Influence of heart failure and chronic kidney disease on cardiovascular outcome in patients with atrial fibrillation - insights from a cohort study of 7,412 patients

Abstract Background Heart failure (HF) and chronic kidney disease (CKD) form a vicious circle, reinforcing each other’s disease development and progression and causing higher rates in both morbidity and mortality. Here, we aimed to investigate the relationship between these two prevalent and interrelated diseases in an unselected patient population with AF. Methods This analysis includes patients with known AF, treated at a tertiary center between 07/2000 and 07/2019. The primary combined endpoint was hospitalization for heart failure (HHF) or cardiovascular (CV) death. We used cox regression models adjusted for age, sex, diabetes, coronary artery disease, hypertension, BMI and CRP-levels. Results We examined 7412 patients with AF and followed them over a median of 5.3 years. The median age was 70 years (IQR 61 to 78 years) and 2,945 (39.7%) were female. 434 (5.0%) patients had known CKD, 1,296 (17.5%) patients had HF, and 372 (5.4%) patients had both CKD and HF. There was a significant stepwise increase in event rates for the composite of CV death/HHF among patients without CKD or HF (KM event rate at 5 years: 23%), patients who had HF but no CKD (KM event rate at 5 years: 61%), patients with CKD but no HF (KM event rate at 5 years: 63%), and those who had both, HF and CKD (KM event rate at 5 years: 82%; P-logrank <0.001; Figure 1A). After multivariable adjustment, both CKD (with an adjusted hazard ratio of 2.22 and a 95% confidence interval of 1.87 to 2.63) and HF (with an adjusted hazard ratio of 2.53 and a 95% confidence interval of 2.26 to 2.84) were significantly associated with CV death/HHF and exerted a similar magnitude of the relationship. Patients with concomitant disease had the highest risk of the primary endpoint (with an adjusted hazard ratio of 3.96 and a 95% confidence interval of 3.34 to 4.68; Figure 1B). Conclusion AF patients with CKD and HF are at very high risk of CV death/HHF. Commonly used risk scores usually focus on stroke as the most dreaded complication in patients with AF. These findings suggest that the influence of CKD and HF expand beyond the risk of stroke to CV death/HHF in an unselected AF patient population.Figure 1