Swedberg Karl, Olsson Lars G, Charlesworth Andrew, Cleland John, Hanrath Peter, Komajda Michel, Metra Marco, Torp-Pedersen Christian, Poole-Wilson Philip
Department of Medicine, Sahlgrenska University Hospital/Ostra, SE-416 85 Göteborg, Sweden.
Eur Heart J. 2005 Jul;26(13):1303-8. doi: 10.1093/eurheartj/ehi166. Epub 2005 Mar 14.
Atrial fibrillation is common in patients with chronic heart failure (CHF). We analysed the risk associated with atrial fibrillation in a large cohort of patients with chronic heart failure all treated with a beta-blocker.
In COMET, 3029 patients with CHF were randomized to carvedilol or metoprolol tartrate and followed for a mean of 58 months. We analysed the prognostic relevance on other outcomes of atrial fibrillation on the baseline electrocardiogram compared with no atrial fibrillation and the impact of new onset atrial fibrillation during follow-up. A multivariate analysis was performed using a Cox regression model where 10 baseline covariates were entered together with study treatment allocation. Six hundred patients (19.8%) had atrial fibrillation at baseline. These patients were older (65 vs. 61 years), included more men (88 vs.78%), had more severe symptoms [higher New York Heart Association (NYHA) class] and a longer duration of heart failure (all P<0.0001). Atrial fibrillation was associated with significantly increased mortality [relative risk (RR) 1.29: 95% CI 1.12-1.48; P<0.0001], higher all-cause death or hospitalization (RR 1.25: CI 1.13-1.38), and cardiovascular death or hospitalization for worsening heart failure (RR 1.34: CI 1.20-1.52), both P<0.0001. By multivariable analysis, atrial fibrillation no longer independently predicted mortality. Beneficial effects on mortality by carvedilol remained significant (RR 0.836: CI 0.74-0.94; P=0.0042). New onset atrial fibrillation during follow-up (n=580) was associated with significant increased risk for subsequent death in a time-dependent analysis (RR 1.90: CI 1.54-2.35; P<0.0001) regardless of treatment allocation and changes in NYHA class.
In CHF, atrial fibrillation significantly increases the risk for death and heart failure hospitalization, but is not an independent risk factor for mortality after adjusting for other predictors of prognosis. Treatment with carvedilol compared with metoprolol offers additional benefits among patients with atrial fibrillation. Onset of new atrial fibrillation in patients on long-term beta-blocker therapy is associated with significant increased subsequent risk of mortality and morbidity.
心房颤动在慢性心力衰竭（CHF）患者中很常见。我们在一大群均接受β受体阻滞剂治疗的慢性心力衰竭患者中分析了与心房颤动相关的风险。
在卡维地洛与美托洛尔对比试验（COMET）中，3029例CHF患者被随机分为接受卡维地洛或酒石酸美托洛尔治疗，并平均随访58个月。我们分析了基线心电图上存在心房颤动与无心房颤动相比对其他结局的预后相关性，以及随访期间新发心房颤动的影响。使用Cox回归模型进行多变量分析，将10个基线协变量与研究治疗分配一起纳入。600例患者（19.8%）在基线时存在心房颤动。这些患者年龄更大（65岁对61岁），男性更多（88%对78%），症状更严重[纽约心脏协会（NYHA）分级更高]且心力衰竭病程更长（所有P<0.0001）。心房颤动与死亡率显著增加相关[相对风险（RR）1.29：95%可信区间（CI）1.12 - 1.48；P<0.0001]，全因死亡或住院风险更高（RR 1.25：CI 1.13 - 1.38），以及心血管死亡或因心力衰竭恶化住院风险更高（RR 1.34：CI 1.20 - 1.52），两者P<0.0001。通过多变量分析，心房颤动不再独立预测死亡率。卡维地洛对死亡率的有益影响仍然显著（RR 0.836：CI 0.74 - 0.94；P = 0.0042）。随访期间新发心房颤动（n = 580）在时间依赖性分析中与随后死亡风险显著增加相关（RR 1.90：CI 1.54 - 2.35；P<0.0001），无论治疗分配及NYHA分级如何变化。
在CHF中，心房颤动显著增加死亡和心力衰竭住院风险，但在调整其他预后预测因素后并非死亡率的独立危险因素。与美托洛尔相比，卡维地洛治疗在心房颤动患者中具有额外益处。长期接受β受体阻滞剂治疗的患者新发心房颤动与随后死亡率和发病率显著增加相关。
