Let Us Pump The Brakes On The Heart: Optimal AV-nodal Agent For Atrial Fibrillation In Heart Failure With Preserved Ejection Fraction

Abstract

Introduction Current AHA/ACC/HRS guidelines recommend either non-dihydropyridine calcium channel blockers (ND-CCB) or beta-blockers (BB) for rate control in atrial fibrillation/flutter (AF) as first line therapy among patients with compensated heart failure and preserved ejection fraction (HFpEF, LVEF≥50%). However, comparing differences if any, in clinical outcomes among patients with HFpEF and AF who are treated with either class of drugs remains unclear. Methods We compared long-term survival among all patients seen at University of Wisconsin Hospitals and Clinics with AF and HFpEF from 2009-2019 (n=2820) who received treatment with a BB (n=2643) or ND-CCB (n=177), patients on combinations of these drugs were excluded. Kaplan Meier curves and Cox regression models were constructed to evaluate mortality and all-cause hospitalizations with length of stay in each group were analyzed. Results Compared to BB group, patients receiving ND-CCB were older (73.9±11.5 vs. 71.5±12.5 years), had a higher prevalence of COPD (38% vs 20%), but lower prevalence of coronary disease (32% vs 55%), hyperlipidemia (56% vs 71%), and diabetes (39% vs 50%), p-value for all <0.05. Upon follow up, (mean 3.3 years) 985 patients died. Kaplan Meier curve (Figure) demonstrated better survival of those on BB therapy (log rank p <0.01) compared to ND-CCB. Multivariable Cox analysis showed that patients on BB had a 26% lower risk of death (95% confidence interval 0.584-0.937) compared to ND-CCB group on long-term follow up. The BB cohort had similar hospitalization rates but longer length of stay (15.1 vs 11.2 days; p=0.04) compared to the CCB group. Conclusions Despite higher prevalence of cardiovascular risk factors, patients treated with BB for AF and HFpEF had better survival than those treated with ND-CCB. Future randomized controlled studies are needed to confirm or refute these findings. Current AHA/ACC/HRS guidelines recommend either non-dihydropyridine calcium channel blockers (ND-CCB) or beta-blockers (BB) for rate control in atrial fibrillation/flutter (AF) as first line therapy among patients with compensated heart failure and preserved ejection fraction (HFpEF, LVEF≥50%). However, comparing differences if any, in clinical outcomes among patients with HFpEF and AF who are treated with either class of drugs remains unclear. We compared long-term survival among all patients seen at University of Wisconsin Hospitals and Clinics with AF and HFpEF from 2009-2019 (n=2820) who received treatment with a BB (n=2643) or ND-CCB (n=177), patients on combinations of these drugs were excluded. Kaplan Meier curves and Cox regression models were constructed to evaluate mortality and all-cause hospitalizations with length of stay in each group were analyzed. Compared to BB group, patients receiving ND-CCB were older (73.9±11.5 vs. 71.5±12.5 years), had a higher prevalence of COPD (38% vs 20%), but lower prevalence of coronary disease (32% vs 55%), hyperlipidemia (56% vs 71%), and diabetes (39% vs 50%), p-value for all <0.05. Upon follow up, (mean 3.3 years) 985 patients died. Kaplan Meier curve (Figure) demonstrated better survival of those on BB therapy (log rank p <0.01) compared to ND-CCB. Multivariable Cox analysis showed that patients on BB had a 26% lower risk of death (95% confidence interval 0.584-0.937) compared to ND-CCB group on long-term follow up. The BB cohort had similar hospitalization rates but longer length of stay (15.1 vs 11.2 days; p=0.04) compared to the CCB group. Despite higher prevalence of cardiovascular risk factors, patients treated with BB for AF and HFpEF had better survival than those treated with ND-CCB. Future randomized controlled studies are needed to confirm or refute these findings.