Department of Cardiology, Medical University of Vienna, Vienna, Austria; 1st Department of Cardiology, Poznan University of Medical Sciences, Poland.
Institute of Informatics, Academy of Sciences of Czech Republic, Prague, Czech Republic.
Int J Cardiol. 2018 Aug 15;265:141-147. doi: 10.1016/j.ijcard.2018.04.093. Epub 2018 Apr 22.
To assess thromboembolic and bleeding risks in patients with heart failure (HF) and atrial fibrillation (AF) according to HF type.
We analyzed 6170 AF patients from the Prevention of thromboembolic events - European Registry in Atrial Fibrillation (PREFER in AF), and categorized patients into: HF with reduced left-ventricular ejection fraction (HFrEF; LVEF < 40%); mid-range EF (HFmrEF; LVEF: 40-49%); lower preserved EF (HFLpEF; LVEF: 50-60%), higher preserved EF (HFHpEF; LVEF > 60%), and no HF. Outcomes were ischemic stroke, major adverse cardiovascular and cerebral events (MACCE) and major bleeding occurring within 1-year.
The annual incidence of stroke was linearly and inversely related to LVEF, increasing by 0.054% per each 1% of LVEF decrease (95% CI: 0.013%-0.096%; p = 0.031). Patients with HFHpEF had the highest CHADS-VASc score, but significantly lower stroke incidence than other HF groups (0.65%, compared to HFLpEF 1.30%; HFmrEF 1.71%; HFrEF 1.75%; trend p = 0.014). The incidence of MACCE was also lower in HFHpEF (2.0%) compared to other HF groups (range: 3.8-4.4%; p = 0.001). Age, HF type, and NYHA class were independent predictors of thromboembolic events. Conversely, major bleeding did not significantly differ between groups (p = 0.168).
Our study in predominantly anticoagulated patients with AF shows that, reduction in LVEF is associated with higher thromboembolic, but not higher bleeding risk. HFHpEF is a distinct and puzzling group, featuring the highest CHADS-VASc score but the lowest residual risk of thromboembolic events, which warrants further investigation.
根据心力衰竭（HF）类型评估心力衰竭合并心房颤动（AF）患者的血栓栓塞和出血风险。
我们分析了来自预防血栓栓塞事件-心房颤动欧洲登记研究（PREFER in AF）的 6170 例 AF 患者，并将患者分为：射血分数降低的心力衰竭（HFrEF；LVEF＜40%）；中间范围 EF（HFmrEF；LVEF：40-49%）；较低的保留 EF（HFLpEF；LVEF：50-60%），较高的保留 EF（HFHpEF；LVEF＞60%）和无心力衰竭。结果是 1 年内发生的缺血性卒中和主要心血管和脑不良事件（MACCE）和大出血。
卒中的年发生率与 LVEF 呈线性反比关系，LVEF 每降低 1%，发生率增加 0.054%（95%CI：0.013%-0.096%；p=0.031）。HFHpEF 患者的 CHADS-VASc 评分最高，但卒中发生率明显低于其他 HF 组（0.65%，与 HFLpEF 组 1.30%；HFmrEF 组 1.71%；HFrEF 组 1.75%；趋势 p=0.014）。HFHpEF 组的 MACCE 发生率也较低（2.0%），明显低于其他 HF 组（范围：3.8-4.4%；p=0.001）。年龄、HF 类型和 NYHA 分级是血栓栓塞事件的独立预测因素。相反，各组之间主要出血差异无统计学意义（p=0.168）。
我们在主要接受抗凝治疗的 AF 合并 HF 患者中的研究表明，LVEF 降低与更高的血栓栓塞风险相关，但与更高的出血风险无关。HFHpEF 是一个独特且令人费解的群体，具有最高的 CHADS-VASc 评分，但血栓栓塞事件的残余风险最低，这需要进一步研究。
