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Temporal Relations of Atrial Fibrillation and Congestive Heart Failure and Their Joint Influence on Mortality: The Framingham Heart Study
Abstract
Background— Atrial fibrillation (AF) and congestive heart failure (CHF) frequently occur together, but there is limited information regarding their temporal relations and the combined influence of these conditions on mortality. Methods and Results— We studied participants in the Framingham Study with new-onset AF or CHF. Multivariable Cox proportional hazards models with time-dependent variables were used to evaluate whether mortality after AF or CHF was affected by the occurrence and timing of the other condition. Hazard ratios (HRs) were adjusted for time period and cardiovascular risk factors. During the study period, 1470 participants developed AF, CHF, or both. Among 382 individuals with both conditions, 38% had AF first, 41% had CHF first, and 21% had both diagnosed on the same day. The incidence of CHF among AF subjects was 33 per 1000 person-years, and the incidence of AF among CHF subjects was 54 per 1000 person-years. In AF subjects, the subsequent development of CHF was associated with increased mortality (men: HR 2.7; 95% CI, 1.9 to 3.7; women: HR 3.1; 95% CI, 2.2 to 4.2). Similarly, in CHF subjects, later development of AF was associated with increased mortality (men: HR 1.6; 95% CI, 1.2 to 2.1; women: HR 2.7, 95% CI, 2.0 to 3.6). Preexisting CHF adversely affected survival in individuals with AF, but preexisting AF was not associated with adverse survival in those with CHF. Conclusions— Individuals with AF or CHF who subsequently develop the other condition have a poor prognosis. Additional studies addressing the pathogenesis, prevention, and optimal management of the joint occurrence of AF and CHF appear warranted.
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“In adjusted models, AF is associated with increased morbidity, especially stroke and heart failure, as well as increased mortality.2–5”
From Worldwide Epidemiology of Atrial Fibrillation: A Global Burden of Disease 2010 Study (2014) · cites this paper as [5]
In the citing paper
“The plasma concentrations of the inflammatory marker C-reactive protein143 and of fibroblast growth factor-23144 have been found to be higher in women than in men in epidemiological studies.”
From Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis (2016) · cites this paper as [143]
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Upper Normal Blood Pressures Predict Incident Atrial Fibrillation in Healthy Middle-Aged Men
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Epidemiology of atrial fibrillation: A current perspective
Chen, L. Y., & Shen, W.-K. (2006) · Heart Rhythm · doi:10.1016/j.hrthm.2006.12.018 · Cited by 140
Fatema, K., Barnes, M. E., Bailey, K. R., Abhayaratna, W. P., Cha, S., Seward, J. B., & Tsang, T. S. M. (2008) · European Journal of Echocardiography · doi:10.1093/ejechocard/jen235 · Cited by 139
McManus, D. D., Hsu, G., Sung, S. H., Saczynski, J. S., Smith, D. H., Magid, D. J., Gurwitz, J. H., Goldberg, R. J., & Go, A. S. (2013) · Journal of the American Heart Association · doi:10.1161/jaha.112.005694 · Cited by 139
“The epidemiologic similarities between AF and HF, as well as their frequent concurrence, are explained, at least in part, by shared underlying risk factors, including hypertension, diabetes mellitus, chronic kidney disease, ischemic heart disease, and valvular heart disease.25 As expected, we found that patients with…”
BackgroundResultInfluentialChiang, C., Wu, T.-J., Ueng, K.-C., Chao, T., Chang, K., Wang, C.-C., Lin, Y., Yin, W., Kuo, J., Lin, W., et al. (2016) · Journal of the Formosan Medical Association · doi:10.1016/j.jfma.2016.10.005 · Cited by 138
Current Perceptions of the Epidemiology of Atrial Fibrillation
Kannel, W. B., & Benjamin, E. J. (2008) · Cardiology Clinics · doi:10.1016/j.ccl.2008.09.015 · Cited by 138
“Framingham Study data indicate that AF and heart failure often coexist and that each may have an adverse impact on the other.(34) The decreased survival rate associated with AF occurs across a wide age range and is partially attributable to the vulnerability of patients who have AF to heart failure.”
Self-citationRivero‐Ayerza, M., Reimer, W. J. M. S. O., Lenzen, M. J., Theuns, D. A. M. J., Jordaens, L. J. L. M., Michel Komajda, N., Folláth, F., Swedberg, K. B., & Cleland, J. G. F. (2008) · European Heart Journal · doi:10.1093/eurheartj/ehn217 · Cited by 134
“Clinical variables, treatment, length of stay in the coronary care unit/intensive care unit (CCU/ICU), length of hospitalization, hospital survival, and cause of death were analysed according to the type of AF.”
