title: 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.
  
  
  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.
authors.affiliation: Framingham Heart Study, 73 Mt Wayte Ave, Suite #2, Framingham, Mass 01702-5827, USA.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Wang
authors.forename: Martin G
authors.initials: MG
authors.lastname: Larson
authors.forename: Daniel
authors.initials: D
authors.lastname: Levy
authors.forename: Ramachandran S
authors.initials: RS
authors.lastname: Vasan
authors.forename: Eric P
authors.initials: EP
authors.lastname: Leip
authors.forename: Philip A
authors.initials: PA
authors.lastname: Wolf
authors.forename: Ralph B
authors.initials: RB
authors.lastname: D'Agostino
authors.forename: Joanne M
authors.initials: JM
authors.lastname: Murabito
authors.forename: William B
authors.initials: WB
authors.lastname: Kannel
authors.forename: Emelia J
authors.initials: EJ
authors.lastname: Benjamin
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000401:mortality*; D015331:Cohort Studies; D015897:Comorbidity; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality*; D006801:Humans; D015994:Incidence; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D008875:Middle Aged; D015999:Multivariate Analysis; D011379:Prognosis; D016016:Proportional Hazards Models; D012307:Risk Factors; D016019:Survival Analysis