Differential Prognostic Impact of Atrial Fibrillation in Hospitalized Heart Failure Patients With Preserved Ejection Fraction According to Coronary Artery Disease Status - Report From the Japanese Nationwide Multicenter Registry

Revascularization for Patients With Heart Failure With Preserved Ejection Fraction and Coronary Artery Disease

Coronary artery disease (CAD) is one of the main causes of heart failure (HF) with preserved ejection fraction (HFpEF). The efficacy of revascularization therapy in patients with HFpEF and CAD, however, remains unclear. Patients who underwent coronary angiography from January 2017 to December 2019 were included in this retrospective study if they further satisfied the diagnosis of HFpEF (left ventricular ejection fraction ≥50% plus plasma N-terminal pro-BNP ≥125 pg/ml) and CAD (patients had a history of confirmed myocardial infarction or ≥50% stenosis in at least 1 epicardial coronary vessel). Clinical data, way of revascularization, and outcome events (unplanned repeated revascularization, HF readmission, cardiovascular death, readmission of cerebral hemorrhage/stroke or gastrointestinal bleeding, and all-cause death) were recorded and analyzed. A total of 1,111 patients were enrolled for the present analysis. Based on whether the revascularization was complete or not, the patients were divided into the complete revascularization group (n = 780) and the incomplete/no revascularization group (n = 331). All patients were followed up with a median of 355 days. The overall rates of unplanned repeated revascularization, HF readmission, and cardiovascular death were 6.6%, 5.0%, and 0.4%, respectively. Compared with incompletely/not revascularized patients, completely revascularized patients had a lower rate of unplanned repeated revascularization (10.9% vs 4.7%, p <0.001) and cardiovascular death (0.9% vs 0.1%, p = 0.048). However, HF readmission, readmission of cerebral hemorrhage/stroke or gastrointestinal bleeding, and noncardiac death were comparable between the 2 groups. The regression analysis showed that hyperlipidemia, previous myocardial infarction, in-stent restenosis, and way of revascularization were associated with the composite events of unplanned repeated revascularization, HF readmission, and cardiovascular death during the follow-up. Complete revascularization may reduce unplanned repeated revascularization and cardiovascular death for patients with HFpEF and CAD.

Catheter Ablation for Atrial Fibrillation in Patients with Heart Failure: Current Evidence and Future Opportunities

Atrial fibrillation (AF) and heart failure (HF) are highly prevalent cardiac disorders worldwide, and both are associated with poor prognosis. The incidence of AF and HF has been increasing substantially in recent years, mainly due to the progressive aging of the population. These disorders often coexist, and may have a causal relationship, with one contributing to the development or progression of the other. AF is a significant risk factor for adverse outcomes in HF patients, including mortality, hospitalization, and stroke. Although the optimal treatment for AF with HF remains unclear, catheter ablation (CA) has emerged as a promising treatment option. This review provides a comprehensive overview of the current scientific evidence regarding the efficacy of CA for managing AF in HF patients. In addition, the potential benefits and risks associated with CA are also discussed. We will also explore the factors that may influence treatment outcomes and highlight the remaining gaps in knowledge in this field.

A review of the impact, pathophysiology, and management of atrial fibrillation in patients with heart failure with preserved ejection fraction

Patients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) have increased mortality and increased risk of stroke. Due to the heterogeneous nature of both disease processes, it is difficult to ascertain whether the diagnosis and progression of AF is the cause of deterioration or if it is a symptom of worsening heart failure. This presents physicians with a clinical conundrum of whether optimizing their heart failure will decrease the overall AF burden or if restoration of sinus rhythm is necessary to optimize patients with HFpEF. In this paper, we will review the impact of AF in patients with HFpEF, the pathophysiology and heterogeneity of HFpEF and AF, and the management of these patients. As HFpEF and AF become more prevalent, managing these disease processes needs standardization to improve outcomes. Further research is needed to understand the complex interplay between AF and HFpEF to help determine the best management strategy.

Machine learning for atrial fibrillation risk prediction in patients with sleep apnea and coronary artery disease

Background

Patients with sleep apnea (SA) and coronary artery disease (CAD) are at higher risk of atrial fibrillation (AF) than the general population. Our objectives were: to evaluate the role of CAD and SA in determining AF risk through cluster and survival analysis, and to develop a risk model for predicting AF.

Methods

Electronic medical record (EMR) database from 22,302 individuals including 10,202 individuals with AF, CAD, and SA, and 12,100 individuals without these diseases were analyzed using K-means clustering technique; k-nearest neighbor (kNN) algorithm and survival analysis. Age, sex, and diseases developed for each individual during 9 years were used for cluster and survival analysis.

