Persistent atrial fibrillation in heart failure with preserved ejection fraction: Prognostic relevance and association with clinical, imaging and invasive haemodynamic parameters

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Abstract

Background

Atrial fibrillation (AF) is a frequent finding in HFpEF. However, its association with invasive haemodynamics, imaging parameters and outcome in HFpEF is not well established. Furthermore, the relevance of AF subtype with regard to outcome is unclear. This study sought to investigate the prognostic impact of paroxysmal and persistent AF in a well‐defined heart failure with preserved ejection fraction (HFpEF) population.

Materials and methods

Between 2010 and 2016, 254 HFpEF patients were prospectively enrolled. All patients underwent echocardiography as well as left and right heart catheterization. Patients without contraindications underwent CMR including T1 mapping. Follow‐up and outcome data were collected. Patients with significant coronary artery disease were excluded.

Results

A total of 153 patients (60%) suffered from AF, 119 (47%) had persistent and 34 (13%) had paroxysmal AF. By multiple logistic regression analysis, persistent AF was independently associated with NT‐proBNP ( P = .003), NYHA functional class ( P = .040), left and right atrial size ( P = .022 and <.001, respectively), cardiac output ( P = .002) and COPD ( P = .034). After a median follow‐up of 23 months (interquartile range 5‐48), 92 patients (36%) reached the primary end point defined as hospitalization for heart failure or cardiovascular death. By multivariate Cox regression analysis, only persistent AF ( P = .005) and six‐minute walk distance ( P = .011) were independently associated with the primary end point.

Conclusions

Sixty percent of our HFpEF patients suffered from AF. Persistent but not paroxysmal AF was strongly associated with event‐free survival and was independently related to NYHA functional class, serum NT‐proBNP, atrial size, cardiac ouput and presence of COPD.

Related collections

Most cited references 21

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Phenotype-Specific Treatment of Heart Failure With Preserved Ejection Fraction: A Multiorgan Roadmap.

Sanjiv Shah, Dalane W. Kitzman, Barry Borlaug … (2016)

Heart failure (HF) with preserved ejection fraction (EF; HFpEF) accounts for 50% of HF cases, and its prevalence relative to HF with reduced EF continues to rise. In contrast to HF with reduced EF, large trials testing neurohumoral inhibition in HFpEF failed to reach a positive outcome. This failure was recently attributed to distinct systemic and myocardial signaling in HFpEF and to diversity of HFpEF phenotypes. In this review, an HFpEF treatment strategy is proposed that addresses HFpEF-specific signaling and phenotypic diversity. In HFpEF, extracardiac comorbidities such as metabolic risk, arterial hypertension, and renal insufficiency drive left ventricular remodeling and dysfunction through systemic inflammation and coronary microvascular endothelial dysfunction. The latter affects left ventricular diastolic dysfunction through macrophage infiltration, resulting in interstitial fibrosis, and through altered paracrine signaling to cardiomyocytes, which become hypertrophied and stiff because of low nitric oxide and cyclic guanosine monophosphate. Systemic inflammation also affects other organs such as lungs, skeletal muscle, and kidneys, leading, respectively, to pulmonary hypertension, muscle weakness, and sodium retention. Individual steps of these signaling cascades can be targeted by specific interventions: metabolic risk by caloric restriction, systemic inflammation by statins, pulmonary hypertension by phosphodiesterase 5 inhibitors, muscle weakness by exercise training, sodium retention by diuretics and monitoring devices, myocardial nitric oxide bioavailability by inorganic nitrate-nitrite, myocardial cyclic guanosine monophosphate content by neprilysin or phosphodiesterase 9 inhibition, and myocardial fibrosis by spironolactone. Because of phenotypic diversity in HFpEF, personalized therapeutic strategies are proposed, which are configured in a matrix with HFpEF presentations in the abscissa and HFpEF predispositions in the ordinate.

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Atrial Fibrillation Begets Heart Failure and Vice Versa: Temporal Associations and Differences in Preserved Versus Reduced Ejection Fraction.

Rajalakshmi Santhanakrishnan, Na Wang, Martin G. Larson … (2016)

Atrial fibrillation (AF) and heart failure (HF) frequently coexist and together confer an adverse prognosis. The association of AF with HF subtypes has not been well described. We sought to examine differences in the temporal association of AF and HF with preserved versus reduced ejection fraction.

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Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography.

Helmut Baumgartner, Judy Hung, Javier Bermejo … (2017)

Echocardiography is the key tool for the diagnosis and evaluation of aortic stenosis. Because clinical decision-making is based on the echocardiographic assessment of its severity, it is essential that standards are adopted to maintain accuracy and consistency across echocardiographic laboratories. Detailed recommendations for the echocardiographic assessment of valve stenosis were published by the European Association of Echocardiography and the American Society of Echocardiography in 2009. In the meantime, numerous new studies on aortic stenosis have been published with particular new insights into the difficult subgroup of low gradient aortic stenosis making an update of recommendations necessary. The document focuses in particular on the optimization of left ventricular outflow tract assessment, low flow, low gradient aortic stenosis with preserved ejection fraction, a new classification of aortic stenosis by gradient, flow and ejection fraction, and a grading algorithm for an integrated and stepwise approach of artic stenosis assessment in clinical practice.

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Author and article information

Contributors

Julia Mascherbauer: julia.mascherbauer@meduniwien.ac.at

Journal

Journal ID (nlm-ta): Eur J Clin Invest

Journal ID (iso-abbrev): Eur. J. Clin. Invest

Journal ID (doi): 10.1111/(ISSN)1365-2362

Journal ID (publisher-id): ECI

Title: European Journal of Clinical Investigation

Publisher: John Wiley and Sons Inc. (Hoboken )

ISSN (Print): 0014-2972

ISSN (Electronic): 1365-2362

Publication date (Electronic): 26 December 2019

Publication date (Print): February 2020

Volume: 50

Issue: 2 ( doiID: 10.1111/eci.v50.2 )

Electronic Location Identifier: e13184

Affiliations

[ ¹ ] Department of Internal Medicine II Division of Cardiology Medical University of Vienna Vienna Austria

[ ² ] Department of Cardiology Wiener Neustadt Hospital Wiener Neustadt Austria

[ ³ ] Department of Bioimiging and Image‐Guided Therapy Division of Cardiovascular and Interventional Radiology Medical University of Vienna Vienna Austria

Author notes

[*] [* ] Correspondence

Julia Mascherbauer, Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Währinger Gürtel, 1090 Vienna, Austria.

Email: julia.mascherbauer@ 123456meduniwien.ac.at

Author information

Robert Schönbauer https://orcid.org/0000-0002-8411-9716

Article

Publisher ID: ECI13184

DOI: 10.1111/eci.13184

PMC ID: 7027581

PubMed ID: 31732964

SO-VID: adbb1c61-f25d-4608-88bf-568605a6f8cc

License:

This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

History

Date received : 30 April 2019

Date revision received : 03 November 2019

Date accepted : 14 November 2019

Page count

Figures: 1, Tables: 3, Pages: 12, Words: 8049

Funding

Funded by: Austrian Society of Cardiology

Funded by: Österreichischer Herzfonds

Funded by: Austrian felowship grant

Award ID: KLI 246

Award ID: KLI 245

Custom metadata

source-schema-version-number 2.0

cover-date February 2020

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:5.7.5 mode:remove_FC converted:18.02.2020

ScienceOpen disciplines: Medicine

Keywords: atrial fibrillation,heart failure with preserved ejection fraction

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