Clinical characteristics and prognostic impact of atrial fibrillation in patients with chronic heart failure
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摘要
AIM To assess the prevalence, clinical characteristics and independent prognostic impact of atrial fibrillation(AF) in chronic heart failure(CHF) patients, and the potential protective effect of disease-modifying medications, particularly beta-blockers(BB). METHODS We retrospectively reviewed the charts of patients referred to our center since January 2004, and collected all clinical information available at their first visit. We assessed mortality to the end of June 2015. We compared patients with and without AF, and assessed the association between AF and all-cause mortality by multivariate Cox regression and Kaplan-Meyer analysis, particularly accounting for ongoing treatment with BB.RESULTS A total of 903 patients were evaluated(mean age 68 ± 12 years, 73% male). Prevalence of AF was 19%, ranging from 10% to 28% in patients ≤ 60 and ≥ 77 years, respectively. Besides the older age, patients with AF had more symptoms(New York Heart Association II-III 60% vs 44%), lower prevalence of dyslipidemia(23% vs 37%), coronary artery disease(28% vs 52%) and left bundle branch block(9% vs 16%). On the contrary, they more frequently presented with an idiopathic etiology(50% vs 24%), a history of valve surgery(13% vs 4%) and received overall more devices implantation(31% vs 21%). The use of disease-modifying medications(i.e., BB and ACE inhibitors/angiotensin receptor blockers) was lower in patients with AF(72% vs 80% and 71% vs 79%, respectively), who on the contrary were more frequently treated with symptomatic and antiarrhythmic drugs including diuretics(87% vs 69%) and digoxin(51% vs 11%). At a mean follow-up of about 5 years, all-cause mortality was significantly higher in patients with AF as compared to those in sinus rhythm(SR)(45% vs 34%, P value < 0.05 for all previous comparisons). However, in a multivariate analysis including the main significant predictors of allcause mortality, the univariate relationship between AF and death(HR = 1.49, 95%CI: 1.15-1.92) became not statistically significant(HR = 0.98, 95%CI: 0.73-1.32). Nonetheless, patients with AF not receiving BB treatment were found to have the worst prognosis, followed by patients with SR not receiving BB therapy and patients with AF receiving BB therapy, who both had similarly worse survival when compared to patients with SR receiving BB therapy.CONCLUSION AF was highly prevalent and associated with older age, worse clinical presentation and underutilization of disease-modifying medications such as BB in a population of elderly patients with CHF. AF had no independent impact on mortality, but the underutilization of BB in this group of patients was associated to a worse long-term prognosis.
AIM To assess the prevalence, clinical characteristics and independent prognostic impact of atrial fibrillation(AF) in chronic heart failure(CHF) patients, and the potential protective effect of disease-modifying medications, particularly beta-blockers(BB). METHODS We retrospectively reviewed the charts of patients referred to our center since January 2004, and collected all clinical information available at their first visit. We assessed mortality to the end of June 2015. We compared patients with and without AF, and assessed the association between AF and all-cause mortality by multivariate Cox regression and Kaplan-Meyer analysis, particularly accounting for ongoing treatment with BB.RESULTS A total of 903 patients were evaluated(mean age 68 ± 12 years, 73% male). Prevalence of AF was 19%, ranging from 10% to 28% in patients ≤ 60 and ≥ 77 years, respectively. Besides the older age, patients with AF had more symptoms(New York Heart Association II-III 60% vs 44%), lower prevalence of dyslipidemia(23% vs 37%), coronary artery disease(28% vs 52%) and left bundle branch block(9% vs 16%). On the contrary, they more frequently presented with an idiopathic etiology(50% vs 24%), a history of valve surgery(13% vs 4%) and received overall more devices implantation(31% vs 21%). The use of disease-modifying medications(i.e., BB and ACE inhibitors/angiotensin receptor blockers) was lower in patients with AF(72% vs 80% and 71% vs 79%, respectively), who on the contrary were more frequently treated with symptomatic and antiarrhythmic drugs including diuretics(87% vs 69%) and digoxin(51% vs 11%). At a mean follow-up of about 5 years, all-cause mortality was significantly higher in patients with AF as compared to those in sinus rhythm(SR)(45% vs 34%, P value < 0.05 for all previous comparisons). However, in a multivariate analysis including the main significant predictors of allcause mortality, the univariate relationship between AF and death(HR = 1.49, 95%CI: 1.15-1.92) became not statistically significant(HR = 0.98, 95%CI: 0.73-1.32). Nonetheless, patients with AF not receiving BB treatment were found to have the worst prognosis, followed by patients with SR not receiving BB therapy and patients with AF receiving BB therapy, who both had similarly worse survival when compared to patients with SR receiving BB therapy.CONCLUSION AF was highly prevalent and associated with older age, worse clinical presentation and underutilization of disease-modifying medications such as BB in a population of elderly patients with CHF. AF had no independent impact on mortality, but the underutilization of BB in this group of patients was associated to a worse long-term prognosis.
