Atrial fibrillation is not an independent predictor of outcome in patients with aortic stenosis

Hongju Zhang, Edward A. El-Am, Jeremy J. Thaden, Sorin V. Pislaru, Christopher G. Scott, Chayakrit Krittanawong, Anwar A. Chahal, Thomas J. Breen, Mackram Eleid, Rowlens Melduni, Kevin L. Greason, Robert B. McCully, Maurice E Sarano, Jae Kuen Oh, Patricia Pellikka, Vuyisile T Nkomo

Research output: Contribution to journalArticle

Abstract

Objectives: To examine the prognostic significance of atrial fibrillation (AF) versus sinus rhythm (SR) on the management and outcomes of patients with severe aortic stenosis (AS). Methods: 1847 consecutive patients with severe AS (aortic valve area ≤1.0 cm2 and aortic valve systolic mean Doppler gradient ≥40 mm Hg or peak velocity ≥4 m/s) and left ventricular ejection fraction ≥50% were identified. The independent association of AF and all-cause mortality was assessed. Results: Age was 76±11 years and 46% were female; 293 (16%) patients had AF and 1554 (84%) had SR. In AF, 72% were symptomatic versus 71% in SR. Survival rate at 5 years for AF (41%) was lower than SR (65%) (age- A nd sex-adjusted HR=1.66 (1.40-1.98), p<0.0001). In multivariable analysis, factors associated with mortality included age (HR per 10 years=1.55 (1.42-1.69), p<0.0001), dyspnoea (HR=1.58 (1.33-1.87), p<0.0001), ≥ moderate mitral regurgitation (HR=1.63 (1.22-2.18), p=0.001), right ventricular systolic dysfunction (HR=1.88 (1.52-2.33), p<0.0001), left atrial volume index (HR per 10 mL/m2=1.13 (1.07-1.19), p<0.0001) and aortic valve replacement (AVR) (HR=0.44 (0.38-0.52), p<0.0001). AF was not a predictor of mortality independent of variables strongly correlated HR=1.02 (0.84-1.25), p=0.81). The 1-year probability of AVR following diagnosis of severe AS was lower in AF (49.8%) than SR (62.5%) (HR=0.73 (0.62-0.86), p<0.001); among patients with AF not referred for AVR, symptoms were frequently attributed to AF instead of AS. Conclusion: AF was associated with poor prognosis in patients with severe AS, but apparent differences in outcomes compared with SR were explained by factors other than AF including concomitant cardiac abnormalities and deferral of AVR due to attribution of cardiac symptoms to AF.

Original languageEnglish (US)
JournalHeart
DOIs
StateAccepted/In press - Jan 1 2019

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Aortic Valve Stenosis
Atrial Fibrillation
Aortic Valve
Mortality
Right Ventricular Dysfunction
Mitral Valve Insufficiency
Stroke Volume
Dyspnea
Survival Rate

Keywords

  • aortic stenosis
  • aortic valve replacement
  • atrial fibrillation
  • mortality
  • natural history
  • prognosis

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Zhang, H., El-Am, E. A., Thaden, J. J., Pislaru, S. V., Scott, C. G., Krittanawong, C., ... Nkomo, V. T. (Accepted/In press). Atrial fibrillation is not an independent predictor of outcome in patients with aortic stenosis. Heart. https://doi.org/10.1136/heartjnl-2019-314996

Atrial fibrillation is not an independent predictor of outcome in patients with aortic stenosis. / Zhang, Hongju; El-Am, Edward A.; Thaden, Jeremy J.; Pislaru, Sorin V.; Scott, Christopher G.; Krittanawong, Chayakrit; Chahal, Anwar A.; Breen, Thomas J.; Eleid, Mackram; Melduni, Rowlens; Greason, Kevin L.; McCully, Robert B.; Sarano, Maurice E; Oh, Jae Kuen; Pellikka, Patricia; Nkomo, Vuyisile T.

In: Heart, 01.01.2019.

