Ejection fraction and outcomes in patients with atrial fibrillation and heart failure: the Loire Valley Atrial Fibrillation Project

Banerjee, Amitava; Taillandier, Sophie; Olesen, Jonas Bjerring; Lane, Deirdre A.; Lallemand, Bénédicte; Lip, Gregory Y.H.; Fauchier, Laurent

doi:10.1093/eurjhf/hfs005

Cited by 101 publications

(57 citation statements)

References 45 publications

(42 reference statements)

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“…In a previously published retrospective study of hospitalized AF patients (58.5% of whom were taking Vitamin K antagonists), no statistically significant differences were observed in the rates of stroke or stroke/thromboembolism between those with HF-PEF versus HF-REF or across categories of LV impairment (mild, moderate, and severe). 25 These data and our results confirm a recent systematic review that found no statistically significant difference in stroke risk between patients with AF and preserved or reduced ejection fraction. 26 In a post hoc analysis, ARISTOTLE investigators found no significant association between LVSD or HF-PEF (defined as LVEF >0.40) and risk of stroke and systemic embolism compared with patients without both HF and LVSD after multivariable adjustment (P=0.71).…”

Section: Systolic Function Hf Symptom Severity and Outcomessupporting

confidence: 92%

Relationship Between Degree of Left Ventricular Dysfunction, Symptom Status, and Risk of Embolic Events in Patients With Atrial Fibrillation and Heart Failure

Sandhu

Hohnloser

Pfeffer

et al. 2015

Stroke

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Background and Purpose-Limited data exists regarding the relationship between left ventricular systolic dysfunction (LVSD) and heart failure (HF) symptoms and embolic risk among patients with atrial fibrillation. Methods-Participants in the Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events (ACTIVE)trials with HF, but not randomized to oral anticoagulation, were categorized as having preserved versus reduced ejection fraction. If reduced, LVSD was classified as mild, moderate, or severe. Symptoms were quantified using New York Heart Association class.The primary outcome was a composite of stroke, transient ischemic attack, and systemic embolism. Results-There were 3487 antiplatelet-treated patients with HF at baseline. Of these patients, 969 (46.8%) had HF with preserved ejection fraction and 1103 (53.2%) had HF with reduced ejection fraction. During 3.6 years of mean followup, first occurrence of stroke, transient ischemic attack, or systemic embolism occurred in 386 patients.The strongest independent predictors of embolic events were age ≥75 years (hazard ratio 2.55; confidence interval, 1.85-3.53), prior stroke or transient ischemic attack (hazard ratio 2.07; 95% confidence interval, 1.65-2.60), and female sex (hazard ratio 1.37; confidence interval, 1.11-1.69). However, ejection fraction <0.50, degree of LVSD, and New York Heart Association class did not predict embolic events. Patients with HF with preserved ejection fraction exhibited similar risk of embolic events as those with HR with reduced ejection fraction: 4.3% versus 4.4% per 100 person-years (hazard ration 1.01; 95% confidence interval, 0.78-1.31). Risk of embolic events was similar across categories of LVSD (P for trend =0.96) and New York Heart Association class (P for trend =0.57). Conclusion-Among

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Section: Systolic Function Hf Symptom Severity and Outcomessupporting

confidence: 92%

Relationship Between Degree of Left Ventricular Dysfunction, Symptom Status, and Risk of Embolic Events in Patients With Atrial Fibrillation and Heart Failure

Sandhu

Hohnloser

Pfeffer

et al. 2015

Stroke

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“…In patients with AF, guidelines define HF (moderate to severe left ventricular systolic dysfunction or recent decompensated HF requiring hospitalization irrespective of EF) as an independent risk factor for thromboembolism. [8][9][10][11]14,30,31 After adjusting for baseline differences, but not treatment randomization, we observed that patients with HF had a similar risk of stroke or systemic embolism, myocardial infarction, and bleeding but a higher observed risk of all-cause death and vascular death than patients without HF. Although HF was not independently associated with an increased risk of stroke or systemic embolism, we hypothesize that the lack of an observed difference may be attributable to the high thromboembolic risk of the ROCKET AF study participants; wherein the mean CHADS 2 in this trial was 3.5 (compared with the RE-LY and ARISTOTLE trials, which had a mean CHADS 2 scores of 2.1), and a large proportion of the study population could be categorized as having HF at the time of randomization.…”

Section: Discussionmentioning

confidence: 91%

Efficacy and Safety of Rivaroxaban in Patients With Heart Failure and Nonvalvular Atrial Fibrillation

