Clinical characteristics and predictors of one-year outcome of heart failure patients with atrial fibrillation compared to heart failure patients in sinus rhythm

Heart Failure in Elderly Patients: Medical Management, Therapies and Biomarkers

Heart failure (HF) is a common condition and one of the main morbidity and mortality factors in elderly patients. The incidence of HF progressively increases with age, reaching >10% in those aged 70 years or over. In the elderly population, both the diagnosis and the management of HF prove challenging, often requiring specialized care and a multidisciplinary approach. In seniors, atypical presentation of HF is much more common than in younger patients; thus, a holistic assessment with biomarkers related to HF allows for early diagnosis and accurate risk stratification in this group of patients. This article reviews the clinical and diagnostic differences in elderly patients with HF, highlighting the presence of comorbidities, frailty, cognitive impairment, and polypharmacy, as well as discussing potential biomarkers that may have clinical application in this population.

Exploring the Epidemiology of Atrial Fibrillation in Nigeria: A Focus on Atrial Fibrillation in Heart Failure Patients and Its Association With Stroke

Atrial fibrillation (AF) represents a significant global public health concern, particularly due to its association with adverse health outcomes such as stroke and heart failure. In Nigeria, where the burden of cardiovascular diseases is rising, understanding the prevalence and impact of AF is crucial for effective healthcare planning and intervention strategies. This review examines the epidemiology of AF in Nigeria, comparing it with global and African data. It explores demographic and regional variations, comorbidity factors, and the impact of AF on the healthcare system, mortality, and quality of life. Notably, the prevalence of AF in Nigeria generally falls just under 5%, but this figure rises to approximately 9% in stroke patients and 11-20% among those with heart failure (HF). Rheumatic heart disease (RHD) is identified as a significant AF risk factor within Africa, affecting around 20% of AF patients - a stark contrast to the 2% in North America. AF's association with higher mortality rates and functional deterioration highlights the urgent need for improved diagnostic and therapeutic approaches, alongside broader public health measures. In conclusion, the review emphasises the significant public health concern AF represents in Nigeria, especially among HF and stroke patients, and stresses the importance of tailored healthcare policies and interventions to mitigate AF's impact and improve patient outcomes.

Neuroimaging Studies of the Neural Correlates of Heart Rate Variability: A Systematic Review

Direct and indirect links between brain regions and cardiac function have been reported. We performed a systematic literature review to summarize current knowledge regarding the associations of heart rate variability (HRV) and brain region morphology, activity and connectivity involved in autonomic control at rest in healthy subjects. Both positive and negative correlations of cortical thickness and gray matter volumes of brain structures with HRV were observed. The strongest were found for a cluster located within the cingulate cortex. A decline in HRV, as well as cortical thickness with increasing age, especially in the orbitofrontal cortex were noted. When associations of region-specific brain activity with HRV were examined, HRV correlated most strongly with activity in the insula, cingulate cortex, frontal and prefrontal cortices, hippocampus, thalamus, striatum and amygdala. Furthermore, significant correlations, largely positive, between HRV and brain region connectivity (in the amygdala, cingulate cortex and prefrontal cortex) were observed. Notably, right-sided neural structures may be preferentially involved in heart rate and HRV control. However, the evidence for left hemispheric control of cardiac vagal function has also been reported. Our findings provide support for the premise that the brain and the heart are interconnected by both structural and functional networks and indicate complex multi-level interactions. Further studies of brain-heart associations promise to yield insights into their relationship to health and disease.

Heart failure in patients with atrial fibrillation: Insights from Polish part of the EORP-AF general long-term registry

AIMS

This study aimed to determine the impact of heart failure (HF) on clinical outcomes in patients with atrial fibrillation (AF).