AIM To assess the prevalence, clinical characteristics and independent prognostic impact of atrial fibrillation(AF) in chronic heart failure(CHF) patients, and the potential protective effect of disease-modifying medications, particularly beta-blockers(BB). METHODS We retrospectively reviewed the charts of patients referred to our center since January 2004, and collected all clinical information available at their first visit. We assessed mortality to the end of June 2015. We compared patients with and without AF, and assessed the association between AF and all-cause mortality by multivariate Cox regression and Kaplan-Meyer analysis, particularly accounting for ongoing treatment with BB.RESULTS A total of 903 patients were evaluated(mean age 68 ± 12 years, 73% male). Prevalence of AF was 19%, ranging from 10% to 28% in patients ≤ 60 and ≥ 77 years, respectively. Besides the older age, patients with AF had more symptoms(New York Heart Association II-III 60% vs 44%), lower prevalence of dyslipidemia(23% vs 37%), coronary artery disease(28% vs 52%) and left bundle branch block(9% vs 16%). On the contrary, they more frequently presented with an idiopathic etiology(50% vs 24%), a history of valve surgery(13% vs 4%) and received overall more devices implantation(31% vs 21%). The use of disease-modifying medications(i.e., BB and ACE inhibitors/angiotensin receptor blockers) was lower in patients with AF(72% vs 80% and 71% vs 79%, respectively), who on the contrary were more frequently treated with symptomatic and antiarrhythmic drugs including diuretics(87% vs 69%) and digoxin(51% vs 11%). At a mean follow-up of about 5 years, all-cause mortality was significantly higher in patients with AF as compared to those in sinus rhythm(SR)(45% vs 34%, P value < 0.05 for all previous comparisons). However, in a multivariate analysis including the main significant predictors of allcause mortality, the univariate relationship between AF and death(HR = 1.49, 95%CI: 1.15-1.92) became not statistically significant(HR = 0.98, 95%CI: 0.73-1.32). Nonetheless, patients with AF not receiving BB treatment were found to have the worst prognosis, followed by patients with SR not receiving BB therapy and patients with AF receiving BB therapy, who both had similarly worse survival when compared to patients with SR receiving BB therapy.CONCLUSION AF was highly prevalent and associated with older age, worse clinical presentation and underutilization of disease-modifying medications such as BB in a population of elderly patients with CHF. AF had no independent impact on mortality, but the underutilization of BB in this group of patients was associated to a worse long-term prognosis.
