Atrial Fibrillation Begets Heart Failure and Vice Versa

Abstract

484 H eart failure (HF) and atrial fibrillation (AF) have emerged as 2 new epidemics of cardiovascular disease in the last 20 years. 1 The prevalence of both conditions is expected to increase with the aging of the population. By the year 2030, there will be 12 million Americans with AF and >8 million with HF. 2,3 Beyond sharing common predisposing risk fac-tors such as hypertension, diabetes mellitus, ischemic heart disease, and valvular heart disease, 4 AF and HF clearly are closely intertwined, with each disease predisposing to the other. When present in combination, AF and HF portend a worse prognosis than either condition alone. 5–7 Clinical Perspective on p 492 AF coexists with both HF with preserved and reduced ejection fraction (HFpEF and HFrEF). 8 However, previous studies have noted differences among HF subtypes in atrial Background—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. Methods and Results—We studied Framingham Heart Study participants with new-onset AF or HF between 1980 and 2012. Among 1737 individuals with new AF (mean age, 75±12 years; 48% women), more than one third (37%) had HF. Conversely, among 1166 individuals with new HF (mean age, 79±11 years; 53% women), more than half (57%) had AF. Prevalent AF was more strongly associated with incident HF with preserved ejection fraction (multivariable-adjusted hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.48–3.70; no AF as referent) versus HF with reduced ejection fraction (HR, 1.32; 95% CI, 0.83–2.10), with a trend toward difference between HF subtypes (P for difference=0.06). Prevalent HF was associated with incident AF (HR, 2.18; 95% CI, 1.26–3.76; no HF as referent). The presence of both AF and HF portended greater mortality risk compared with neither condition, particularly among individuals with new HF with reduced ejection fraction and prevalent AF (HR, 2.72; 95% CI, 2.12–3.48) compared with new HF with preserved ejection fraction and prevalent AF (HR, 1.83; 95% CI, 1.41–2.37; P for difference=0.02). Conclusions—AF occurs in more than half of individuals with HF, and HF occurs in more than one third of individuals with AF. AF precedes and follows HF with both preserved and reduced ejection fraction, with some differences in temporal association and prognosis. Future studies focused on underlying mechanisms of these dual conditions are warranted.