Patients with new-onset vs patients without or with preexisting atrial fibrillation (AF) who underwent transcatheter aortic valve replacement (TAVR) were found to have a higher risk for all-cause mortality, stroke, bleeding, and heart failure (HF) hospitalization, according to study results published in JACC: Cardiovascular Interventions.
The presence of AF has been associated with poorer outcomes in patients receiving TAVR for aortic stenosis.
In this retrospective chart review, United States Medicare claims data of 72,660 patients ≥65 years old (mean age, 81.9 years; 53% men) who had non-apical TAVR performed between 2014 and 2016 were examined. Patients who had a diagnosis of AF in the 3 years preceding the TAVR were considered to have preexisting AF, and occurrence of AF for the first time during the TAVR inpatient hospital stay or within 30 days of discharge was categorized as new-onset disease. The study’s primary outcome was all-cause mortality, and secondary outcomes were hospital readmission for stroke, bleeding, and HF after TAVR.
In this cohort, 6.8% of patients were diagnosed with new-onset AF (n=2948; mean age, 83.8 years; 49.6% men), 40.7% had preexisting AF (n=29,563; mean age, 82.4 years; 55.1% men), and the remainder of the cohort had no AF (n=40,149; mean age, 81.3 years; 51.8% men). Patients with preexisting AF had the highest comorbidity burden, including higher prevalence of previously diagnosed chronic pulmonary disease, renal disease, coronary artery disease, and congestive HF. The median follow-up time was 305 days, with a total of 73,732 person-years of data examined.
The long-term all-cause mortality rate was higher in patients with new-onset AF (29.7 per 100 person-years; P <.0001) vs no AF and preexisting AF (12.8 and 22.6 per 100 person-years, respectively). After adjusting for hospital volume of TAVR procedures and patient characteristics, the association between new-onset vs preexisting or no AF and higher mortality was still significant (preexisting AF: adjusted hazard ratio [aHR], 1.35; 95% CI, 1.26-1.45; P <.001; no AF: aHR, 2.068; 95% CI, 1.92-2.20; P <.0001). Preexisting AF was associated with a higher mortality risk compared with no AF (aHR, 1.53; 95% CI, 1.47-1.58; P <.0001).
New-onset AF was associated with elevated long-term risks for stroke (subdistribution HR [sHR], 1.92; 95% CI, 1.63-2.26; P <.01), bleeding (sHR, 1.66; 95% CI, 1.48-1.86; P <.01), and HF (sHR, 1.98; 95% CI, 1.81-2.16; P <.01). Preexisting vs no AF was also associated with increased risk of bleeding (sHR, 1.36; 95% CI, 1.28-1.45; P <.0001) and HF hospitalization (sHR, 1.77; 95% CI, 1.67-1.86; P <.0001).
Study limitations included a lack of information on medication intake and the possibility that extended hospital stays were the cause vs the consequence of new-onset AF diagnoses.
“[O]ur results suggest that patients who develop new-onset AF after TAVR represent a distinct population with a high risk for poor long-term outcomes that need to be appropriately managed,” concluded the study investigators.
Disclosure: One study author declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
Mentias A, Saad M, Girotra S, et al. Impact of pre-existing and new onset atrial fibrillation on outcomes after transcatheter aortic valve replacement. JACC Cardiovas Interv. 2019;12(21):2119-2129.