Using data from 2 large randomized drug studies assessing outcome in patients with
heart failure (HF) with reduced ejection fraction (HFrEF), Mogensen et al (J Am Coll
Cardiol 2017;70:2490, PMID 29145948) sought to assess the effect of the presence and
type of atrial fibrillation (AF) on the outcome. Of the 15,415 patients included in
the 2 trials, 5461 (35.6%) had a history of AF. These patients were grouped according
to the type of AF, with 1645 (30%) having paroxysmal AF (PAF), 3770 (69%) with persistent
or permanent AF (pers/perm AF), and 369 who developed new-onset AF during the course
of the study. The groups were analyzed by comparing them to each other and to those
with no history of AF (9828 [64%]) with regard to study outcomes (composite outcome
of cardiovascular death defined as death due to worsening HF, stroke, sudden death,
all-cause mortality, and HF hospitalization). Patients with AF reached the composite
end points at a higher rate than did those without AF; however, in adjusted analyses
this was driven mainly by higher rates in those with PAF rather than those with pers/perm
AF. Patients with PAF had higher rates of HF hospitalization and stroke than did those
with no AF or pers/perm AF. Patients who fared the worst overall were those with new-onset
AF with higher rates of stroke, all-cause, and cardiovascular mortality, and HF hospitalization
as compared with other groups with AF and those without AF. Importantly, oral anticoagulation
was underutilized (71% in patients with pers/perm AF, 53% in those with PAF, and 16%
in those with new-onset AF) in all AF groups despite a high CHA2DS2-VASc score of ≥2 in 90% of patients. The authors conclude that patients with HFrEF and PAF have higher risk of HF hospitalization
and stroke, highlighting the need for oral anticoagulation therapy in these patients.
In addition, new-onset AF was associated with worse outcomes, which may be mitigated
by anticoagulation and close follow-up for HF decompensation.
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Published online: December 20, 2017