Research output: Contribution to journalArticle

Zhang, Hongju ; El-Am, Edward A. ; Thaden, Jeremy J. ; Pislaru, Sorin V. ; Scott, Christopher G. ; Krittanawong, Chayakrit ; Chahal, Anwar A. ; Breen, Thomas J. ; Eleid, Mackram ; Melduni, Rowlens ; Greason, Kevin L. ; McCully, Robert B. ; Sarano, Maurice E ; Oh, Jae Kuen ; Pellikka, Patricia ; Nkomo, Vuyisile T. / Atrial fibrillation is not an independent predictor of outcome in patients with aortic stenosis. In: Heart. 2019.
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abstract = "Objectives: To examine the prognostic significance of atrial fibrillation (AF) versus sinus rhythm (SR) on the management and outcomes of patients with severe aortic stenosis (AS). Methods: 1847 consecutive patients with severe AS (aortic valve area ≤1.0 cm2 and aortic valve systolic mean Doppler gradient ≥40 mm Hg or peak velocity ≥4 m/s) and left ventricular ejection fraction ≥50{\%} were identified. The independent association of AF and all-cause mortality was assessed. Results: Age was 76±11 years and 46{\%} were female; 293 (16{\%}) patients had AF and 1554 (84{\%}) had SR. In AF, 72{\%} were symptomatic versus 71{\%} in SR. Survival rate at 5 years for AF (41{\%}) was lower than SR (65{\%}) (age- A nd sex-adjusted HR=1.66 (1.40-1.98), p<0.0001). In multivariable analysis, factors associated with mortality included age (HR per 10 years=1.55 (1.42-1.69), p<0.0001), dyspnoea (HR=1.58 (1.33-1.87), p<0.0001), ≥ moderate mitral regurgitation (HR=1.63 (1.22-2.18), p=0.001), right ventricular systolic dysfunction (HR=1.88 (1.52-2.33), p<0.0001), left atrial volume index (HR per 10 mL/m2=1.13 (1.07-1.19), p<0.0001) and aortic valve replacement (AVR) (HR=0.44 (0.38-0.52), p<0.0001). AF was not a predictor of mortality independent of variables strongly correlated HR=1.02 (0.84-1.25), p=0.81). The 1-year probability of AVR following diagnosis of severe AS was lower in AF (49.8{\%}) than SR (62.5{\%}) (HR=0.73 (0.62-0.86), p<0.001); among patients with AF not referred for AVR, symptoms were frequently attributed to AF instead of AS. Conclusion: AF was associated with poor prognosis in patients with severe AS, but apparent differences in outcomes compared with SR were explained by factors other than AF including concomitant cardiac abnormalities and deferral of AVR due to attribution of cardiac symptoms to AF.",
keywords = "aortic stenosis, aortic valve replacement, atrial fibrillation, mortality, natural history, prognosis",
author = "Hongju Zhang and El-Am, {Edward A.} and Thaden, {Jeremy J.} and Pislaru, {Sorin V.} and Scott, {Christopher G.} and Chayakrit Krittanawong and Chahal, {Anwar A.} and Breen, {Thomas J.} and Mackram Eleid and Rowlens Melduni and Greason, {Kevin L.} and McCully, {Robert B.} and Sarano, {Maurice E} and Oh, {Jae Kuen} and Patricia Pellikka and Nkomo, {Vuyisile T}",
year = "2019",
month = "1",
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doi = "10.1136/heartjnl-2019-314996",
language = "English (US)",
journal = "Heart",
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TY - JOUR

T1 - Atrial fibrillation is not an independent predictor of outcome in patients with aortic stenosis

AU - Zhang, Hongju

AU - El-Am, Edward A.

AU - Thaden, Jeremy J.

AU - Pislaru, Sorin V.

AU - Scott, Christopher G.

AU - Krittanawong, Chayakrit

AU - Chahal, Anwar A.

AU - Breen, Thomas J.

AU - Eleid, Mackram

AU - Melduni, Rowlens

AU - Greason, Kevin L.

AU - McCully, Robert B.