METHODS AND RESULTS

We analysed data from Polish participants of the EURObservational Research Programme-AF General Long-Term Registry. The primary endpoint was all-cause death, and the secondary endpoints included hospital readmissions, cardiovascular (CV) interventions, thromboembolic and haemorrhagic events, rhythm control interventions, and other CV or non-CV diseases development during one-year follow up. Overall, 688 patients with available data on HF were included into analysis; 51% (n = 351) had HF; of these 48% (n = 168) had reduced ejection fraction (HFrEF), 22% (n = 77) mid-range EF (HFmrEF), and 30% (n = 106) preserved EF (HFpEF). Compared with patients without HF, those with HF had higher mortality rate (aHR 5.61; 95% CI 1.94-16.22, P < 0.01). Patients with HF (vs. without HF) had more often CV interventions (10% vs. 5.4%, P = 0.046) and events (14% vs. 7.1%, P = 0.02), and had less often atrial arrhythmia-related hospital admissions (6.8% vs. 15%, P < 0.01). Over follow-up, patients with HFmrEF and HFpEF had similar mortality rate versus HFrEF (aHR 0.45, 95% CI 0.13-1.57, P = 0.45 for HFmrEF and aHR 0.54, 95% CI 0.20-1.48, P = 0.54 for HFpEF). Mortality rate was similar among rhythm versus rate control group (aHR 0.34; 95% CI 0.10-1.16; P = 0.34).

CONCLUSIONS

AF patients with HF have greater mortality rate and more CV interventions/events. No statistically significant difference in long-term outcomes between patients with HFrEF, HFmrEF, and HFpEF highlights the need to develop therapeutic strategies targeting functional status and survival for patients with HF and AF.

Dysnatremia is associated with increased risk of all-cause mortality within 365 days post-discharge in patients with atrial fibrillation without heart failure: A prospective cohort study

AIM

The aim of this study is to evaluate the association between serum sodium concentrations at hospital admission and all-cause mortality within 365 days post-discharge in patients with atrial fibrillation (AF) without heart failure (HF).

METHODS

The prospective cohort study enrolled 1,446 patients with AF without HF between November 2018 and October 2020. A follow-up was performed 30, 90, 180, and 365 days after enrollment through outpatient visits or telephone interviews. All-cause mortality was estimated in three groups according to serum sodium concentrations: hyponatremia (< 135 mmol/L), normonatremia (135-145 mmol/L), and hypernatremia (> 145 mmol/L). We estimated the risk of all-cause mortalities using univariable and multivariable Cox proportional hazards models with normonatremia as the reference.

RESULTS

The all-cause mortalities of hyponatremia, normonatremia, and hypernatremia were 20.6, 9.4, and 33.3% within 365 days post-discharge, respectively. In the univariable analysis, hyponatremia (HR: 2.19, CI 1.5-3.2) and hypernatremia (HR: 4.03, CI 2.32-7.02) increased the risk of all-cause mortality. The HRs for hyponatremia and hypernatremia were 1.55 (CI 1.05-2.28) and 2.55 (CI 1.45-4.46) after adjustment for age, diabetes mellitus, loop diuretics, antisterone, antiplatelet drugs, and anticoagulants in the patients with AF without HF. The association between serum sodium concentrations and the HRs of all-cause mortality was U-shaped.

CONCLUSION

Dysnatremia at hospital admission was an independent factor for all-cause mortality in patients with AF without HF within 365 days post-discharge.

Predictive Value of Increased Perioperative Heart Rate for All-Cause Mortality After Cardiac Surgery: A Systematic Review and Meta-Analysis

Background: Accumulated studies have revealed that heart rates are associated with all-cause mortality in cardiac surgery patients, but the results remain controversial. This meta-analysis aimed to evaluate the predictive value of increased perioperative heart rate for all-cause mortality after cardiac surgery. Methods: We searched PubMed, Embase, Web of Science, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases for studies from inception to October 11, 2021. Two researchers independently screened the studies. Titles, authors, publication years, and hazard ratios were extracted. We used a random-effects model to combine the HRs and 95% confidence intervals. Several subgroup analyses were conducted. Statistical significance was set at p < .05. Results: Eleven studies were included in the meta-analysis of 33,849 patients and 3166 (9.4%) deaths. The HR of higher perioperative heart rates was 2.09 (95% CI 1.53-2.86, p < .001, I² = 81%). The HR with a 10-bpm increase in preoperative heart rate was 1.19 (95% CI 1.11-1.26, p < .001, I² = 51%). Subgroup analysis showed patients with higher preoperative heart rates had an HR of 1.88 (95% CI 1.51-2.34, p < .001, I² = 0%), and patients with a higher postoperative heart rate had an HR of 2.29 (95% CI 1.28- 4.09, p < .0001, I² = 91%) compared to patients with lower postoperative heart rates. Conclusion: Increased perioperative heart rate is associated with all-cause mortality in patients undergoing cardiac surgery.

