Importance of non-cardiovascular comorbidities in atrial fibrillation and heart failure with preserved ejection fraction

AIMS

Atrial fibrillation (AF) and heart failure (HF) with preserved ejection fraction (HFpEF) are interlinked and frequently coexisting conditions. To date, patients with AF and HFpEF have limited evidence guiding their management. This study aimed to investigate the predictors of adverse outcomes among patients with AF and HFpEF.

METHODS

The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Kyoto, Japan. From the registry, we explored predictors for a composite of cardiac death or HF hospitalization among AF patients with HFpEF (defined as having a prior HF hospitalization or New York Heart Association class ≥2 in association with heart disease and left ventricular ejection fraction ≥50%). Besides, we investigated whether the scoring using the predictors identified by the Fushimi AF Registry could stratify the outcomes in patients with AF and HFpEF registered in another independent Kyoto Congestive Heart Failure Registry.

RESULTS

Of 755 patients with AF and HFpEF [mean age: 77.5 ± 9.9 years; female: 391 (52%); paroxysmal AF: 258 (34%); and mean CHA2DS2-VASc score: 4.5 ± 1.5], cardiac death or HF hospitalization occurred in 246 patients (33%) during the median follow-up period of 4.4 years in the Fushimi AF Registry. Using multivariate Cox regression analysis, age ≥75 years [hazard ratio (HR): 1.72, 95% confidence interval (CI): 1.26-2.36] and non-cardiovascular comorbidities such as anaemia (HR: 1.83, 95% CI: 1.37-2.46), chronic kidney disease (HR: 1.69, 95% CI: 1.27-2.26), diabetes mellitus (HR: 1.55, 95% CI: 1.15-2.09) and chronic obstructive pulmonary disease (HR: 1.87, 95% CI: 1.08-3.22) were independent predictors of adverse outcomes. Meanwhile, cardiovascular comorbidities including coronary artery disease, valvular heart disease or cardiomyopathy were not significantly associated with adverse outcomes. These results were also the case when analysed for patients with AF and HFpEF who registered in the Kyoto Congestive Heart Failure registry (N = 878). The score assigning 1 point for each five predictors (age, anaemia, chronic kidney disease, diabetes mellitus and chronic obstructive pulmonary disease; ranging 0-5 points) stratified the incidence of adverse outcomes among patients with AF and HFpEF registered in the Kyoto Congestive Heart Failure Registry as well as among those in the Fushimi AF Registry (both log-rank; P < 0.001).

CONCLUSIONS

Non-cardiovascular comorbidities such as anaemia, diabetes mellitus and kidney or pulmonary disease in addition to advanced age were independent predictors of adverse outcomes in patients with AF and HFpEF. Our study suggests the importance of focusing on these non-cardiovascular comorbidities for individualized risk stratification and optimal management in patients with AF and HFpEF.

Trastuzumab deruxtecan versus trastuzumab emtansine in Asian patients with HER2-positive metastatic breast cancer

The global phase 3 DESTINY-Breast03 study (ClinicalTrials.gov; NCT03529110) showed statistically significant and clinically meaningful improvements in progression-free survival (PFS) and overall survival (OS) with trastuzumab deruxtecan (T-DXd) over trastuzumab emtansine (T-DM1) in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (mBC) previously treated with trastuzumab and a taxane. Here, we report a subgroup analysis of Asian patients enrolled in DESTINY-Breast03. In total, 309 patients (149 in the T-DXd arm and 160 in the T-DM1 arm) from Asian countries and regions were randomized. At data cutoff (July 25, 2022), the median duration of follow-up in the Asian subpopulation was 29.0 months with T-DXd and 26.0 months with T-DM1. The PFS (determined by blinded independent central review) hazard ratio was 0.30 (95% confidence interval 0.22-0.41) favoring T-DXd over T-DM1 (median PFS 25.1 vs. 5.4 months). Median OS was not reached in the T-DXd arm and was 37.7 months in the T-DM1 arm. The median treatment duration was 15.4 months with T-DXd and 5.5 months with T-DM1. The incidence of grade ≥3 drug-related treatment-emergent adverse events was similar between both treatment arms (49.0% vs. 46.5%) and was consistent with the overall DESTINY-Breast03 population. Adjudicated drug-related interstitial lung disease or pneumonitis occurred in 12.9% of patients treated with T-DXd and 2.5% treated with T-DM1, with a higher incidence in Japanese patients; none of these were grade ≥4 events. These efficacy and safety data reinforce the favorable benefit-risk profile of T-DXd in HER2-positive mBC, including in the Asian subgroup.