引文
1 Wang TJ,Larson MG,Levy D,Vasan RS,Leip EP,Wolf PA,D’Agostino RB,Murabito JM,Kannel WB,Benjamin EJ.Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality:the Framingham Heart Study Circulation 2003;107:2920-2925[PMID:12771006 DOI:10.1161/01.CIR.0000072767.89944.6E]
2 Smit MD,Moes ML,Maass AH,Achekar ID,Van Geel PP,Hillege HL,van Veldhuisen DJ,Van Gelder IC.The importance of whether atrial fibrillation or heart failure develops first.Eur J Heart Fail 2012;14:1030-1040[PMID:22733981 DOI:10.1093/eurjhf/hfs097]
3 Nieuwlaat R,Eurlings LW,Cleland JG,Cobbe SM,Vardas PECapucci A,López-Sendòn JL,Meeder JG,Pinto YM,Crijns HJAtrial fibrillation and heart failure in cardiology practice:reciprocal impact and combined management from the perspective of atrial fibrillation:results of the Euro Heart Survey on atrial fibrillation J Am Coll Cardiol 2009;53:1690-1698[PMID:19406345 DOI:10.1016/j.jacc.2009.01.055]
4 Carson PE,Johnson GR,Dunkman WB,Fletcher RD,Farrell LCohn JN.The influence of atrial fibrillation on prognosis in mild to moderate heart failure.The V-He FT Studies.The V-He FT VACooperative Studies Group.Circulation 1993;87:VI102-VI110[PMID:8500233]
5 Swedberg K,Olsson LG,Charlesworth A,Cleland J,Hanrath P,Komajda M,Metra M,Torp-Pedersen C,Poole-Wilson PPrognostic relevance of atrial fibrillation in patients with chronic heart failure on long-term treatment with beta-blockers:results from COMET.Eur Heart J 2005;26:1303-1308[PMID:15767288 DOI:10.1093/eurheartj/ehi166]
6 Paolillo S,Agostoni P,Masarone D,CorràU,Passino C,Scrutinio D,Correale M,Cattadori G,Metra M,Girola D,Piepoli MF,Salvioni E,Giovannardi M,Iorio A,Emdin M,Raimondo R,Re F,Cicoira M,Belardinelli R,Guazzi M,Clemenza F,Parati G,Scardovi AB,Di Lenarda A,La Gioia R,Frigerio M,Lombardi C,Gargiulo P,Sinagra G,Pacileo G,Perrone-Filardi P,Limongelli G.Prognostic role of atrial fibrillation in patients affected by chronic heart failure.Data from the MECKI score research group.Eur J Intern Med 2015;26:515-520[PMID:26026698 DOI:10.1016/j.ejim.2015.04.023]
7 Mamas MA,Caldwell JC,Chacko S,Garratt CJ,Fath-Ordoubadi F,Neyses L.A meta-analysis of the prognostic significance of atrial fibrillation in chronic heart failure.Eur J Heart Fail 2009;11:676-683[PMID:19553398 DOI:10.1093/eurjhf/hfp085]
8 Wasywich CA,Pope AJ,Somaratne J,Poppe KK,Whalley GA,Doughty RN.Atrial fibrillation and the risk of death in patients with heart failure:a literature-based meta-analysis.Intern Med J 2010;40:347-356[PMID:19460059 DOI:10.1111/j.1445-5994.2009.01991.x]
9 Nielsen PB,Larsen TB,Gorst-Rasmussen A,Skj?th F,Lip GY.β-Blockers in Atrial Fibrillation Patients With or Without Heart Failure:Association With Mortality in a Nationwide Cohort Study.Circ Heart Fail 2016;9:e002597[PMID:26823497 DOI:10.1161/CIRCHEARTFAILURE.115.002597]
10 Feinberg WM,Blackshear JL,Laupacis A,Kronmal R,Hart RG.Prevalence,age distribution,and gender of patients with atrial fibrillation.Analysis and implications.Arch Intern Med 1995;155:469-473[PMID:7864703]
11 Suman-Horduna I,Roy D,Frasure-Smith N,Talajic M,Lespérance F,Blondeau L,Dorian P,Khairy P.Quality of life and functional capacity in patients with atrial fibrillation and congestive heart failure.J Am Coll Cardiol 2013;61:455-460[PMID:23265334DOI:10.1016/j.jacc.2012.10.031]