Influence of hemoglobin concentration on the in-hospital outcomes in newly diagnosed heart failure patients with atrial fibrillation: Finding from CCC-AF (improving care for cardiovascular disease in China-atrial fibrillation) project

Atrial fibrillation (AF) and heart failure (HF) coexistence is common of clinical significance. Although anemia is a well-recognized risk factor for adverse outcomes, the prognostic value of hemoglobin is controversial in AF and HF. We aimed to determine whether hemoglobin is associated with in-hospital outcomes in such patients.On the basis of the data from the CCC-AF (Improving Care for Cardiovascular Diseases in China-Atrial Fibrillation) project, 2367 inpatients with a definitive diagnosis of AF and HF and record of admission hemoglobin concentration were included. Logistic regression analysis was performed to investigate the relationship between hemoglobin and in-hospital outcomes.All patients were divided into 4 groups according to quartiles of hemoglobin values. Compared with patients with higher hemoglobin, patients with lower hemoglobin had higher proportion of males, heart rate (HR), and diastolic blood pressure (DBP). On the contrary, they had lower age, medical history, left ventricular ejection fraction (LVEF), and brain natriuretic peptide (P < .05). Spearman correlation showed that hemoglobin was negatively correlated with age, LVEF, international normalized ratio, and serum creatinine but positively correlated with HR, DBP, and blood urea nitrogen (P < .05). Multivariable logistic regression analysis revealed that increasing hemoglobin was an independent protective factor for in-hospital outcomes (odds ratio = 0.989; 95% confidence interval: 0.979-1.000; P = .046).Admission hemoglobin concentration was an independent protective factor for in-hospital outcomes in HF patients with AF. Our study indicated that increasing hemoglobin level and improving anemia degree might improve the prognosis of patients with AF and HF.

Randomized controlled clinical trials versus real-life atrial fibrillation patients treated with oral anticoagulants. Do we treat the same patients?

BACKGROUND

The aim of the study was to compare clinical characteristics of real-life atrial fibrillation (AF) patients with populations included in randomized clinical trials (ROCKET AF and RE-LY).

METHODS

The analysis included 3528 patients who are participants of the ongoing, multicentre, retrospective CRAFT study. The study is registered in ClinicalTrials.gov: NCT02987062. The study is based on a retrospective analysis of hospital records of AF patients treated with vitamin K antagonists (VKAs) (acenocoumarol, warfarin) and non-vitamin K oral anticoagulants (NOACs) (dabigatran, rivaroxaban). CHADS2 score was used for risk of stroke stratification.

RESULTS

VKA was prescribed in 1973 (56.0%), while NOAC in 1549 (44.0%), including dabigatran - 504 (14.3%) and rivaroxaban - 1051 (29.8%), of the 3528 patients. VKA patients in the CRAFT study were at significantly lower risk of stroke (CHADS2 1.9 ± 1.3), compared with the VKA population from the RE-LY (2.1 ± 1.1) and the ROCKET-AF (3.5 ± 1.0). Patients in the CRAFT study treated with NOAC (CHADS2 for patients on dabigatran 150 mg - 1.3 ± 1.2 and on rivaroxaban - 2.2 ± 1.4) had lower risk than patients from the RE-LY (2.2 ± 1.2) and the ROCKET AF (3.5 ± 0.9).

CONCLUSIONS

Real-world patients had a lower risk of stroke than patients included in the RE-LY and ROCKET AF trials.

Clinical characteristics and thromboembolic risk of atrial fibrillation patients with and without congestive heart failure. Results from the CRATF study

