Atrial fibrillation or flutter on initial electrocardiogram is associated with worse outcomes in patients admitted for worsening heart failure with reduced ejection fraction: Findings from the EVEREST Trial

• Published in: The American heart journal Vol. 164; no. 6; pp. 884 - 892.e2
• Main Authors: Mentz, Robert J., MD, Chung, Matthew J., MD, Gheorghiade, Mihai, MD, Pang, Peter S., MD, Kwasny, Mary J., ScD, Ambrosy, Andrew P., MD, Vaduganathan, Muthiah, MD, MPH, O'Connor, Christopher M., MD, Swedberg, Karl, MD, PhD, Zannad, Faiez, MD, Konstam, Marvin A., MD, Maggioni, Aldo P., MD
• Format: Journal Article
• Language: English
• Published: New York, NY Mosby, Inc 01.12.2012; Mosby; Elsevier Limited
• Subjects: Aged; Antidiuretic Hormone Receptor Antagonists; Arrhythmia, Sinus - diagnosis; Arrhythmia, Sinus - physiopathology; Atrial Fibrillation - diagnosis; Atrial Fibrillation - physiopathology; Atrial Flutter - diagnosis; Atrial Flutter - physiopathology; Biological and medical sciences; Cardiac and Cardiovascular Systems; Cardiac arrhythmia; Cardiac dysrhythmias; Cardiology. Vascular system; Cardiovascular; Cardiovascular system; Cohort Studies; disease; Double-Blind Method; Drug therapy; Electrocardiography; epidemiology; Female; Heart; Heart attacks; Heart Failure - diagnosis; Heart Failure - mortality; Heart Failure - physiopathology; Heart failure, cardiogenic pulmonary edema, cardiac enlargement; Hospitalization; Humans; Investigative techniques of hemodynamics; Investigative techniques, diagnostic techniques (general aspects); Kardiologi; Male; Medical sciences; Middle Aged; Mortality; myocardial-infarction; Prognosis; prognostic-significance; Proportional Hazards Models; Prospective Studies; quality-of-care; rationale; Receptors, Vasopressin - therapeutic use; Retrospective Studies; risk; sinus rhythm; Stroke Volume - physiology; Treatment Outcome; ventricular dysfunction; Human; Heart failure; Prognosis; Arrhythmia; Atrial fibrillation; Cardiovascular disease; Patient; Excitability disorder; Atrial flutter; Electrodiagnosis; Heart disease; Electrocardiography; Circulatory system; Hemodynamics; Cardiology; Aggravation; Ejection fraction
• ISSN: 0002-8703; 1097-6744
• DOI: 10.1016/j.ahj.2012.09.011

Background Heart failure (HF) complicated by atrial fibrillation/flutter (AF/AFL) is associated with worse outcomes. However, the clinical profile and outcomes of patients following hospitalization for HF with AF/AFL on initial electrocardiogram (ECG) has not been well studied. Methods EVEREST was a randomized trial of vasopressin-2 receptor blockade, in addition to standard therapy, in 4133 patients hospitalized with HF with ejection fraction ≤40%. A post hoc analysis was performed comparing the clinical characteristics and outcomes [all-cause mortality and cardiovascular mortality/HF hospitalization] of patients with AF/AFL versus sinus rhythm (SR) on baseline ECG, which were centrally analyzed. Times to events were compared using log-rank tests and Cox regression models. Results Of the 4133 patients, 1195 (29%) were classified with AF/AFL and 2071(50%) with SR. The remaining patients (21%) were excluded because ECGs were unavailable (n = 106), rhythm was paced (n = 727), or junctional/other supraventricular (n = 34). AF/AFL patients were older, with increased weight, faster heart rate, higher blood urea nitrogen, and natriuretic peptide levels compared to SR patients. Anticoagulation was prescribed in 67% of AF/AFL patients on discharge. AF/AFL patients were less likely to receive β-blockers or angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (all P < .05). After risk adjustment, AF/AFL was associated with increased mortality (hazard ratio 1.23; 95% CI, 1.04-1.46) and cardiovascular mortality/HF hospitalization (hazard ratio 1.26; 95% CI, 1.07-1.47). Conclusion AF/AFL on initial ECG in patients hospitalized with HF with reduced ejection fraction is associated with lower use of evidence-based therapies and increased mortality and rehospitalization compared to patients in SR.