Atrial Fibrillation Is An Independent Predictor Of Outcome In Patients With Left Ventricular Dysfunction.
Giovanni Benfari, MD, Clemance Antoine, MD, Wayne L. Miller, MD, PhD, Hector I. Michelena, MD, Vuyisile T. Nkomo, MD, MPH, Maurice Enriquez-Sarano, MD.
Mayo Clinic, Rochester, MN, USA.
OBJECTIVE: Prognostic implications of atrial fibrillation (AFib) in patients with left ventricular dysfunction have been mainly inferred from meta-analyses and post-hoc analysis of trials testing different hypotheses. Thus, intrinsic prognostic role of AFib vs. rapid ventricular response in routine clinical practice is undefined.
METHODS: Consecutive patients with left ventricular dysfunction (ejection fraction <50%) diagnosed at Mayo Clinic 2003-2011 with complete electrocardiographic (12 leads), clinical and comorbidities characterization were enrolled. Organic valve disease and previous valve surgery were excluded. Primary endpoint was mortality under medical management.
RESULTS: Left ventricular dysfunction was diagnosed in a total of 16,709 patients (age 67±14 years, ejection fraction 36 ±10%, 32% female); among them, 20% were in AFib (Warfarin prescribed in 78% of cases). During follow-up of 4.38 ±3.5 years, 49% of patients died. AFib predicted excess-mortality under medical management univariately (hazard-ratio 1.34 [1.27-1.40], p<0.0001) and after a comprehensive adjustment for age, sex, comorbidities, symptoms, ejection fraction, and heart rate (hazard-ratio 1.11[1.04-1.18], p=0.001) with incremental power to the model (p<0.0001). Subgroup analysis demonstrated excess mortality associated to the presence of AFib in all patients' subsets, even with controlled heart rate.
CONCLUSIONS: AFib is an incremental and independent marker of excess mortality in patients with left ventricular dysfunction regardless of associated clinical and hemodynamic characteristics and heart rate. The potential to reduce this excess mortality should be evaluated in clinical trials.
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