Results

The risk models for AF, CAD, and SA were identified with high accuracy and sensitivity (0.98). Cluster analysis showed that CAD and high blood pressure (HBP) are the most prevalent diseases in the AF group, HBP is the most prevalent disease in CAD; and HBP and CAD are the most prevalent diseases in the SA group. Survival analysis demonstrated that individuals with HBP, CAD, and SA had a 1.5-fold increased risk of developing AF [hazard ratio (HR): 1.49, 95% CI: 1.18-1.87, p = 0.0041; HR: 1.46, 95% CI: 1.09-1.96, p = 0.01; HR: 1.54, 95% CI: 1.22-1.94, p = 0.0039, respectively] and individuals with chronic kidney disease (CKD) developed AF approximately 50% earlier than patients without these comorbidities in a period of 7 years (HR: 3.36, 95% CI: 1.46-7.73, p = 0.0023). Comorbidities that contributed to develop AF earlier in females compared to males in the group of 50-64 years were HBP (HR: 3.75 95% CI: 1.08-13, p = 0.04) CAD and SA in the group of 60-75 years were (HR: 2.4 95% CI: 1.18-4.86, p = 0.02; HR: 2.51, 95% CI: 1.14-5.52, p = 0.02, respectively).

Conclusion

Machine learning based algorithms demonstrated that CAD, SA, HBP, and CKD are significant risk factors for developing AF in a Latin-American population.

Catheter Ablation for Atrial Fibrillation in Patients with Heart Failure with Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

BACKGROUND

Catheter ablation (CA) for atrial fibrillation (AF) has been proposed as a means of improving outcomes among patients with heart failure and reduced ejection fraction (HFrEF) who are otherwise receiving appropriate treatment. Unlike HFrEF, treatment options are more limited in patients with preserved ejection fraction (HFpEF) and the data pertaining to the management of AF in these patients are controversial. The aim of this systematic review and meta-analysis was to investigate the effects of CA on outcomes of patients with AF and HFpEF, such as functional status, post-procedural complications, hospitalization, morbidity and mortality, based on data from observational studies.

METHODS

We systematically searched the electronic databases MEDLINE, PUBMED, EMBASE and the Cochrane Library for Central Register of Clinical Trials until May 2020.

RESULTS

Overall, the pooling of our data showed that sinus rhythm was achieved long-term in 58.0% (95% CI 0.44-0.71). Long-term AF recurrence was noticed in 22.3% of patients. Admission for HF occurred in 6.2% (95% CI 0.04-0.09) whilst all-cause mortality was identified in 6.3% (95% CI 0.02-0.13).

CONCLUSION

This meta-analysis is the first to focus on determining the benefits of a rhythm control strategy for patients with AF and HFpEF using CA, suggesting it may be worthwhile to investigate the effects of a CA rhythm control strategy as the default treatment of AF in HFpEF patients in randomized trials.

Predictive Value of HFA-PEFF Score in Patients With Heart Failure With Preserved Ejection Fraction

Aims: HFA-PEFF score has been proposed for diagnosing heart failure with preserved ejection fraction (HFpEF). Currently, there are only a limited number of tools for predicting the prognosis. In this study, we evaluated whether the HFA-PEFF score can predict mortality in patients with HFpEF.

Methods: This single-center, retrospective observational study enrolled patients diagnosed with HFpEF at the First Affiliated Hospital of Dalian Medical University between January 1, 2015, and April 30, 2018. The subjects were divided according to their HFA-PEFF score into low (0–2 points), intermediate (3–4 points), and high (5–6 points) score groups. The primary outcome was all-cause mortality.

Results: A total of 358 patients (mean age: 70.21 ± 8.64 years, 58.1% female) were included. Of these, 63 (17.6%), 156 (43.6%), and 139 (38.8%) were classified into the low, intermediate, and high score groups, respectively. Over a mean follow-up of 26.9 months, 46 patients (12.8%) died. The percentage of patients who died in the low, intermediate, and high score groups were 1 (1.6%), 18 (11.5%), and 27 (19.4%), respectively. A multivariate Cox regression identified HFA-PEFF score as an independent predictor of all-cause mortality [hazard ratio (HR):1.314, 95% CI: 1.013–1.705, P = 0.039]. A Cox analysis demonstrated a significantly higher rate of mortality in the intermediate (HR: 4.912, 95% CI 1.154–20.907, P = 0.031) and high score groups (HR: 5.291, 95% CI: 1.239–22.593, P = 0.024) than the low score group. A receiver operating characteristic (ROC) analysis indicated that the HFA-PEFF score can effectively predict all-cause mortality after adjusting for age and New York Heart Association (NYHA) class [area under the curve (AUC) 0.726, 95% CI 0.651–0.800, P = 0.000]. With an HFA-PEFF score cut-off value of 3.5, the sensitivity and specificity were 78.3 and 54.8%, respectively. The AUC on ROC analysis for the biomarker component of the score was similar to that of the total score.

Conclusions: The HFA-PEFF score can be used both to diagnose HFpEF and predict the prognosis. The higher scores are associated with higher all-cause mortality.