TY - JOUR
T1 - Type of Atrial Fibrillation and Outcomes in Patients With Heart Failure and Reduced Ejection Fraction
AU - Mogensen, Ulrik M.
AU - Jhund, Pardeep S.
AU - Abraham, William T.
AU - Desai, Akshay S.
AU - Dickstein, Kenneth
AU - Packer, Milton
AU - Rouleau, Jean L.
AU - Solomon, Scott D.
AU - Swedberg, Karl
AU - Zile, Michael R.
AU - Køber, Lars
AU - McMurray, John J.V.
AU - PARADIGM-HF and ATMOSPHERE Investigators and Committees
N1 - Funding Information:
Dr. Mogensen was supported by a research grant from the Danish Heart Foundation. The PARADIGM-HF and ATMOSPHERE trials were funded by Novartis, but Novartis had no role in this analysis. Except for Dr. Mogensen, all authors or their institutions have received payments from Novartis for their involvement in PARADIGM-HF and/or ATMOSPHERE trials. Dr. Mogensen has received a speaker fee from Novo Nordisk and Merck Sharp & Dohme. Dr. Jhund has received consulting and speaker fees from Novartis. Dr. Desai has received research grant support from Novartis; and has served as a consultant for Novartis, Abbott, Relypsa, AstraZeneca, Janssen, and DalCor. Dr. Dickstein has served as a member of the Executive Steering Committee for Atmosphere. Dr. Packer has served as a consultant for Bayer, Amgen, AstraZeneca, Boehringer Ingelheim, Cardiorentis, Daiichi-Sankyo, Celyad, Relypsa, Novartis, Sanofi, Admittance, Takeda, and ZS Pharma. Dr. Rouleau has served as a consultant for Novartis, AstraZeneca, and Bayer. Drs. Solomon and Zile have received research grant support from and served as a consultant for Novartis. Dr. Swedberg has served as a consultant for and received honoraria from Novartis. Dr. Køber has received a speaker honorarium from Novartis. Dr. McMurray’s employer, Glasgow University, was paid by Novartis for his role in the PARADIGM-HF and ATMOSPHERE trials. Novartis has paid for open access to this paper.
Publisher Copyright:
© 2017 The Authors
PY - 2017/11/14
Y1 - 2017/11/14
N2 - Background Atrial fibrillation (AF) is common in heart failure (HF), but the outcome by type of AF is largely unknown. Objectives This study investigated outcomes related to type of AF (paroxysmal, persistent or permanent, or new onset) in 2 recent large trials in patients with HF with reduced ejection fraction. Methods The study analyzed patients in the PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) and ATMOSPHERE (Aliskiren Trial to Minimize Outcomes in Patients with Heart Failure) trials. Multivariable Cox regression models were used to estimate hazard ratios (HRs) for outcomes related to AF type. Results Of 15,415 patients, 5,481 (35.6%) had a history of AF at randomization, and of these, 1,645 (30.0%) had paroxysmal AF. Compared with patients without AF, patients with paroxysmal AF at randomization had a higher risk of the primary composite endpoint of cardiovascular death or HF hospitalization (HR: 1.20; 95% confidence interval [CI]: 1.09 to 1.32; p < 0.001), HF hospitalization (HR: 1.34; 95% CI: 1.19 to 1.51; p < 0.001), and stroke (HR: 1.34; 95% CI: 1.02 to 1.76; p = 0.037), whereas the corresponding risks in patients with persistent or permanent AF were not elevated. Neither type of AF was associated with higher mortality. New onset AF was associated with the greatest risk of adverse outcomes: primary endpoint (HR: 2.21; 95% CI: 1.80 to 2.71), HF hospitalization (HR: 2.11; 95% CI: 1.58 to 2.81), stroke (HR: 2.20; 95% CI: 1.25 to 3.88), and all-cause mortality (HR: 2.26; 95% CI: 1.86 to 2.74), all p values < 0.001, compared with patients without AF. Anticoagulants were used less often in patients with paroxysmal (53%) and new onset (16%) AF than in patients with persistent or permanent AF (71%). Conclusions Among HF patients with a history of AF, those with paroxysmal AF were at greater risk of HF hospitalization and stroke than were patients with persistent or permanent AF, underlining the importance of anticoagulant therapy. New onset AF was associated with increased risk of all outcomes. (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure [PARADIGM-HF]; NCT01035255) (Aliskiren Trial to Minimize Outcomes in Patients with Heart Failure [ATMOSPHERE]; NCT00853658)
AB - Background Atrial fibrillation (AF) is common in heart failure (HF), but the outcome by type of AF is largely unknown. Objectives This study investigated outcomes related to type of AF (paroxysmal, persistent or permanent, or new onset) in 2 recent large trials in patients with HF with reduced ejection fraction. Methods The study analyzed patients in the PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) and ATMOSPHERE (Aliskiren Trial to Minimize Outcomes in Patients with Heart Failure) trials. Multivariable Cox regression models were used to estimate hazard ratios (HRs) for outcomes related to AF type. Results Of 15,415 patients, 5,481 (35.6%) had a history of AF at randomization, and of these, 1,645 (30.0%) had paroxysmal AF. Compared with patients without AF, patients with paroxysmal AF at randomization had a higher risk of the primary composite endpoint of cardiovascular death or HF hospitalization (HR: 1.20; 95% confidence interval [CI]: 1.09 to 1.32; p < 0.001), HF hospitalization (HR: 1.34; 95% CI: 1.19 to 1.51; p < 0.001), and stroke (HR: 1.34; 95% CI: 1.02 to 1.76; p = 0.037), whereas the corresponding risks in patients with persistent or permanent AF were not elevated. Neither type of AF was associated with higher mortality. New onset AF was associated with the greatest risk of adverse outcomes: primary endpoint (HR: 2.21; 95% CI: 1.80 to 2.71), HF hospitalization (HR: 2.11; 95% CI: 1.58 to 2.81), stroke (HR: 2.20; 95% CI: 1.25 to 3.88), and all-cause mortality (HR: 2.26; 95% CI: 1.86 to 2.74), all p values < 0.001, compared with patients without AF. Anticoagulants were used less often in patients with paroxysmal (53%) and new onset (16%) AF than in patients with persistent or permanent AF (71%). Conclusions Among HF patients with a history of AF, those with paroxysmal AF were at greater risk of HF hospitalization and stroke than were patients with persistent or permanent AF, underlining the importance of anticoagulant therapy. New onset AF was associated with increased risk of all outcomes. (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure [PARADIGM-HF]; NCT01035255) (Aliskiren Trial to Minimize Outcomes in Patients with Heart Failure [ATMOSPHERE]; NCT00853658)
KW - atrial fibrillation
KW - heart failure
KW - mortality
KW - paroxysmal
KW - stroke
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U2 - 10.1016/j.jacc.2017.09.027
DO - 10.1016/j.jacc.2017.09.027
M3 - Article
C2 - 29145948
AN - SCOPUS:85032660868
SN - 0735-1097
VL - 70
SP - 2490
EP - 2500
JO - Journal of the American College of Cardiology
JF - Journal of the American College of Cardiology
IS - 20
ER -