12 Goyal P,Almarzooq ZI,Horn EM,Karas MG,Sobol I,Swaminathan RV,Feldman DN,Minutello RM,Singh HS,Bergman GW,Wong SC,Kim LK.Characteristics of Hospitalizations for Heart Failure with Preserved Ejection Fraction.Am J Med 2016;129:635.e15-635.e26[PMID:27215991 DOI:10.1016/j.amjmed.2016.02.007]
13 Dries DL,Exner DV,Gersh BJ,Domanski MJ,Waclawiw MA,Stevenson LW.Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction:a retrospective analysis of the SOLVD trials.Studies of Left Ventricular Dysfunction.J Am Coll Cardiol 1998;32:695-703[PMID:9741514]
14 Olsson LG,Swedberg K,Ducharme A,Granger CB,Michelson EL,Mc Murray JJ,Puu M,Yusuf S,Pfeffer MA.Atrial fibrillation and risk of clinical events in chronic heart failure with and without left ventricular systolic dysfunction:results from the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity(CHARM)program.J Am Coll Cardiol 2006;47:1997-2004[PMID:16697316 DOI:10.1016/j.jacc.2006.01.060]
15 Ponikowski P,Voors AA,Anker SD,Bueno H,Cleland JG,Coats AJ,Falk V,González-Juanatey JR,Harjola VP,Jankowska EA,Jessup M,Linde C,Nihoyannopoulos P,Parissis JT,Pieske B,Riley JP,Rosano GM,Ruilope LM,Ruschitzka F,Rutten FH,van der Meer P.2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure:The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology(ESC)Developed with the special contribution of the Heart Failure Association(HFA)of the ESC.Eur Heart J 2016;37:2129-2200[PMID:27206819 DOI:10.1093/eurheartj/ehw128]
16 Al-Zakwani I,Panduranga P,Zubaid M,Sulaiman K,Rashed WA,Alsheikh-Ali AA,Al Mahmeed W,Shehab A,Al Qudaimi A,Asaad N,Amin H.Impact of Digoxin on Mortality in Patients With Atrial Fibrillation Stratified by Heart Failure:Findings From Gulf Survey of Atrial Fibrillation Events in the Middle East.J Cardiovasc Pharmacol Ther 2016;21:273-279[PMID:26341119 DOI:10.1177/1074248415603505]
17 Patel N,Ju C,Macon C,Thadani U,Schulte PJ,Hernandez AF,Bhatt DL,Butler J,Yancy CW,Fonarow GC.Temporal Trends of Digoxin Use in Patients Hospitalized With Heart Failure:Analysis From the American Heart Association Get With The GuidelinesHeart Failure Registry.JACC Heart Fail 2016;4:348-356[PMID:26874392 DOI:10.1016/j.jchf.2015.12.003]
18 Yancy CW,Jessup M,Bozkurt B,Butler J,Casey DE,Drazner MH,Fonarow GC,Geraci SA,Horwich T,Januzzi JL,Johnson MR,Kasper EK,Levy WC,Masoudi FA,Mc Bride PE,Mc Murray JJ,Mitchell JE,Peterson PN,Riegel B,Sam F,Stevenson LW,Tang WH,Tsai EJ,Wilkoff BL.2013 ACCF/AHA guideline for the management of heart failure:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol 2013;62:e147-e239[PMID:23747642 DOI:10.1016/j.jacc.2013.05.019]
19 Ziff OJ,Lane DA,Samra M,Griffith M,Kirchhof P,Lip GY,Steeds RP,Townend J,Kotecha D.Safety and efficacy of digoxin:systematic review and meta-analysis of observational and controlled trial data.BMJ 2015;351:h4451[PMID:26321114 DOI:10.1136/bmj.h4451]
20 Turakhia MP,Santangeli P,Winkelmayer WC,Xu X,Ullal AJ,Than CT,Schmitt S,Holmes TH,Frayne SM,Phibbs CS,Yang F,Hoang DD,Ho PM,Heidenreich PA.Increased mortality associated with digoxin in contemporary patients with atrial fibrillation:findings from the TREAT-AF study.J Am Coll Cardiol 2014;64:660-668[PMID:25125296 DOI:10.1016/j.jacc.2014.03.060]
