Prognostic value of the presence and development of atrial fibrillation inpatients with advanced chronic heart failure

Aims To examine whether the presence, or development, of atrial fibrillatio n in patients with advanced chronic heart failure, is associated with a poo rer prognosis, compared to patients with sinus rhythm and chronic heart fai lure. Methods and Results We examined 409 patients with moderate to severe chroni c heart failure, and compared patients with sinus rhythm (n=325) to those w ith atrial fibrillation (n=84). At baseline, the two groups were similar re garding most indices of severity of chronic heart failure, such as left ven tricular ejection fraction (0.23) and New York Heart Association (NYHA) fun ctional class, while they were different for age (70 years for atrial fibri llation vs 67 rears for sinus rhythm patients), aetiology of chronic heart failure, blood pressure, concomitant treatment, and plasma neurohormones (a ll P<0.05). During a mean follow-up of 3.4 years (range 2.0-5.4), 203 patie nts (50%) died. The majority of deaths was due to progressive chronic heart failure (55%) or was sudden (28%), but there was no difference in mode of death between sinus rhythm and atrial fibrillation patients. Overall mortal ity was higher in atrial fibrillation patients (60%), than in those with si nus rhythm (47%; risk ratio 1.40, 95% CI 1.01-1.92, P=0.04). After adjustin g for important prognostic variables, such as age, left ventricular ejectio n Fraction, NYHA class, renal function. and blood pressure, the presence of atrial fibrillation was no longer related to increased mortality (risk rat io 0.86, range 0.59-1.24, P=ns). Of the 325 patients who had sinus rhythm a t baseline, 30 (9%) developed atrial fibrillation during the study. These p atients were older (70 vs 66 years, P<0.007), and had slightly lower blood pressure and plasma norepinephrine concentrations (P<0.05), but were otherw ise similar. During follow-up, mortality was similar in these two groups (4 7% in those with new onset atrial fibrillation, vs 47% in those who had sin us rhythm throughout the study). Conclusions The present data do not support the concept that the presence, or the development of atrial fibrillation in patients with advanced chronic heart failure is independently related to an adverse outcome during long-t erm follow-zip. The generally observed higher mortality in patients with at rial fibrillation thus seems to be related to other factors, associated wit h atrial fibrillation. (Eur Heart J 2000; 21: 1238-1245) (C) 2000 The Europ ean Society of Cardiology.