BACKGROUND AND OBJECTIVES: To assess thromboembolic and bleeding risks in patients with heart failure (HF) and atrial fibrillation (AF) according to HF type. METHODS: 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. RESULTS: 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 CHA2DS2-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). CONCLUSION: 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 CHA2DS2-VASc score but the lowest residual risk of thromboembolic events, which warrants further investigation.

1st Department of Cardiology Poznan University of Medical Sciences Poland

3rd Medical Department Cardiology and Intensive Care Medicine Wilhelminen Hospital and Sigmund Freud University Medical School Vienna Austria

3rd Medical Department Cardiology and Intensive Care Medicine Wilhelminen Hospital Vienna Austria

Clinic for Cardiology and Pneumology University Medical Center Göttingen Göttingen Germany; German Center for Cardiovascular Research partner site Göttingen Germany

Daiichi Sankyo Europe Munich Germany

Department for General and Interventional Cardiology University Heart Center Hamburg Hamburg Germany; German Center for Cardiovascular Research partner site Hamburg Kiel Lübeck Hamburg Germany

Department of Cardiology Medical University of Vienna Vienna Austria

Department of Cardiology Medical University of Vienna Vienna Austria; 1st Department of Cardiology Poznan University of Medical Sciences Poland

Department of Cardiology University Hospital Nancy France

Department of Cardiovascular Sciences Campus Bio Medico University of Rome Italy

Emeritus Professor of Cardiology Amsterdam The Netherlands

G d'Annunzio University of Chieti and Center of Excellence on Aging CeSI Met Italy

Institute of Cardiovascular Sciences University of Birmingham and SWBH and UHB NHS Trusts Birmingham UK

Institute of Cardiovascular Sciences University of Birmingham and SWBH and UHB NHS Trusts Birmingham UK; AFNET Münster Germany

Institute of Informatics Academy of Sciences of Czech Republic Prague Czech Republic

References provided by Crossref.org

Outcomes of patients with atrial fibrillation on oral anticoagulation with and without heart failure: the ETNA-AF-Europe registry