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Atrial Fibrillation Begets Heart Failure and Vice Versa: Temporal Associations and Differences in Preserved Versus
Rajalakshmi Santhanakrishnan1, Na Wang1, Martin G Larson1
1From Cardiovascular Medicine Section, Department of Medicine (R.S., J.W.M., R.S.V., E.J.B.) and Section of Preventive Medicine and Epidemiology (R.S.V.), Boston University School of Medicine, MA; Data Coordinating Center (N.W.) and Department of Epidemiology (E.J.B.), Boston University School of Public Health, MA; Department of Mathematics and Statistics, Boston University, MA (M.G.L.); National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study, MA (M.G.L., J.W.M., S.C., R.S.V., D.L., E.J.B., J.E.H.); Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Boston (D.D.M., E.J.B.); Cardiology Division (S.A.L., P.T.E., J.E.H.) and Cardiovascular Research Center (S.A.L., P.T.E., J.E.H.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical Population Genetics, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge (S.A.L., P.T.E.); Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.C.); Institute for Clinical Evaluative Sciences and Toronto General Hospital, University of Toronto, ON, Canada (D.S.L.); Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, TN (T.J.W.); and Population Sciences Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, MD (D.L.).
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.
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