Design, Rationale and Initial Findings From HERA-FIB on 10 222 Patients With Atrial Fibrillation Presenting to an Emergency Department Over An 11-Year Period

BACKGROUND

For the majority of patients with atrial fibrillation (AF), disease management has improved in recent years. However, there are still populations underrepresented or excluded in current registries and randomized controlled trials. HERA-FIB (Heidelberg Registry of Atrial Fibrillation) was planned to assess real-world evidence for the prevalence, demographic characteristics and management of patients with the diagnosis of AF presenting consecutively to a chest pain unit.

METHODS AND RESULTS

HERA-FIB is a retrospective, observational, single-center study on patients with a diagnosis of AF presenting to a chest pain unit from June 2009 until March 2020. This article describes the structure, governance, outcome assessment, quality and data collection processes of the registry. Additionally, characteristics of populations of special interest are described. The study consecutively enrolled 10 222 patients presenting with AF to the chest pain unit of the University Hospital of Heidelberg. Clinical parameters and patient characteristics were assessed retrospectively. Outcome parameters included rates for all-cause death, stroke, myocardial infarction and major bleedings. We were able to investigate patient cohorts of special interest such as advanced chronic kidney disease, octogenarians, and those with acute coronary syndrome who are often underrepresented in current studies and randomized controlled trials.

CONCLUSIONS

HERA-FIB is one of the largest real-world single-center retrospective registries on patients with AF, which captures the era of transition from vitamin K antagonists to non-vitamin K oral anticoagulation regimens in clinical practice and offers the possibility to investigate patient populations usually underrepresented or excluded in current available randomized controlled trials and registries.

REGISTRATION

URL: https://www.clinicaltrials.gov; unique identifier: NCT05995561.

Transcatheter aortic valve implantation for combined aortic and mitral stenoses: Insights from the OCEAN-TAVI Registry

AIMS

Mitral stenosis (MS) occasionally coexists with aortic stenosis (AS). Limited data are available regarding the functional class and clinical outcomes of patients who undergo transcatheter aortic valve implantation (TAVI) for combined AS and MS. This study compared the clinical outcomes in patients with and without MS who underwent TAVI for severe AS and assessed the impact of mitral annulus calcification (MAC) severity, transmitral gradient (TMG) and mitral valve area (MVA) on outcomes in patients with combined AS and MS.

METHODS

We investigated patients in the OCEAN-TAVI registry who underwent TAVI. MS was defined as an MVA ≤ 1.5 cm2 or TMG ≥ 5 mmHg. The composite of all-cause death and admission for heart failure was compared between patients with and without MS. The impact of MAC, TMG and MVA on outcomes was assessed in patients with combined AS and MS.

RESULTS

We identified 106 patients with MS (MAC 84%; TMG 6.4 ± 2.6 mmHg; MVA 1.10 ± 0.31 cm2) and 6570 without MS as controls. The MS group was older (85 ± 5 vs. 84 ± 5 years, P = 0.033), more of women (85 vs. 67%, P < 0.01), and had a higher risk of surgery (the Society of Thoracic Surgeons Mortality Score 8.7 ± 5.1 vs. 7.6 ± 5.9, P = 0.047) than the controls. In the MS group, the New York Heart Association Functional Class was 3 or 4 in 56% of the patients at baseline and 6% at 1 year after TAVI. Thirty-day mortality (2.8% vs. 1.3%, P = 0.18) and early composite outcomes (17% vs. 15%, P = 0.56) were comparable between patients with and without MS. During a median follow-up of 2.1 years, the presence of MS was associated with a higher incidence of adverse events compared with controls (adjusted hazard ratio [HR] 1.84; 95% confidence interval [CI] 1.34-2.51, P < 0.01), even on propensity score matched analysis (adjusted HR 1.91; 95% CI 1.14-3.22, P < 0.01). Moderate or severe MAC contributed to increased risk of adverse events in patients with MS (adjusted HR 2.89; 95% CI 1.20-6.99, P = 0.018), but TMG and MVA did not.

CONCLUSIONS

In patients undergoing TAVI for severe AS, those with moderate or severe MS experienced worse outcomes after TAVI compared with those without MS. Patients with combined AS and MS sustained symptom improvement at 1-year post-TAVI. MAC severity was a useful predictor of adverse events compared with MS haemodynamics such as TMG and MVA in patients with combined AS and MS.