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Arrhythmias and sudden death
Original research
Atrial fibrillation and risk of incident heart failure with reduced versus preserved ejection fraction
  1. Charles D Nicoli1,
  2. Wesley T O’Neal2,
  3. Emily B Levitan3,
  4. Matthew J Singleton4,
  5. Suzanne E Judd5,
  6. George Howard5,
  7. Monika M Safford6,
  8. Elsayed Z Soliman7
  1. 1 Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
  2. 2 Noninvasive Cardiology, Cone Health Heart and Vascular Center, Greensboro, North Carolina, USA
  3. 3 Epidemiology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
  4. 4 Medicine, Section on Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
  5. 5 Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
  6. 6 General Internal Medicine, Weill Cornell Medical College, New York, New York, USA
  7. 7 Epidemiological Cardiology Research Center (EPICARE), Department of Epidemiology, Division of Public Health, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
  1. Correspondence to Dr Charles D Nicoli, Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA; cdnicoli.md{at}gmail.com

Abstract

Objective Associations between atrial fibrillation (AF) and heart failure (HF) have been established. We compared the extent to which AF is associated with each primary subtype of HF, with reduced (HFrEF) versus preserved ejection fraction (HFpEF).

Methods We included 25 787 participants free of baseline HF from the REGARDS (REasons for Geographic And Racial Differences in Stroke) cohort. Baseline AF was ascertained from ECG and self-reported history of physician diagnosis. Incident HF events were determined from physician-adjudicated review of hospitalisation medical records and HF deaths. Based on left ventricular ejection fraction (LVEF) at the time of HF event, HFrEF, HFpEF, and mid-range HF were defined as LVEF <40%, ≥50% and 40%–49%, respectively. Multivariable Cox proportional-hazards models examined the association between AF and HF. The Lunn-McNeil method was used to compare associations of AF with incident HFrEF versus HFpEF.

Results Over a median of 9 years of follow-up, 1109 HF events occurred (356 HFpEF, 388 HFrEF, 77 mid-range and 288 unclassified). In a model adjusted for sociodemographics, cardiovascular risk factors, and incident coronary heart disease, AF was associated with increased risk of all HF events (HR 1.67, 95% CI 1.38 to 2.01). The associations of AF with HFrEF versus HFpEF events did not differ significantly (HR 1.87 (95% CI 1.38 to 2.54) and HR 1.65 (95% CI 1.20 to 2.28), respectively; p value for difference=0.581). These associations were consistent in sex and race subgroups.

Conclusions AF is associated with both HFrEF and HFpEF events, with no significant difference in the strength of association among these subtypes.

  • atrial fibrillation
  • heart failure with preserved ejection fraction
  • heart failure with reduced ejection fraction

Data availability statement

Data are available upon reasonable request. The data used in these analyses include potentially identifying participant information and therefore are not publicly available due to legal and ethical restrictions. Qualified investigators may request access from the University of Alabama at Birmingham to obtain de-identified data (regardsadmin@uab.edu).

https://doi.org/10.1136/heartjnl-2021-319122

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    Data availability statement

    Data are available upon reasonable request. The data used in these analyses include potentially identifying participant information and therefore are not publicly available due to legal and ethical restrictions. Qualified investigators may request access from the University of Alabama at Birmingham to obtain de-identified data (regardsadmin@uab.edu).

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    Footnotes

    • Twitter @CNicoli_MD

    • Contributors WTO, EZS, and CDN contributed to the conceptualisation and planning of the study. CDN, EBL and EZS contributed to data analysis. CDN drafted the manuscript. GH, EZS, SEJ, and MMS contributed to data acquisition. CDN, EZS, MJS, SEJ, GH, EBL, WTO, and MMS provided critical revision and review of the manuscript. All authors have contributed to this research project in a manner sufficient for authorship and have read and approved the submitted manuscript.

    • Funding This research project is supported by cooperative agreement U01 NS041588 cofunded by the National Institute of Neurological Disorders and Stroke (NINDS) and the National Institute on Aging (NIA), National Institutes of Health, Department of Health and Human Services. Additional funding was provided by R01 HL80477 from the National Heart, Lung, and Blood Institute (NHLBI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NINDS or the NIA. Representatives of the NINDS were involved in the review of the manuscript but were not directly involved in the collection, management, analysis or interpretation of the data.

    • Disclaimer The identification of specific products or scientific instrumentation is considered an integral part of the scientific endeavor and does not constitute endorsement or implied endorsement on the part of the author, Department of Defense (DoD), or any component agency. The views expressed in this manuscript are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, DoD, or U.S. Government.

    • Competing interests EBL: research funding from Amgen and scientific consulting for a research project funded by Novartis.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.