Temporal Relationship and Prognostic Significance of Atrial Fibrillation in Heart Failure Patients with Preserved Ejection Fraction: A Community-Based Study
Background—In patients with heart failure (HF) and preserved ejection fraction (HFpEF), atrial fibrillation (AF) may predate, concur with, or develop after HFpEF diagnosis. We sought to define the temporal relationship between AF and HFpEF, identify factors associated with AF, and determine the prognostic impact of prevalent and incident AF in HFpEF.
Method and Results—From 1983 to 2010, 939 Olmsted County, MN residents (age 77±12years, 61% female) newly diagnosed with HFpEF (EF≥0.50) were evaluated. Baseline rhythm classification included: prior AF (>3 months before HFpEF diagnosis), concurrent AF (±3months), or sinus rhythm (SR). Incident AF (>3months after HFpEF diagnosis) and all-cause mortality were ascertained through February 2012. Prior (29%) and concurrent AF (23%) were associated with older age, higher BNP, and larger left atrial volume index at HFpEF diagnosis compared to SR. Of HFpEF patients in SR at diagnosis, 32% developed AF over a median (IQR) follow-up of 3.7(1.5-6.7) years (69 events per 1000 person-years). Age and diastolic dysfunction were positively, while statin use was inversely associated with incident AF. Using no AF as the referent, prior or concurrent AF (combined HR 1.3, 95%CI 1.0-1.6, p=0.03) and incident AF, modeled as a time-dependent covariate, (HR 2.1, 95%CI 1.4-3.0, p<0.001), were independently associated with death adjusting for pertinent covariates.
Conclusions—AF occurs in two-thirds of HFpEF patients at some point in the natural history and confers a poor prognosis. Further study is required to determine whether intervention for AF may improve outcomes or if statin use can prevent AF in HFpEF.
- Received January 22, 2013.
- Revision received July 2, 2013.
- Accepted July 19, 2013.