Congestive heart failure (CHF) and atrial fibrillation (AF) frequently coexist and are associated with increased risk of cardiovascular events.To compare baseline characteristics, comorbidities and pharmacotherapy in AF patients with concomitant CHF to those without CHF.The study included 3506 real-life AF patients with (37.1%) and without CHF - participants of the multicentre, retrospective MultiCenter expeRience in AFib patients Treated with OAC (CRAFT) trial (NCT02987062).All patients were treated with non-vitamin K antagonist oral anticoagulants (NOAC) or vitamin K antagonists (VKA). The frequency of NOAC among patients with and without CHF was 45.6% and 43.2%, respectively (P = .17). Patients with CHF were older (73.3 vs 64.7 years, P <.001), less likely to be women (37.4% vs 42%, P = .007), had higher CHA2DS2-VASc score (3.8 ± 1.7 vs 2.6 ± 1.8, P <.001), more often had permanent AF (53.0% vs 13.4%, P <.001), chronic obstructive pulmonary disease (16.7% vs 4.9%, P <.001), coronary artery disease (64.3% vs 29.8%, P <.001), peripheral vascular disease (65.3% vs 31.4%, P <.001), chronic kidney disease (43.1% vs 10.0%, P <.001), liver fibrosis (5.7% vs 2.6%, P <.001), neoplasm (9.6% vs 7.3%, P = .05), history of composite of stroke, transient ischemic attack or systemic embolization (16.2% vs 10.7%, P <.001), pacemaker (27.4% vs 22.1%, P = .004), implantable cardioverter-defibrillator (22.7% vs 0.8%, P <.001) or transaortic valve implantation (4.0% vs 0.8%, P <.001), cardiac resynchronization therapy (8.7% vs 0.3%, P <.001), composite of kidney transplantation, hemodialysis or creatinine level > 2.26 mg/dL (3.6% vs 0.8%, P <.001) and had less often hypertension (69.4% vs 72.5%, P = .05).Patients with AF and CHF had a higher thromboembolic risk and had more concomitant diseases.

Atrial Fibrillation in Patients with Heart Failure: Current State and Future Directions

Heart failure affects nearly 26 million people worldwide. Patients with heart failure are frequently affected with atrial fibrillation, and the interrelation between these pathologies is complex. Atrial fibrillation shares the same risk factors as heart failure. Moreover, it is associated with a higher-risk baseline clinical status and higher mortality rates in patients with heart failure. The mechanisms by which atrial fibrillation occurs in a failing heart are incompletely understood, but animal studies suggest they differ from those that occur in a healthy heart. Data suggest that heart failure-induced atrial fibrosis and atrial ionic remodeling are the underlying abnormalities that facilitate atrial fibrillation. Therapeutic considerations for atrial fibrillation in patients with heart failure include risk factor modification and guideline-directed medical therapy, anticoagulation, rate control, and rhythm control. As recommended for atrial fibrillation in the non-failing heart, anticoagulation in patients with heart failure should be guided by a careful estimation of the risk of embolic events versus the risk of hemorrhagic episodes. The decision whether to target a rate-control or rhythm-control strategy is an evolving aspect of management. Currently, both approaches are good medical practice, but recent data suggest that rhythm control, particularly when achieved through catheter ablation, is associated with improved outcomes. A promising field of research is the application of neurohormonal modulation to prevent the creation of the "structural substrate" for atrial fibrillation in the failing heart.

Clinical and Echocardiographic Predictors of Arrhythmias Detected With 24-Hour Holter Electrocardiography Among Hypertensive Heart Failure Patients in Nigeria

Background

Hypertensive heart failure (HHF) is the commonest form of heart failure in Nigeria. There is paucity of data in Nigeria on 24-hour Holter electrocardiography (24-HHECG) and important predictors of arrhythmias among HHF patients.

Objectives

To determine the 24-HHECG characteristics among HHF patients. To determine the clinical and echocardiographic predictors of arrhythmias detected using 24-HHECG among HHF patients.

Methods

A total of 100 HHF patients as well as 50 age-matched and sex-matched apparently healthy controls were prospectively recruited over a period of 1 year. They all had baseline laboratory tests, echocardiography, and 24-HHECG.

Results

Hypertensive heart failure patients had significantly higher counts of premature ventricular contractions (PVCs) than the controls (P ≤ .001). Ventricular tachycardia (VT) was recorded in 29% of HHF patients as compared with controls who had no VT on 24-HHECG. The standard deviation of all normal to normal sinus RR intervals over 24 hours (SDNN) was abnormally reduced among HHF patients when compared with controls (P = .046). There was positive correlation between atrial fibrillation (AF) and the following parameters: PVCs (r = .229, P = .015), New York Heart Association (NYHA) (r = .196, P = .033), and VT (r = .223, P = .018). Following multiple linear regression, left ventricular ejection fraction (LVEF) (P ≤ .001) and serum urea (P = .037) were predictors of PVCs among HHF patients. Serum creatinine (P ≤ .001), elevated systolic blood pressure (SBP) (P = .005), and PVCs (P ≤ .001) were important predictors of VT among HHF patients.

