By Will Boggs MD
NEW YORK (Reuters Health) - 23/5/2019
"Congestive heart failure (CHF) (is present) in 22% of patients with new AF in GARFIELD-AF, the largest AF registry performed around the world," Dr. Ramon Corbalan from Catholic University School of Medicine, in Santiago, Chile, told Reuters Health by email. "Patients with underlying ischemic heart disease and AF have a higher risk profile than patients with nonischemic cardiomyopathy. In addition, they exhibit higher rates of cardiovascular mortality, stroke, and new acute coronary syndromes."
Dr. Corbalan and colleagues assessed treatment strategies and one-year clinical outcomes in more than 11,000 patients with newly diagnosed AF and concomitant CHF stratified by etiology (ischemic, or ICM, versus nonischemic, or NICM).
Compared with NICM patients, those with ICM had higher rates of depressed left ventricular ejection fraction (LVEF) and more frequently had NYHA class III/IV CHF.
Patients with ICM were also more likely to have carotid occlusive disease, a history of stroke/transient ischemic attack, hypertension, hypercholesterolemia, type 2 diabetes and moderate-to-severe chronic kidney disease.
Fewer patients with ICM than patients with NICM were prescribed oral anticoagulants alone or in combination with antiplatelets (31.5% vs. 61.2%, respectively, alone; 60.1% vs. 73.7%, respectively, combined), the researchers report in JAMA Cardiology, online May 8. In contrast, patients with ICM were about twice as likely as those with NICM to receive dual antiplatelet therapy and were more likely to be prescribed angiotensin-converting enzyme inhibitors or angiotensin receptor blockers or beta-blockers.
At one-year follow-up, incidence rates per 100 person-years were significantly higher in patients with ICM for all-cause death (10.2 vs. 7.0) and cardiovascular death (5.1 vs. 2.9).
Major bleeding and new acute coronary syndromes were significantly more likely in the ICM group than in the NICM group.
The higher rates of all-cause death, cardiovascular death and major bleeding in the ICM group were confined to patients who did not receive antiplatelet therapy at enrollment. "Physicians should be encouraged to prescribe anticoagulant drugs, alone or associated with antiplatelet drugs, to new AF patients according to baseline risk score," Dr. Corbalan said. "This is particularly relevant in patients with AF and CHF with ICM, who have a high risk profile and worst prognosis."
"In recent years, after the introduction of direct anticoagulants and the performance of large multicenter trials, the use of anticoagulants has increased around the world," he said. "It is surprising, then, that the use of anticoagulants in AF patients with CHF and ICM continues to be low and similar to what was found in the past. There is a need to renew educational methods in the medical community to better comply with evidence-based medicine to reduce the risks of stroke and death of AF patients with CHF and ICM."
JAMA Cardiol 2019.