Prognostic impact of global longitudinal strain in patients hospitalized for acute heart failure with preserved ejection fraction and atrial fibrillation

In patients with atrial fibrillation (AF), heart failure (HF) with preserved ejection fraction (HFpEF) has a lower risk of cardiovascular death (CD) than HF with reduced ejection fraction (HFrEF). Therefore, there are few reports on prognostic factors in those patients. Patients with HFpEF with reduced global longitudinal strain (GLS) may have a poor prognosis and may be good candidates for catheter ablation.

We investigated whether GLS predicts CD in patients with acute HFpEF complicated by AF.

We retrospectively enrolled patients aged 18 years or older with acute HF complicated by AF who were consecutively admitted to our hospital from January 2014 to December 2018. Exclusion criteria were acute coronary syndromes, no transthoracic echocardiogram performed within 30 days before or after admission, and missing data. All patients were followed up from admission to CD (due to myocardial infarction, HF, stroke or sudden death), or were censored at the date of last contact or 3 years. Patients were divided into three groups (HFpEF, HF with mildly reduced ejection fraction (HFmrEF) and HFrEF) according to left ventricular ejection fraction.

A total of 320 patients (mean age 79 ± 12 years, 163 females) were included in the analysis. The median duration of AF was 1.2 years; 11% (36/320) had paroxysmal AF. The median brain natriuretic peptide value was 623 pg/ml, and 52% of the patients (165/320) were in New York Heart Association functional class 4. During a median follow-up of 528 days, 24% (77/320) patients were observed with CDs: 2 myocardial infarctions, 51 HF-related deaths, 6 strokes, and 18 sudden cardiac deaths. At the 3-year follow-up, the survival rate by the Kaplan-Meier curve was 74% (95% confidence interval (CI) 63%-82%) in the HFpEF group (n=131), 66% (95% CI 50%-78%) in the HFmrEF group (n=67) and 58% (95% CI 47%-68%) in the HFrEF group (n=122) (p=0.098, log-rank test). Predictors of CD were GLS (hazard ratio (HR) 1.08, 95% CI 1.01-1.16, p = 0.027) and female (HR 3.07, 95% CI 1.23-7.70, p = 0.017) and OAC medication (HR 0.27, 95% CI 0.10-0.74, p = 0.011) in the HFpEF group, but GLS was not a significant predictor of CD in the HFrEF and HFmrEF groups. In the ROC analysis, the optimal cut-off value of GLS to predict CD in the HFpEF group was -9.4% (area under the curve 0.66, sensitivity 87%, specificity 44%), the low GLS group (>-9.4%) had a significantly higher risk of CD than the high GLS group (≤-9.4%) (HR 3.69, 95% CI 1.65-8.23, p=0.001).

Patients with low GLS with AF and HFpEF may have a poor prognosis. Prospective studies are needed to determine whether catheter ablation improves the prognosis of such patients.