7.5 and 26.4 ng/mL, respectively) were increased at one-year follow-up (8.5 ng/mL, p &lt; 0.001 and 31.4 ng/mL, p = 0.001, respectively). Fifty of 105 pts (48%) developed HF and 30% of the study population had LVEF &lt;50% at one-year. There were no significant differences between pts with LVEF &lt;50% and ≥50% in terms of baseline, follow-up, nor changes in Gal-3 and sST2 concentrations from baseline to the one-year visit. Gal-3 and sST2 concentrations at baseline, after one-year, and their changes were correlated with echocardiographic parameters. Correlation analysis revealed that higher baseline Gal-3 concentrations correlated inversely only with LV end-diastolic volume at one-year. There were no other significant correlations of baseline, follow-up, nor changes in Gal-3 concentration with echocardiographic parameters. Baseline sST2 values correlated positively with LV end-diastolic diameter, LV end-systolic volume, LV mass index, and inversely with LVEF at one-year, but not with baseline echocardiographic parameters. Changes in sST2 concentration correlated positively only with LVEF at one-year. There were no significant correlations of sST2 concentrations at follow-up with echocardiographic parameters. Only pts with a higher sST2 baseline level had lower LVEF at baseline and after one-year, and pts with higher concentrations of both Gal-3 and sST2 at baseline were more likely to have LV hypertrophy initially and after one-year. There was no clear association of rising biomarkers’ quartiles with other echocardiographic parameters. Conclusions:There was no clear association between both biomarkers and echocardiographic parametersof diastolic dysfunction. Increasing levels of Gal-3 and sST2 do not reflect the HFpEF development in pts after STEMI.

Association of galectin-3 and soluble ST2 with in-hospital and 1-year outcomes in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

INTRODUCTION

Galectin‑3 (Gal‑3) and soluble interleukin-1 receptor-like 1 (sST2) have known prognostic value in already diagnosed heart failure (HF).

OBJECTIVES

To investigate the association of Gal‑3 and sST2 with prognosis in patients with ST‑segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI).

PATIENTS AND METHODS

The analysis was based on data collected in a prospective observational BIOSTRAT (Biomarkers for Risk Stratification After STEMI; ClinicalTrials.gov identifier, NCT03735719) study. Analysis included 117 patients with first‑time STEMI treated with pPCI. Serum for Gal‑3 and sST2 was sampled 72 to 96 hours after admission due to STEMI. The patients were followed for the primary endpoint (cardiovascular [CV] death or HF hospitalization at 1 year).

RESULTS

Both biomarkers correlated with N‑terminal pro‑B‑type natriuretic peptide (NT‑proBNP); Gal‑3 correlated with older age. Data on the primary endpoint were available for 104 patients (89%). At 1‑year follow‑up, 9 patients (8.7%) reached the primary endpoint. In univariate Cox proportional hazards regression analysis, both Gal‑3 and sST2 as continuous variables, as well as their newly‑established cutoffs (≥9.57 ng/ml for Gal‑3 and ≥45.99 ng/ml for sST2, based on the Youden index) were predictors of the primary endpoint, and of HF hospitalizations alone. Gal‑3 also predicted CV death. After adjustment for age and NT‑proBNP, Gal‑3 and sST2 remained predictors of the primary endpoint in multivariate models.

CONCLUSIONS

In patients with first‑time STEMI treated with pPCI, baseline Gal‑3 and sST2 predicted the composite of CV death and HF hospitalization at 1 year. Both biomarkers may play an important role in CV risk stratification after STEMI, although Gal‑3 may be considered preferable.

Comparative Analysis of Long-Term Outcomes of Torasemide and Furosemide in Heart Failure Patients in Heart Failure Registries of the European Society of Cardiology

PURPOSE

Current clinical recommendations do not emphasise superiority of any of diuretics, but available reports are very encouraging and suggest beneficial effects of torasemide. This study aimed to compare the effect of torasemide and furosemide on long-term outcomes and New York Heart Association (NYHA) class change in patients with chronic heart failure (HF).

METHODS

Of 2019 patients enrolled in Polish parts of the heart failure registries of the European Society of Cardiology (Pilot and Long-Term), 1440 patients treated with a loop diuretic were included in the analysis. The main analysis was performed on matched cohorts of HF patients treated with furosemide and torasemide using propensity score matching.

