Heart failure and atrial fibrillation - does heart failure subtype matter?

Heart failure (HF) and atrial fibrillation (AF) are highly prevalent diseases and are considered global epidemics. Worldwide in 2017, the prevalence of HF was approximately 64 million [ [1] Bragazzi N.L. Zhong W. Shu J. et al. Burden of heart failure and underlying causes in 195 countries and territories from 1990 to 2017. Eur. J. Prev. Cardiol. 2021; (Epub ahead of print. PMID: 33571994)https://doi.org/10.1093/eurjpc/zwaa147 Crossref PubMed Scopus (33) Google Scholar ], and in 2019, the prevalence of AF was almost 60 million [ [2] Roth G.A. Mensah G.A. Johnson C.O. et al. Global burden of cardiovascular diseases and risk factors, 1990–2019: update from the GBD 2019 study. J. Am. Coll. Cardiol. 2020; 76: 2982-3021 Crossref PubMed Scopus (789) Google Scholar ]. The conditions often coexist, predispose to each other, have many risk factors in common, and worsen each other's prognosis [ [3] Karnik A.A. Gopal D.M. Ko D. Benjamin E.J. Helm R.H. Epidemiology of atrial fibrillation and heart failure: a growing and important problem. Cardiol. Clin. 2019; 37: 119-129 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar ]. The temporal association between the two diseases is complex, but the Framingham Heart Study (FHS) has provided valuable insights into their interrelations [ [4] Santhanakrishnan R. Wang N. Larson M.G. et al. Atrial fibrillation begets heart failure and vice versa: temporal associations and differences in preserved versus reduced ejection fraction. Circulation. 2016; 133: 484-492 Crossref PubMed Scopus (11) Google Scholar ]. In multivariable-adjusted analyses, both prevalent and incident HF were associated with ~2-fold increased hazards of incident AF [ [4] Santhanakrishnan R. Wang N. Larson M.G. et al. Atrial fibrillation begets heart failure and vice versa: temporal associations and differences in preserved versus reduced ejection fraction. Circulation. 2016; 133: 484-492 Crossref PubMed Scopus (11) Google Scholar ]. Among participants with prevalent HF, the cumulative incidence of AF after 8 years of follow-up was ~20% [ [4] Santhanakrishnan R. Wang N. Larson M.G. et al. Atrial fibrillation begets heart failure and vice versa: temporal associations and differences in preserved versus reduced ejection fraction. Circulation. 2016; 133: 484-492 Crossref PubMed Scopus (11) Google Scholar ]. Conversely, both prevalent and incident AF were associated with HF with preserved ejection fraction (HFpEF), but only incident AF was associated with incident HF with reduced ejection fraction (HFrEF) [ [4] Santhanakrishnan R. Wang N. Larson M.G. et al. Atrial fibrillation begets heart failure and vice versa: temporal associations and differences in preserved versus reduced ejection fraction. Circulation. 2016; 133: 484-492 Crossref PubMed Scopus (11) Google Scholar ]. The FHS study found a marginally significant difference in the analysis of prevalent AF as a predictor of HFpEF (hazard ratio, 2.3) versus HFrEF (hazard ratio, 1.3), whereas incident AF did not appear to be differentially associated with HFpEF versus HFrEF [ [4] Santhanakrishnan R. Wang N. Larson M.G. et al. Atrial fibrillation begets heart failure and vice versa: temporal associations and differences in preserved versus reduced ejection fraction. Circulation. 2016; 133: 484-492 Crossref PubMed Scopus (11) Google Scholar ]. Understanding the temporal association by left ventricular ejection fraction (LVEF) group may be relevant to optimize and personalize care for HF patients to target preventive efforts and reduce risk of AF. However, the sample size of the FHS was too small to stratify by HF subtypes and follow-up for incident AF.