Conclusions

Renal dysfunction and reduced LVEF were important predictors of ventricular arrhythmias. High counts of PVCs and elevated SBP were predictive of the occurrence of VT among HHF patients. The NYHA class and ventricular arrhythmias have a significant positive correlation with AF. The SDNN is reduced in HHF patients.

Anemia at Hospital Admission and Its Relation to Outcomes in Patients With Heart Failure (from the Polish Cohort of 2 European Society of Cardiology Heart Failure Registries)

Anemia is a commonly observed co-morbidity in heart failure (HF). The aim of the study was to assess prevalence, risk factors for, and effect of anemia on short- and long-term outcomes in HF. The study included 1,394 Caucasian patients hospitalized for HF, with known hemoglobin concentration on hospital admission, participating in 2 HF registries of the European Society of Cardiology (Pilot and Long-Term). Anemia was defined as hemoglobin concentration of <13 g/dl for men and <12 g/dl for women. Primary end points were (1) all-cause death at 1 year and (2) a composite of all-cause death and rehospitalization for HF at 1 year. Secondary end points included inter alia death during index hospitalization. In addition, we investigated the effect of changes in hemoglobin concentration during hospitalization on prognosis. Anemia occurred in 33% of patients. Predictors of anemia included older age, diabetes, greater New York Heart Association class at hospital admission and kidney disease. During 1-year follow-up, 21% of anemic and 13% of nonanemic patients died (p <0.0001). Combined primary end point occurred in 45% of anemic and in 33% of nonanemic patients (p <0.0001). Anemia was strongly predictive of all the prespecified clinical end points in univariate analyses but not in multivariate analyses. Changes in hemoglobin concentration during hospitalization had no effect on 1-year outcomes. In conclusion, anemia was present in 1/3 of patients with HF. Mild-to-moderate anemia seems more a marker of older age, worse clinical condition, and a higher co-morbidity burden, rather than an independent risk factor in HF.

Diagnosis, Clinical Course, and 1-Year Outcome in Patients Hospitalized for Heart Failure With Preserved Ejection Fraction (from the Polish Cohort of the European Society of Cardiology Heart Failure Long-Term Registry)

Compared with heart failure (HF) with reduced ejection fraction (HF-REF), the diagnosis of HF with preserved EF (HF-PEF) is more challenging. The aim of the study was to assess the prevalence of HF-PEF among patients hospitalized for HF, to evaluate the pertinence of HF-PEF diagnosis and to compare HF-PEF and HF-REF patients with respect to outcomes. The analysis included 661 Polish patients hospitalized for HF, selected from the European Society of Cardiology (ESC)-HF Long-Term Registry. Patients with an EF of ≥50% were included in the HF-PEF group and patients with an EF of <50% - in the HF-REF group. The primary end point was all-cause death at 1 year. The secondary end point was a composite of all-cause death and rehospitalization for HF at 1 year. HF-PEF was present in 187 patients (28%). Of those 187 patients, mitral inflow pattern was echocardiographically assessed in 116 patients (62%) and classified as restrictive/pseudonormal in 37 patients (20%). Compared with HF-REF subjects, patients with HF-PEF were older, more often female, and had a higher prevalence of hypertension, atrial fibrillation and sleep apnea. Despite lower B-type natriuretic peptide concentrations and lower prevalence of moderate-to-severe mitral regurgitation in patients with HF-PEF, congestive symptoms at admission were as severe as in patients with HF-REF. There were no significant differences in in-hospital mortality between the HF groups. One-year mortality was high in both groups (17% in HF-PEF vs 21% in HF-REF, p = 0.22). There was a trend toward a lower frequency of the secondary end point in the HF-PEF group (32% vs 40%, p = 0.07). In conclusion, in clinical practice, even easily obtainable echocardiographic indexes of diastolic dysfunction are relatively rarely acquired. One-year survival rate of patients with HF-PEF is not significantly better than that of patients with HF-REF.