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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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Dronedarone: current evidence for its safety and efficacy in the management of atrial fibrillation
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“To date, few studies have evaluated the predictive value of new onset AF in heart failure populations; the results of which have been contradictory.(7,9-11,14-17)”
BackgroundSoluble ST2 in Patients with Nonvalvular Atrial Fibrillation and Prediction of Heart Failure
Chen, C., Qu, X., Gao, Z., Zheng, G., Wang, Y., Chen, X., Li, H., Huang, W., & Zhou, H. (2017) · International Heart Journal · doi:10.1536/ihj.16-520 · Cited by 34
Ökçün, B., Yiğit, Z., Özkan, A. A., & Küçükoğlu, S. (2004) · Japanese Heart Journal · doi:10.1536/jhj.45.591 · Cited by 33
Marston, H. R., Hadley, R., Banks, D., & Miranda-Duro, M. D. C. (2019) · Healthcare · doi:10.3390/healthcare7030096 · Cited by 33
Congestive Heart Failure and Atrial Fibrillation: Rhythm Versus Rate Control
Kareti, K., Chiong, J. R., Hsu, S. S., & Miller, A. B. (2005) · Journal of Cardiac Failure · doi:10.1016/j.cardfail.2004.09.011 · Cited by 33
Girerd, N., Leclercq, C., Hanon, O., Bayés‐Genís, A., Januzzi, J. L., Damy, T., Lequeux, B., Meune, C., Sabouret, P. F., & Roubille, F. (2023) · Revista Española de Cardiología (English Edition) · doi:10.1016/j.rec.2023.03.005 · Cited by 32
Naganuma, M., Shiga, T., Sato, K., Murasaki, K., Hashiguchi, M., Mochizuki, M., & Hagiwara, N. (2011) · Thrombosis Research · doi:10.1016/j.thromres.2011.11.005 · Cited by 32
miR-132 in atrial fibrillation directly targets connective tissue growth factor
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Impact of the Pattern of Atrial Fibrillation on Stroke Risk and Mortality
Botto, G. L., Tortora, G., Casale, M. C., Canevese, F. L., & Brasca, F. M. A. (2021) · Arrhythmia & Electrophysiology Review · doi:10.15420/aer.2021.01 · Cited by 32
Atrial fibrillation management in Asia: From the Asian expert forum on atrial fibrillation
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“Reports from the Western world indicated that patients with AF have a 2-fold higher risk of mortality, 3-fold higher risk of hospitalization, and 5-fold higher risk of stroke compared to matched controls [21–23].”
BackgroundSmit, M. D., van Dessel, P. F. H. M., Rienstra, M., Nieuwland, W., Wiesfeld, A. C. P., Tan, E. S., Anthonio, R. L., van Veldhuisen, D. J., & Gelder, I. C. V. (2006) · EP Europace · doi:10.1093/europace/eul081 · Cited by 32
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“The European guidelines of AF recommend AF catheter ablation in symptomatic patients refractory to drugs or with tachycardiomyopathy [8,11,12] to improve symptoms of AF recurrences in patients with paroxysmal AF, persistent AF without major risk factors for AF recurrence (Class IA), or persistent…”
BackgroundRani, S., Kumar, L., Ali, S. M. E., Ashraf, S., Bhimani, S., Kumar, S., Raja, A., Abdullah, B. S., Ayalew, B. D., & Malik, M. H. B. A. (2025) · BMC Cardiovascular Disorders · doi:10.1186/s12872-025-05036-5 · Cited by 31
“…mortality rates in both heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF), although this correlation is more significant in HFpEF, likely due to the heightened atrial stiffness and fibrotic changes observed in these patients [33, 34].”
Management of Noncardiac Comorbidities in Chronic Heart Failure
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“Previous data on the presence and effect of comorbidities on CHF were derived from geographically limited studies of relatively small numbers of patients such as the Framingham cohort [8].”
BackgroundAtrial Fibrillation and Vascular Disease—A Bad Combination
Olesen, J. B., Gislason, G., Torp-Pedersen, C. T., & Lip, G. Y. H. (2012) · Clinical Cardiology · doi:10.1002/clc.20955 · Cited by 32
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Atrial Fibrillation Ablation in Systolic Dysfunction: Clinical and Echocardiographic Outcomes
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Quantitative-Electrogram-Based Methods for Guiding Catheter Ablation in Atrial Fibrillation
Baumert, M., Sanders, P., & Ganesan, A. N. (2016) · Proceedings of the IEEE · doi:10.1109/jproc.2015.2505318 · Cited by 31
“The downstream consequences of AF are highly significant and include heart failure [4], stroke [5], dementia [6], and a doubling in mortality [3].”
BackgroundFerreira, J. P., Girerd, N., Alshalash, S., Konstam, M. A., & Zannad, F. M. (2016) · European Heart Journal · doi:10.1093/eurheartj/ehw213 · Cited by 31
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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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