Diepen

Hellkamp

Patel

et al. 2013

Circ: Heart Failure

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Background— In Rivaroxaban Once daily, oral, direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF), rivaroxaban was noninferior to warfarin for the prevention of stroke and systemic embolic events and significantly reduced intracranial bleeding in patients with nonvalvular atrial fibrillation. We explore the safety and efficacy of rivaroxaban in patients with heart failure (HF). Methods and Results— A total of 9033 (63.7%) patients had HF. The primary efficacy analysis was rates of stroke or systemic embolism (per 100 patient-years) by intention to treat. The safety outcomes were major or nonmajor clinically relevant bleeding and hemorrhagic stroke during treatment. Patients with HF were younger (72 versus 74 years), more likely to have persistent atrial fibrillation (83.0% versus 77.6%), and had higher mean CHADS 2 scores (3.7 versus 3.1). The efficacy of rivaroxaban compared with warfarin was similar in patients with HF (1.90 versus 2.09) and without HF (2.10 versus 2.54; P -interaction=0.62). The risk of major or nonmajor clinically relevant bleeding with rivaroxaban was similar to warfarin in patients with HF (14.22 versus 14.02) and without HF (16.12 versus 15.35; P -interaction=0.99). A reduction in hemorrhagic stroke was observed with rivaroxaban in patients with HF as in the overall trial (adjusted hazard ratio, 0.38; 95% confidence interval, 0.19–0.76; P -interaction=0.067). Among patients with HF, the efficacy of rivaroxaban was similar, irrespective of ejection fraction <40 or ≥40% ( P -interaction=0.38), New York Heart Association class I-II versus III-IV ( P -interaction=0.68), HF preserved or reduced ejection fraction ( P -interaction=0.35), or CHADS 2 score 2 versus ≥3 ( P -interaction=0.48). Conclusions— Treatment-related outcomes were similar in patients with and without HF and across HF subgroups. These findings support the use of rivaroxaban as an alternative to warfarin in patients with atrial fibrillation and HF. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00403767.

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“…12 The institution includes 4 hospitals covering all medical and surgical specialties, and it is the only public institution in an area of ≈4000 km 2 , serving ≈400 000 inhabitants. All patients diagnosed with nonvalvular AF or atrial flutter by the cardiology department between 2000 and 2010 were identified, 13 excluding patients with valvular AF.…”

Section: Study Populationmentioning

confidence: 99%

Stroke and Major Bleeding Risk in Elderly Patients Aged ≥75 Years With Atrial Fibrillation

Lip

Clémenty

Pericart

et al. 2015

Stroke

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The limitations of the VKAs have also been partly overcome by the availability of the non-VKA oral anticoagulants (OACs), which offer relative efficacy, safety, and convenience compared with the VKAs. 6 Ancillary analyses reporting the elderly subgroup from the large randomized trials have been reported, showing consistency in the effect size for benefits/ harms for the elderly compared with younger patients with Background and Purpose-Atrial fibrillation (AF) is increasingly prevalent in the elderly, but such patients tend to be under-represented in clinical trials. Increasing age confers a higher risk of stroke and bleeding when antithrombotic therapy is used. We examined risk factors for stroke and bleeding among elderly (age, >75 years) patients within a real world hospitalized cohort from the Loire Valley AF project. Methods-We identified elderly (age, >75 years) patients with AF, assessed their risk factors, and followed up for stroke, thromboembolism, death, or major bleeding. The effect of vitamin K antagonist (VKA) use on these end points was assessed. Results-We studied 8962 patients with AF, and we identified 4130 elderly (age, ≥75 years) patients. Using Kaplan-Meier analyses, event rates of death, stroke/thromboembolism, the composite of stroke/thromboembolism/death, and major bleeding increased with increasing age. For mortality, VKA-treated patients did better than non-VKA-treated patients. The risk of death and stroke/thromboembolism/death increased with increasing age. The risk of major bleeding did not increase with increasing age strata. VKA treatment was associated with lower mortality in those aged <75 years (adjusted hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.45-0.72), and the effect size was maintained with increasing age strata (P int =0.67). For stroke/thromboembolism/death, VKA also has a significant benefit in those aged <75 years (adjusted HR, 0.69;, and the effect size was maintained with increasing age strata (P int =0.58). For major bleeding, there was no statistically significant difference between age strata (P int =0.67). In elderly patients, age and previous stroke emerged as the main predictors of stroke and thromboembolism. Renal impairment and VKA use were predictors of major bleeding. Conclusions-Elderly patients with AF have a higher risk of stroke and bleeding, but the benefits of VKA therapy for stroke/thromboembolism or mortality were present regardless of increasing age.

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Ejection fraction and outcomes in patients with atrial fibrillation and heart failure: the Loire Valley Atrial Fibrillation Project

Cited by 101 publications

References 45 publications

Relationship Between Degree of Left Ventricular Dysfunction, Symptom Status, and Risk of Embolic Events in Patients With Atrial Fibrillation and Heart Failure

Relationship Between Degree of Left Ventricular Dysfunction, Symptom Status, and Risk of Embolic Events in Patients With Atrial Fibrillation and Heart Failure

Efficacy and Safety of Rivaroxaban in Patients With Heart Failure and Nonvalvular Atrial Fibrillation

Stroke and Major Bleeding Risk in Elderly Patients Aged ≥75 Years With Atrial Fibrillation

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