Circulation, Vol 84, 40-48, Copyright © 1991 by American Heart Association
HR Middlekauff, WG Stevenson and LW Stevenson
BACKGROUND. Atrial fibrillation is common in advanced heart failure, but
its prognostic significance is controversial. METHODS AND RESULTS. We
evaluated the relation of atrial rhythm to overall survival and sudden
death in 390 consecutive advanced heart failure patients. Etiology of heart
failure was coronary artery disease in 177 patients (45%) and nonischemic
cardiomyopathy or valvular heart disease in 213 patients (55%). Mean left
ventricular ejection fraction was 0.19 +/- 0.07. Seventy-five patients
(19%) had paroxysmal (26 patients) or chronic (49 patients) atrial
fibrillation. Compared with patients with sinus rhythm, patients with
atrial fibrillation did not differ in etiology of heart failure, mean
pulmonary capillary wedge pressure on therapy, or embolic events but were
more likely to be receiving warfarin and antiarrhythmic drugs and had a
slightly higher left ventricular ejection fraction. After a mean follow-up
of 236 +/- 303 days, 98 patients died: 56 (57%) died suddenly, and 36 (37%)
died of progressive heart failure. Actuarial 1-year overall survival was
68%, and sudden death-free survival was 79%. Actuarial survival was
significantly worse for atrial fibrillation than for sinus rhythm patients
(52% versus 71%, p = 0.0013). Similarly, sudden death-free survival was
significantly worse for atrial fibrillation than for sinus rhythm patients
(69% versus 82%, p = 0.0013). By Cox proportional hazards model, pulmonary
capillary wedge pressure on therapy, left ventricular ejection fraction,
coronary artery disease, and atrial fibrillation were independent risk
factors for total mortality and sudden death. For patients who had
pulmonary capillary wedge pressure of less than 16 mm Hg on therapy, atrial
fibrillation was associated with poorer 1-year survival (44% versus 83%, p
= 0.00001); however, in the high pulmonary capillary wedge pressure group,
atrial fibrillation did not confer an increased risk (58% versus 57%).
CONCLUSIONS. Atrial fibrillation is a marker for increased risk of death,
especially in heart failure patients who have lower filling pressures on
vasodilator and diuretic therapy. Whether aggressive attempts to maintain
sinus rhythm will reduce this risk is unknown.
ARTICLES
Prognostic significance of atrial fibrillation in advanced heart failure. A study of 390 patients
Department of Medicine, UCLA School of Medicine.
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J Feenstra, D E Grobbee, F A M Jonkman, A W Hoes, and B H C. Stricker Prevention of relapse in patients with congestive heart failure: the role of precipitating factors Heart, November 1, 1998; 80(5): 432 - 436. [Abstract] [Full Text]
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D. Dries, D. Exner, B. Gersh, M. Domanski, M. Waclawiw, and L. Stevenson Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials J. Am. Coll. Cardiol., September 1, 1998; 32(3): 695 - 703. [Abstract] [Full Text] [PDF]
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J. L. Blackshear, J. Kaplan, R. C. Thompson, R. E. Safford, and E. J. Atkinson Nocturnal Dyspnea and Atrial Fibrillation Predict Cheyne-Stokes Respirations in Patients With Congestive Heart Failure Arch Intern Med, June 26, 1995; 155(12): 1297 - 1302. [Abstract] [PDF]
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