InfluentialHanna, I. R., Heeke, B., Bush, H., Brosius, L., King-Hageman, D., Dudley, S. C., Beshai, J. F., & Langberg, J. J. (2006) · Heart Rhythm · doi:10.1016/j.hrthm.2006.05.010 · Cited by 132
Miyasaka, Y., Barnes, M. E., Petersen, R. C., Cha, S. S., Bailey, K. R., Gersh, B. J., Casaclang-Verzosa, G., Abhayaratna, W. P., Seward, J. B., Iwasaka, T., et al. (2007) · European Heart Journal · doi:10.1093/eurheartj/ehm012 · Cited by 133
Serum potassium levels and the risk of atrial fibrillation
Krijthe, B. P., Heeringa, J., Kors, J. A., Albert Hofman, D., Franco, O. H., Witteman, J. C. M., & Stricker, B. H. C. (2013) · International Journal of Cardiology · doi:10.1016/j.ijcard.2013.08.048 · Cited by 134
“Atrial fibrillation is associated with a 3 to 5 times higher risk of stroke [1], and with a higher risk of heart failure, cardiac mortality, and total mortality [2,3].”
BackgroundGenetic Obesity and the Risk of Atrial Fibrillation
Chatterjee, N. A., Giulianini, F., Geelhoed, B., Lunetta, K. L., Misialek, J. R., Niemeijer, M. N., Rienstra, M., Rose, L. M., Smith, A. V., Arking, D. E., et al. (2016) · Circulation · doi:10.1161/circulationaha.116.024921 · Cited by 136
Self-citationRisk Assessment for Incident Heart Failure in Individuals With Atrial Fibrillation
Schnabel, R. B., Rienstra, M., SULLIVAN, L. M., Sun, F. X., Moser, C., Levy, D. A., Pencina, M. J., Fontes, J. D., Magnani, J. W., McManus, D. D., et al. (2013) · European Journal of Heart Failure · doi:10.1093/eurjhf/hft041 · Cited by 133
Self-citationCatheter Ablation of Atrial Fibrillation in Patients With Heart Failure
Turagam, M. K., Garg, J., Whang, W., Sartori, S., Koruth, J. S., Miller, M. A., Langan, N., Sofi, A. A., Gomes, A., Choudry, S., et al. (2018) · Annals of Internal Medicine · doi:10.7326/m18-0992 · Cited by 133
Atrial Fibrillation and Aortic Stenosis
Stortecky, S., Buellesfeld, L., Wenaweser, P., Heg, D., Pilgrim, T., Khattab, A. A., Gloekler, S., Huber, C. H., Nietlispach, F., Meier, B., et al. (2013) · Circulation Cardiovascular Interventions · doi:10.1161/circinterventions.112.000124 · Cited by 134
“Previous CABG, n (%) 72 (19) 56 (22) 16 (12) 0.”
Atrial Fibrillation and Cognitive Decline–The Role of Subclinical Cerebral Infarcts
Chen, L. Y., Norby, F. L., Gottesman, R. F., Huxley, R., Agarwal, S. K., Loehr, L. R., Mosley, T. H., & Alonso, Á. (2014) · Stroke · doi:10.1161/strokeaha.114.005243 · Cited by 134
Development of heart failure in recent hypertension trials
Tocci, G., Sciarretta, S., & Volpe, M. (2008) · Journal of Hypertension · doi:10.1097/hjh.0b013e3282fe1d3d · Cited by 133
Maret, E., Tödt, T., Brudin, L. H., Nylander, E., Swahn, E., Ohlsson, J. L., & Engvall, J. E. (2009) · Cardiovascular Ultrasound · doi:10.1186/1476-7120-7-53 · Cited by 128
“Unless compensated for by hyperkinetic wall motion in remote areas, the physiological effect of a WMA is a reduction in the left ventricular ejection fraction (LVEF) which is closely related to prognosis in chronic coronary artery disease [7-11].”
Nagai, R., Kinugawa, K., Inoue, H., Atarashi, H., Seino, Y., Yamashita, T., Shimizu, W., Aiba, T., Kitakaze, M., Sakamoto, A., et al. (2013) · Circulation Journal · doi:10.1253/circj.cj-12-1618 · Cited by 128
Monogenic and Polygenic Contributions to Atrial Fibrillation Risk
Choi, S. H., Jurgens, S. J., Weng, L.-C. C., Pirruccello, J. P., Roselli, C., Chaffin, M. D., Lee, C. J., Hall, A. W., Khera, A. V., Lunetta, K. L., et al. (2019) · Circulation Research · doi:10.1161/circresaha.119.315686 · Cited by 129
Adverse prognosis of incidentally detected ambulatory atrial fibrillation
Martínez, C., Katholing, A., & Freedman, S. B. (2014) · Thrombosis and Haemostasis · doi:10.1160/th4-04-0383 · Cited by 130
“Atrial fibrillation (AF) is increasing in prevalence (1) due in part to population ageing, and is associated with a significant but variable increase in risk of stroke (2) (usually large and severe) (3, 4), death (5) and heart failure(6).”