2 Smit MD,Moes ML,Maass AH,Achekar ID,Van Geel PP,Hillege HL,van Veldhuisen DJ,Van Gelder IC.The importance of whether atrial fibrillation or heart failure develops first.Eur J Heart Fail 2012;14:1030-1040[PMID:22733981 DOI:10.1093/eurjhf/hfs097]
3 Nieuwlaat R,Eurlings LW,Cleland JG,Cobbe SM,Vardas PECapucci A,López-Sendòn JL,Meeder JG,Pinto YM,Crijns HJAtrial fibrillation and heart failure in cardiology practice:reciprocal impact and combined management from the perspective of atrial fibrillation:results of the Euro Heart Survey on atrial fibrillation J Am Coll Cardiol 2009;53:1690-1698[PMID:19406345 DOI:10.1016/j.jacc.2009.01.055]
4 Carson PE,Johnson GR,Dunkman WB,Fletcher RD,Farrell LCohn JN.The influence of atrial fibrillation on prognosis in mild to moderate heart failure.The V-He FT Studies.The V-He FT VACooperative Studies Group.Circulation 1993;87:VI102-VI110[PMID:8500233]
5 Swedberg K,Olsson LG,Charlesworth A,Cleland J,Hanrath P,Komajda M,Metra M,Torp-Pedersen C,Poole-Wilson PPrognostic relevance of atrial fibrillation in patients with chronic heart failure on long-term treatment with beta-blockers:results from COMET.Eur Heart J 2005;26:1303-1308[PMID:15767288 DOI:10.1093/eurheartj/ehi166]
6 Paolillo S,Agostoni P,Masarone D,CorràU,Passino C,Scrutinio D,Correale M,Cattadori G,Metra M,Girola D,Piepoli MF,Salvioni E,Giovannardi M,Iorio A,Emdin M,Raimondo R,Re F,Cicoira M,Belardinelli R,Guazzi M,Clemenza F,Parati G,Scardovi AB,Di Lenarda A,La Gioia R,Frigerio M,Lombardi C,Gargiulo P,Sinagra G,Pacileo G,Perrone-Filardi P,Limongelli G.Prognostic role of atrial fibrillation in patients affected by chronic heart failure.Data from the MECKI score research group.Eur J Intern Med 2015;26:515-520[PMID:26026698 DOI:10.1016/j.ejim.2015.04.023]
7 Mamas MA,Caldwell JC,Chacko S,Garratt CJ,Fath-Ordoubadi F,Neyses L.A meta-analysis of the prognostic significance of atrial fibrillation in chronic heart failure.Eur J Heart Fail 2009;11:676-683[PMID:19553398 DOI:10.1093/eurjhf/hfp085]
8 Wasywich CA,Pope AJ,Somaratne J,Poppe KK,Whalley GA,Doughty RN.Atrial fibrillation and the risk of death in patients with heart failure:a literature-based meta-analysis.Intern Med J 2010;40:347-356[PMID:19460059 DOI:10.1111/j.1445-5994.2009.01991.x]
9 Nielsen PB,Larsen TB,Gorst-Rasmussen A,Skj?th F,Lip GY.β-Blockers in Atrial Fibrillation Patients With or Without Heart Failure:Association With Mortality in a Nationwide Cohort Study.Circ Heart Fail 2016;9:e002597[PMID:26823497 DOI:10.1161/CIRCHEARTFAILURE.115.002597]
10 Feinberg WM,Blackshear JL,Laupacis A,Kronmal R,Hart RG.Prevalence,age distribution,and gender of patients with atrial fibrillation.Analysis and implications.Arch Intern Med 1995;155:469-473[PMID:7864703]
11 Suman-Horduna I,Roy D,Frasure-Smith N,Talajic M,Lespérance F,Blondeau L,Dorian P,Khairy P.Quality of life and functional capacity in patients with atrial fibrillation and congestive heart failure.J Am Coll Cardiol 2013;61:455-460[PMID:23265334DOI:10.1016/j.jacc.2012.10.031]
