Relationship between degree of left ventricular dysfunction, symptom status, and risk of embolic events in patients with atrial fibrillation and heart failure

Roopinder K Sandhu; Stefan H Hohnloser; Marc A Pfeffer; Fei Yuan; Robert G Hart; Salim Yusuf; Stuart J Connolly; Finlay A McAlister; Jeff S Healey

doi:10.1161/STROKEAHA.114.007140

Relationship between degree of left ventricular dysfunction, symptom status, and risk of embolic events in patients with atrial fibrillation and heart failure

Stroke. 2015 Mar;46(3):667-72. doi: 10.1161/STROKEAHA.114.007140. Epub 2015 Jan 27.

Authors

Roopinder K Sandhu¹, Stefan H Hohnloser², Marc A Pfeffer², Fei Yuan², Robert G Hart², Salim Yusuf², Stuart J Connolly², Finlay A McAlister², Jeff S Healey²

Affiliations

¹ From the Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.K.S.); Division of Cardiac Electrophysiology, J.W. Goethe University, Frankfurt, Germany (S.H.H.); Division of Cardiology, Brigham and Women's Hospital, Harvard University, Boston, MA (M.A.P.); Division of Neurology (R.G.H.), Division of Cardiology (S.Y., S.J.C., J.S.H.), Population Health Research Institute (F.Y.), McMaster University, Hamilton, ON, Canada; The Canadian VIGOUR Center, Edmonton, Alberta, Canada (F.A.M.); and Division of General Internal Medicine, University of Alberta, Edmonton, Canada (F.A.M.). rsandhu2@ualberta.ca.
² From the Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.K.S.); Division of Cardiac Electrophysiology, J.W. Goethe University, Frankfurt, Germany (S.H.H.); Division of Cardiology, Brigham and Women's Hospital, Harvard University, Boston, MA (M.A.P.); Division of Neurology (R.G.H.), Division of Cardiology (S.Y., S.J.C., J.S.H.), Population Health Research Institute (F.Y.), McMaster University, Hamilton, ON, Canada; The Canadian VIGOUR Center, Edmonton, Alberta, Canada (F.A.M.); and Division of General Internal Medicine, University of Alberta, Edmonton, Canada (F.A.M.).

PMID: 25628308
DOI: 10.1161/STROKEAHA.114.007140

Abstract

Background and purpose: Limited data exists regarding the relationship between left ventricular systolic dysfunction (LVSD) and heart failure (HF) symptoms and embolic risk among patients with atrial fibrillation.

Methods: Participants in the Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events (ACTIVE) trials with HF, but not randomized to oral anticoagulation, were categorized as having preserved versus reduced ejection fraction. If reduced, LVSD was classified as mild, moderate, or severe. Symptoms were quantified using New York Heart Association class.The primary outcome was a composite of stroke, transient ischemic attack, and systemic embolism.

Results: There were 3487 antiplatelet-treated patients with HF at baseline. Of these patients, 969 (46.8%) had HF with preserved ejection fraction and 1103 (53.2%) had HF with reduced ejection fraction. During 3.6 years of mean follow-up, first occurrence of stroke, transient ischemic attack, or systemic embolism occurred in 386 patients.The strongest independent predictors of embolic events were age ≥75 years (hazard ratio 2.55; confidence interval, 1.85-3.53), prior stroke or transient ischemic attack (hazard ratio 2.07; 95% confidence interval, 1.65-2.60), and female sex (hazard ratio 1.37; confidence interval, 1.11-1.69). However, ejection fraction <0.50, degree of LVSD, and New York Heart Association class did not predict embolic events. Patients with HF with preserved ejection fraction exhibited similar risk of embolic events as those with HR with reduced ejection fraction: 4.3% versus 4.4% per 100 person-years (hazard ration 1.01; 95% confidence interval, 0.78-1.31). Risk of embolic events was similar across categories of LVSD (P for trend =0.96) and New York Heart Association class (P for trend =0.57).

Conclusion: Among HF patients in ACTIVE, neither the presence of LVSD or degree of symptom severity influenced risk of embolic events.

Keywords: atrial fibrillation; heart failure; stroke.

Publication types

Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Administration, Oral
Aged
Anticoagulants / administration & dosage
Aspirin / therapeutic use
Atrial Fibrillation / drug therapy
Atrial Fibrillation / physiopathology*
Biphenyl Compounds / therapeutic use
Clopidogrel
Female
Heart Failure / drug therapy
Heart Failure / physiopathology*
Humans
Irbesartan
Ischemic Attack, Transient / drug therapy
Ischemic Attack, Transient / physiopathology
Male
Middle Aged
Platelet Aggregation Inhibitors / therapeutic use
Proportional Hazards Models
Stroke / diagnosis
Tetrazoles / therapeutic use
Thromboembolism / prevention & control*
Ticlopidine / analogs & derivatives
Ticlopidine / therapeutic use
Treatment Outcome
Ventricular Dysfunction, Left / diagnosis*
Ventricular Dysfunction, Left / physiopathology

Substances

Anticoagulants
Biphenyl Compounds
Platelet Aggregation Inhibitors
Tetrazoles
Clopidogrel
Irbesartan
Ticlopidine
Aspirin