Mountantonakis, S., Grau‐Sepulveda, M. V., Bhatt, D. L., Hernandez, A. F., Peterson, E. D., & Fonarow, G. C. (2012) · Circulation Heart Failure · doi:10.1161/circheartfailure.111.965681 · Cited by 127
SCHMIDT, M., DORWARTH, U., ANDRESEN, D., BRACHMANN, J., KUCK, K., KUNISS, M., LEWALTER, T., SPITZER, S., WILLEMS, S., SENGES, J., et al. (2014) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.12267 · Cited by 126
Cuoco, F. A. (2010) · Yearbook of Cardiology · doi:10.1016/s0145-4145(10)79886-5 · Cited by 124
Sanchis, K., Cariou, E., Colombat, M., Ribes, D., Huart, A., Cintas, P., Fournier, P., Rollin, A., Carrié, D., Galinier, M., et al. (2019) · Amyloid · doi:10.1080/13506129.2019.1620724 · Cited by 125
“Although the role of AF as a risk factor for mortality has been clearly demonstrated over the last decades [6,7], particularly in heart failure [8], its impact in patients with CA is controversial.”
BackgroundNgaage, D. L., Schaff, H. V., Barnes, S. A., Sundt, T. M., Mullany, C. J., Dearani, J. A., Daly, R. C., & Orszulak, T. A. (2006) · The Annals of Thoracic Surgery · doi:10.1016/j.athoracsur.2006.04.004 · Cited by 124
Treatment of Patients With Atrial Fibrillation and Heart Failure With Reduced Ejection Fraction
Verma, A., Kalman, J. M., & Callans, D. J. (2017) · Circulation · doi:10.1161/circulationaha.116.026054 · Cited by 124
Chopard, R., Teíger, E., Meneveau, N. F., Chocron, S., Gilard, M., Laskar, M., Eltchaninoff, H., Iung, B., Leprince, P. N., Chevreul, K., et al. (2015) · JACC: Cardiovascular Interventions · doi:10.1016/j.jcin.2015.06.010 · Cited by 124
“Moreover, the loss of atrioventricular synchrony, leading to impaired ventricular filling, reduced cardiac output, and increased afterload, are hemodynamic factors known to adversely affect clinical outcomes in heart failure patients (28).”
BackgroundLong-term effects of cardiac resynchronisation therapy in patients with atrial fibrillation
Khadjooi, K., Foley, P. W. X., Chalil, S., Anthony, J., Smith, R. E. A., Frenneaux, M. P., & Leyva, F. (2008) · Heart · doi:10.1136/hrt.2007.129429 · Cited by 117
Santini, M., Gasparini, M., Landolina, M., Lunati, M., Proclemer, A., Padeletti, L., Catanzariti, D., Molon, G., Botto, G. L., La Rocca, L., et al. (2011) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2010.08.624 · Cited by 121
Management of Atrial Fibrillation in Patients 75 Years and Older
Volgman, A. S., Nair, G. G., Lyubarova, R., Merchant, F. M., Mason, P. K., Curtis, A. B., WENGER, N. K., Aggarwal, N. T., Kirkpatrick, J. N., & Benjamin, E. J. (2022) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2021.10.037 · Cited by 124
Self-citationNon-cardiac comorbidities in chronic heart failure
Lang, C. C., & MANCINI, D. M. (2006) · Heart · doi:10.1136/hrt.2005.068296 · Cited by 124
“Previous data on the presence and effect of comorbidities on CHF were derived from clinical trials and geographically limited studies of relatively small numbers of patients such as the Framingham cohort.”
MethodAtrial fibrillation and heart failure: natural history and pharmacological treatment
Savelieva, I., & JOHNCAMM, A. (2004) · EP Europace · doi:10.1016/j.eupc.2004.07.003 · Cited by 120
Coenzyme Q10: Clinical Applications in Cardiovascular Diseases
Martelli, A., Testai, L., Colletti, A., & Cicero, A. F. G. (2020) · Antioxidants · doi:10.3390/antiox9040341 · Cited by 121
Metadata
- Authors
- Wang, T. J., Larson, M. G., Levy, D., Vasan, R. S., Leip, E. P., Wolf, P. A., D’Agostino, R. B., Murabito, J. M., Kannel, W. B., & Benjamin, E. J.
- Affiliations
- Boston University (US)
- ORCID
- Venue
- Circulation
- Published
- 2003-06-17
- Volume
- 107
- Issue
- 23
- Pages
- 2920-2925
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W1998083759
- Cited by
- 1,970
- References
- 28
- Citations by year
- 2026: 49 · 2025: 65 · 2024: 114 · 2023: 93 · 2022: 117 · 2021: 137 · 2020: 109 · 2019: 103 · 2018: 120 · 2017: 107 · 2016: 111 · 2015: 115 · 2014: 112 · 2013: 101 · 2012: 84
- FWCI
- 27.01
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (n01hc25195-41-0-1)
- National Heart, Lung, and Blood Institute (K24-HL-04334-01A1, N01‐HC25195, K24HL004334)
- National Institute of Neurological Disorders and Stroke (5-RO1-NS-17950, R01NS017950)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Keywords
- atrial fibrillation, congestive heart failure, mortality, comorbidities, prognosis, Framingham Heart Study
- MeSH terms
- Aged, Atrial Fibrillation, Female, Follow-Up Studies, Heart Failure, Humans, Male, Massachusetts, Middle Aged, Prognosis, Risk Factors, Cohort Studies, Comorbidity, Incidence, Multivariate Analysis, Proportional Hazards Models, Survival Analysis, Disease Progression
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