12 Goyal P,Almarzooq ZI,Horn EM,Karas MG,Sobol I,Swaminathan RV,Feldman DN,Minutello RM,Singh HS,Bergman GW,Wong SC,Kim LK.Characteristics of Hospitalizations for Heart Failure with Preserved Ejection Fraction.Am J Med 2016;129:635.e15-635.e26[PMID:27215991 DOI:10.1016/j.amjmed.2016.02.007]
13 Dries DL,Exner DV,Gersh BJ,Domanski MJ,Waclawiw MA,Stevenson LW.Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction:a retrospective analysis of the SOLVD trials.Studies of Left Ventricular Dysfunction.J Am Coll Cardiol 1998;32:695-703[PMID:9741514]
14 Olsson LG,Swedberg K,Ducharme A,Granger CB,Michelson EL,Mc Murray JJ,Puu M,Yusuf S,Pfeffer MA.Atrial fibrillation and risk of clinical events in chronic heart failure with and without left ventricular systolic dysfunction:results from the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity(CHARM)program.J Am Coll Cardiol 2006;47:1997-2004[PMID:16697316 DOI:10.1016/j.jacc.2006.01.060]
15 Ponikowski P,Voors AA,Anker SD,Bueno H,Cleland JG,Coats AJ,Falk V,González-Juanatey JR,Harjola VP,Jankowska EA,Jessup M,Linde C,Nihoyannopoulos P,Parissis JT,Pieske B,Riley JP,Rosano GM,Ruilope LM,Ruschitzka F,Rutten FH,van der Meer P.2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure:The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology(ESC)Developed with the special contribution of the Heart Failure Association(HFA)of the ESC.Eur Heart J 2016;37:2129-2200[PMID:27206819 DOI:10.1093/eurheartj/ehw128]
16 Al-Zakwani I,Panduranga P,Zubaid M,Sulaiman K,Rashed WA,Alsheikh-Ali AA,Al Mahmeed W,Shehab A,Al Qudaimi A,Asaad N,Amin H.Impact of Digoxin on Mortality in Patients With Atrial Fibrillation Stratified by Heart Failure:Findings From Gulf Survey of Atrial Fibrillation Events in the Middle East.J Cardiovasc Pharmacol Ther 2016;21:273-279[PMID:26341119 DOI:10.1177/1074248415603505]
17 Patel N,Ju C,Macon C,Thadani U,Schulte PJ,Hernandez AF,Bhatt DL,Butler J,Yancy CW,Fonarow GC.Temporal Trends of Digoxin Use in Patients Hospitalized With Heart Failure:Analysis From the American Heart Association Get With The GuidelinesHeart Failure Registry.JACC Heart Fail 2016;4:348-356[PMID:26874392 DOI:10.1016/j.jchf.2015.12.003]
18 Yancy CW,Jessup M,Bozkurt B,Butler J,Casey DE,Drazner MH,Fonarow GC,Geraci SA,Horwich T,Januzzi JL,Johnson MR,Kasper EK,Levy WC,Masoudi FA,Mc Bride PE,Mc Murray JJ,Mitchell JE,Peterson PN,Riegel B,Sam F,Stevenson LW,Tang WH,Tsai EJ,Wilkoff BL.2013 ACCF/AHA guideline for the management of heart failure:a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol 2013;62:e147-e239[PMID:23747642 DOI:10.1016/j.jacc.2013.05.019]
19 Ziff OJ,Lane DA,Samra M,Griffith M,Kirchhof P,Lip GY,Steeds RP,Townend J,Kotecha D.Safety and efficacy of digoxin:systematic review and meta-analysis of observational and controlled trial data.BMJ 2015;351:h4451[PMID:26321114 DOI:10.1136/bmj.h4451]
20 Turakhia MP,Santangeli P,Winkelmayer WC,Xu X,Ullal AJ,Than CT,Schmitt S,Holmes TH,Frayne SM,Phibbs CS,Yang F,Hoang DD,Ho PM,Heidenreich PA.Increased mortality associated with digoxin in contemporary patients with atrial fibrillation:findings from the TREAT-AF study.J Am Coll Cardiol 2014;64:660-668[PMID:25125296 DOI:10.1016/j.jacc.2014.03.060]