RESULTS

Torasemide was associated with a similar primary endpoint (all-cause death; 9.8% vs. 14.1%; p = 0.13) occurrence and 23.8% risk reduction of the secondary endpoint (a composite of all-cause death or hospitalisation for worsening HF; 26.4% vs. 34.7%; p = 0.04). Treatment with both torasemide and furosemide was associated with the significantly most frequent occurrence of the primary (23.8%) and secondary (59.2%) endpoints. In the matched cohort after 12 months, NYHA class was higher in the furosemide group (p = 0.04), while furosemide use was associated with a higher risk (20.0% vs. 12.9%; p = 0.03) of worsening ≥ 1 NYHA class. Torasemide use impacted positively upon the primary endpoint occurrence, especially in younger patients (aged < 65 years) and with dilated cardiomyopathy.

CONCLUSIONS

Our findings contribute to the body of research on the optimal diuretic choice. Torasemide may have advantageous influence on NYHA class and long-term outcomes of HF patients, especially younger patients or those with dilated cardiomyopathy, but it needs further investigations in prospective randomised trials.

Effect of β-blockers on 1-year survival and hospitalizations in patients with heart failure and atrial fibrillation: results from ESC-HF Pilot and ESC-HF Long-Term Registry

Introduction The positive effect of β-blocker therapy in patients with heart failure (HF) and atrial fibrillation (AF) has been questioned. Objectives We aimed to assess the effect of β-blockers and heart rate (HR) control on 1-year outcomes in patients with HF and AF. Patients and methods Of the 2019 Polish patients enrolled in ESC-HF Pilot and ESC-HF Long-Term Registry, 797 patients with HF and AF were classified into 2 groups depending on β-blocker use. Additionally, patient survival was compared between 3 groups classified according to HR: lower than 80 bpm, between 80 and 109 bpm, and of 110 bpm or higher. The primary endpoint was all-cause death and the secondary endpoint was all-cause death or HF hospitalization. Results In patients treated with β-blockers, the primary and secondary endpoints were less frequent than in patients not using β-blockers (10.9% vs 25.6%, P = 0.001 and 30.6% vs 44.2%, P = 0.02, respectively). Absence of β-blocker treatment was a predictor of both endpoints in a univariate analysis but remained an independent predictor only of the primary endpoint in a multivariate analysis (hazard ratio for β-blocker use, 0.52; 95% CI, 0.31-0.89; P = 0.02). The primary and secondary endpoints were more frequent in patients with a HR of 110 bpm or higher, but the HR itself did not predict the study endpoints in the univariate analysis. Conclusions β-blocker use might decrease mortality in patients with HF and AF, but it seems to have no impact on the risk of HF hospitalization. An HR of 110 bpm or higher may be related to worse survival in these patients.

Heart failure patients with a previous coronary revascularization: results from the ESC-HF Registry

BACKGROUND

Coronary revascularization is common in heart failure (HF).

AIMS

Clinical characteristic and assessment of in-hospital and long-term outcomes in patients hospitalized for HF with or without a previous percutaneous coronary intervention (PCI) or a coronary artery bypass grafting (CABG).

METHODS

The primary endpoint (PE) (all-cause death) and the secondary endpoint (SE) (all-cause death or hospitalization for HF-worsening) were assessed at one-year in 649 inpatients of the ESC-HF Pilot Survey. Additionally, occurrence of death during index hospitalization was evaluated.

RESULTS

PCI/CABG-patients (32.7%) were more frequently male, smokers, had myocardial infarction, hypertension (HT), peripheral artery disease and diabetes. The non-PCI/CABG-patients more often had a cardiogenic shock and died in-hospital. The PE occurred in 33 of the 212 PCI/CABG-patients (15.6%) and in 56 of the 437 non-PCI/CABG-patients (12.8%; P=0.3). The SE occurred in 82 of the 170 PCI/CABG-patients (48.2%) and in 122 of the 346 non-PCI/CABG-patients (35.3%; P=0.01). Independent predictors of the PE in the PCI/CABG-patients were: lower left ventricular ejection fraction, use of antiplatelets; in the non-PCI/CABG-patients were: age, ACS at admission. Independent predictors of the SE in the PCI/CABG-patients were: diabetes, NYHA (New York Heart Association) class at admission, HT; in the non-PCI/CABG-patients were: NYHA class, haemoglobin at admission. Serum sodium concentration at admission was a predictor of the PE and the SE in both groups. Heart rate at discharge was a predictor of the PE and the SE in the non-PCI/CABG patients.

CONCLUSIONS

The revascularized HF patients had a similar mortality and higher risk of death or hospitalizationsat 12 months compared with the non-PCI/CABG-patients. The revascularized patients had more comorbidities, while the non-PCI/CABG-patients had a higher incidence of cardiogenic shock and in-hospital mortality.