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

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.

Automated summary

The prevalence of combined heart failure and atrial fibrillation is increasing, which leads to high mortality rates. This study aimed to provide reliable data on factors associated with death in these patients, through post-mortem examination. The cause of death varied depending on the baseline factors, with higher NYHA class and lower left ventricular ejection fraction associated with HF-related death, hypertension and higher LVEF associated with vascular death, and clinical obesity and higher LVEF associated with non-cardiovascular death. There was no relationship between mortality and AF type, HF type, or LVEF. The study highlights the need for improved management beyond anticoagulation to address the poor prognosis in this patient population.