Heart Failure Subtypes and Thromboembolic Risk in Patients with Atrial Fibrillation in the PREFER in AF Registry

Abstrakt

OBJECTIVE: To assess 1) the incidence of thromboembolic events; and 2) the mortality-weighted net clinical benefit of oral anticoagulation (OAC) according to the heart failure (HF) subtype in patients with atrial fibrillation (AF). METHODS: In this study we included 6,170 patients (1599 with HF and 4751 without HF) with AF from the Prevention of thromboembolic events - European Registry in Atrial Fibrillation (PREFER in AF Registry). We classified patients based on the current ESC HF definitions: HF with reduced ejection fraction (HFrEF; EF<40%); with mid-range EF (HFmrEF; EF: 40–49%); and with preserved ejection fraction (HFpEF; EF≥50%). We then further subdivided patients with HFpEF into HF with lower preserved ejection fraction (HFlpEF; EF: 50–60%) and HF with higher preserved ejection fraction (HFhpEF; EF>60%). We considered as study endpoints ischemic stroke, major adverse cardiovascular and cerebral events (MACCE: stroke, systemic embolism, myocardial infarction and acute coronary syndrome), the composite of thromboembolic events (stroke/TIA/arterial embolism), major bleeding occurring within 1 year of follow-up, and a mortality-weighted net clinical benefit estimate. CONCLUSION: In patients with AF, the subtype of HF predicts the thromboembolic risk: patients with HFhpEF, apparently representing a distinct patient population with the highest CHA2DS2-VASc score, also have the lowest incidence of thromboembolic events. Despite this lowest incidence of thromboembolic events and of MACCE, these patients also feature the highest net clinical benefit, a compounded evaluation of benefit and harm, for OAC. HFrEF is associated with most severe adverse events as ischemic stroke and MACCE.