AU - Sarano, Maurice E

AU - Oh, Jae Kuen

AU - Pellikka, Patricia

AU - Nkomo, Vuyisile T

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Objectives: To examine the prognostic significance of atrial fibrillation (AF) versus sinus rhythm (SR) on the management and outcomes of patients with severe aortic stenosis (AS). Methods: 1847 consecutive patients with severe AS (aortic valve area ≤1.0 cm2 and aortic valve systolic mean Doppler gradient ≥40 mm Hg or peak velocity ≥4 m/s) and left ventricular ejection fraction ≥50% were identified. The independent association of AF and all-cause mortality was assessed. Results: Age was 76±11 years and 46% were female; 293 (16%) patients had AF and 1554 (84%) had SR. In AF, 72% were symptomatic versus 71% in SR. Survival rate at 5 years for AF (41%) was lower than SR (65%) (age- A nd sex-adjusted HR=1.66 (1.40-1.98), p<0.0001). In multivariable analysis, factors associated with mortality included age (HR per 10 years=1.55 (1.42-1.69), p<0.0001), dyspnoea (HR=1.58 (1.33-1.87), p<0.0001), ≥ moderate mitral regurgitation (HR=1.63 (1.22-2.18), p=0.001), right ventricular systolic dysfunction (HR=1.88 (1.52-2.33), p<0.0001), left atrial volume index (HR per 10 mL/m2=1.13 (1.07-1.19), p<0.0001) and aortic valve replacement (AVR) (HR=0.44 (0.38-0.52), p<0.0001). AF was not a predictor of mortality independent of variables strongly correlated HR=1.02 (0.84-1.25), p=0.81). The 1-year probability of AVR following diagnosis of severe AS was lower in AF (49.8%) than SR (62.5%) (HR=0.73 (0.62-0.86), p<0.001); among patients with AF not referred for AVR, symptoms were frequently attributed to AF instead of AS. Conclusion: AF was associated with poor prognosis in patients with severe AS, but apparent differences in outcomes compared with SR were explained by factors other than AF including concomitant cardiac abnormalities and deferral of AVR due to attribution of cardiac symptoms to AF.

AB - Objectives: To examine the prognostic significance of atrial fibrillation (AF) versus sinus rhythm (SR) on the management and outcomes of patients with severe aortic stenosis (AS). Methods: 1847 consecutive patients with severe AS (aortic valve area ≤1.0 cm2 and aortic valve systolic mean Doppler gradient ≥40 mm Hg or peak velocity ≥4 m/s) and left ventricular ejection fraction ≥50% were identified. The independent association of AF and all-cause mortality was assessed. Results: Age was 76±11 years and 46% were female; 293 (16%) patients had AF and 1554 (84%) had SR. In AF, 72% were symptomatic versus 71% in SR. Survival rate at 5 years for AF (41%) was lower than SR (65%) (age- A nd sex-adjusted HR=1.66 (1.40-1.98), p<0.0001). In multivariable analysis, factors associated with mortality included age (HR per 10 years=1.55 (1.42-1.69), p<0.0001), dyspnoea (HR=1.58 (1.33-1.87), p<0.0001), ≥ moderate mitral regurgitation (HR=1.63 (1.22-2.18), p=0.001), right ventricular systolic dysfunction (HR=1.88 (1.52-2.33), p<0.0001), left atrial volume index (HR per 10 mL/m2=1.13 (1.07-1.19), p<0.0001) and aortic valve replacement (AVR) (HR=0.44 (0.38-0.52), p<0.0001). AF was not a predictor of mortality independent of variables strongly correlated HR=1.02 (0.84-1.25), p=0.81). The 1-year probability of AVR following diagnosis of severe AS was lower in AF (49.8%) than SR (62.5%) (HR=0.73 (0.62-0.86), p<0.001); among patients with AF not referred for AVR, symptoms were frequently attributed to AF instead of AS. Conclusion: AF was associated with poor prognosis in patients with severe AS, but apparent differences in outcomes compared with SR were explained by factors other than AF including concomitant cardiac abnormalities and deferral of AVR due to attribution of cardiac symptoms to AF.

KW - aortic stenosis

KW - aortic valve replacement

KW - atrial fibrillation

KW - mortality

KW - natural history

KW - prognosis

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U2 - 10.1136/heartjnl-2019-314996

DO - 10.1136/heartjnl-2019-314996

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JO - Heart

JF - Heart

SN - 1355-6037

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