Post-mortem examination of high mortality in patients with heart failure and atrial fibrillation

Otilia Țica, Karina V Bunting, Joseph deBono, Georgios V Gkoutos, Mircea I Popescu, Dipak Kotecha

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Abstract

BACKGROUND: The prevalence of combined heart failure (HF) and atrial fibrillation (AF) is rising, and these patients suffer from high rates of mortality. This study aims to provide robust data on factors associated with death, uniquely supported by post-mortem examination.

METHODS: A retrospective cohort study of hospitalized adults with a clinical diagnosis of HF and AF at a tertiary centre in Romania between 2014 and 2017. A standardized post-mortem examination was performed where death occurred within 24 h of admission, when the cause of death was not clear or by physician request. National records were used to collect mortality data, subsequently categorized and analysed as HF-related death, vascular death and non-cardiovascular death using Cox proportional hazards regression.

RESULTS: A total of 1009 consecutive patients with a mean age of 73 ± 11 years, 47% women, NYHA class 3.0 ± 0.9, left ventricular ejection fraction (LVEF) 40.1 ± 11.0% and 100% anticoagulated were followed up for 1.5 ± 0.9 years. A total of 291 (29%) died, with post-mortems performed on 186 (64%). Baseline factors associated with mortality were dependent on the cause of death. HF-related death in 136 (47%) was associated with higher NYHA class (hazard ratio [HR] 2.45 per one class increase, 95% CI 1.73-3.46; p < 0.001) and lower LVEF (0.95 per 1% increase, 0.93-0.97; p < 0.001). Vascular death occurred in 75 (26%) and was associated with hypertension (HR 2.83, 1.36-5.90; p = 0.005) and higher LVEF (1.08 per 1% increase, 1.05-1.11; p < 0.001). Non-cardiovascular death in 80 (28%) was associated with clinical obesity (HR 2.20, 1.21-4.00; p = 0.010) and higher LVEF (1.10 per 1% increase, 1.06-1.13; p < 0.001). Across all causes, there was no relationship between mortality and AF type (p = 0.77), HF type (p = 0.85) or LVEF (p = 0.58).

CONCLUSIONS: Supported by post-mortem data, the cause of death in HF and AF patients is heterogeneous, and the relationships with typical markers of mortality are critically dependent on the mode of death. The poor prognosis in this group demands further attention to improve management beyond anticoagulation.

Original languageEnglish
Article number331
Number of pages11
JournalBMC medicine
Volume20
Issue number1
Early online date5 Oct 2022
DOIs
Publication statusPublished - Oct 2022

Bibliographical note

Funding Information:
No specific funding was used for the local collection of healthcare data in this study. Data collation, statistical analysis, and drafting of results were supported by grants awarded to the University of Birmingham/University Hospitals Birmingham NHS Foundation Trust: (a) Medical Research Council Health Data Research UK (HDRUK/CFC/01), an initiative funded by UK Research and Innovation, Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities; (b) British Heart Foundation Accelerator Award to the University of Birmingham Institute of Cardiovascular Sciences (AA/18/2/34218); and (c) the Innovative Medicines Initiative 2 Joint Undertaking (116074 BigData@Heart), which receives support from the European Union’s Horizon 2020 research and innovation programme and the European Federation of Pharmaceutical Industries and Associations. The views expressed in this publication are those of the authors and do not represent any of the stated funders.

All authors have completed the ICMJE uniform disclosure form and declare the following: Otilia Tica received salary funding from the EU/EEPIA Innovative Medicines Initiative (BigData@Heart 116074) and Amomed Pharma, awarded to Professor Kotecha. Professor Kotecha reports grants from the National Institute for Health Research (NIHR CDF-2015–08-074 RATE-AF; NIHR HTA-130280 DaRe2THINK), the British Heart Foundation (PG/17/55/33087 and AA/18/2/34218), EU/EFPIA Innovative Medicines Initiative (BigData@Heart 116074), the European Society of Cardiology supported by educational grants from Boehringer Ingelheim/BMS-Pfizer Alliance/Bayer/Daiichi Sankyo/Boston Scientific, the NIHR/University of Oxford Biomedical Research Centre and British Heart Foundation/University of Birmingham Accelerator Award (STEEER-AF NCT04396418) and Amomed Pharma and IRCCS San Raffaele/Menarini (Beta-blockers in Heart Failure Collaborative Group NCT0083244), in addition to personal fees from Bayer (Advisory Board), AtriCure (Speaker fees), Amomed (Advisory Board), Protherics Medicines Development (Advisory Board) and Myokardia (Advisory Board). Dr. Ovidiu Tica, Dr. deBono, Professor Popescu and Professor Gkoutos declare that they have no competing interests. Dr. Bunting was the research fellow for the RATE-AF trial funded by the NIHR (NIHR CDF-2015–08-074) and has been awarded a grant from the University of Birmingham’s British Heart Foundation Accelerator Award (BHF AA/18/2/34218) and the British Heart Foundation Fellowship scheme (FS/CDRF/21/21032).

Publisher Copyright:
© 2022, The Author(s).

Keywords

  • Aged
  • Aged, 80 and over
  • Anticoagulants
  • Atrial Fibrillation/complications
  • Autopsy
  • Female
  • Heart Failure
  • Humans
  • Male
  • Middle Aged
  • Prognosis
  • Retrospective Studies
  • Risk Factors
  • Stroke Volume
  • Ventricular Function, Left
  • Heart failure
  • Atrial fibrillation
  • Mortality
  • Post-mortem

ASJC Scopus subject areas

  • Medicine(all)

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