title: Atrial fibrillation or flutter on initial electrocardiogram is associated with worse outcomes in patients admitted for worsening heart failure with reduced ejection fraction: findings from the EVEREST Trial.
abstract: BACKGROUND
  Heart failure (HF) complicated by atrial fibrillation/flutter (AF/AFL) is associated with worse outcomes. However, the clinical profile and outcomes of patients following hospitalization for HF with AF/AFL on initial electrocardiogram (ECG) has not been well studied.
  
  
  METHODS
  EVEREST was a randomized trial of vasopressin-2 receptor blockade, in addition to standard therapy, in 4133 patients hospitalized with HF with ejection fraction ≤40%. A post hoc analysis was performed comparing the clinical characteristics and outcomes [all-cause mortality and cardiovascular mortality/HF hospitalization] of patients with AF/AFL versus sinus rhythm (SR) on baseline ECG, which were centrally analyzed. Times to events were compared using log-rank tests and Cox regression models.
  
  
  RESULTS
  Of the 4133 patients, 1195 (29%) were classified with AF/AFL and 2071(50%) with SR. The remaining patients (21%) were excluded because ECGs were unavailable (n = 106), rhythm was paced (n = 727), or junctional/other supraventricular (n = 34). AF/AFL patients were older, with increased weight, faster heart rate, higher blood urea nitrogen, and natriuretic peptide levels compared to SR patients. Anticoagulation was prescribed in 67% of AF/AFL patients on discharge. AF/AFL patients were less likely to receive β-blockers or angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (all P < .05). After risk adjustment, AF/AFL was associated with increased mortality (hazard ratio 1.23; 95% CI, 1.04-1.46) and cardiovascular mortality/HF hospitalization (hazard ratio 1.26; 95% CI, 1.07-1.47).
  
  
  CONCLUSIONS
  AF/AFL on initial ECG in patients hospitalized with HF with reduced ejection fraction is associated with lower use of evidence-based therapies and increased mortality and rehospitalization compared to patients in SR.
authors.affiliation: Duke University Medical Center, Durham, NC, USA.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Mentz
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Chung
authors.forename: Mihai
authors.initials: M
authors.lastname: Gheorghiade
authors.forename: Peter S
authors.initials: PS
authors.lastname: Pang
authors.forename: Mary J
authors.initials: MJ
authors.lastname: Kwasny
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Ambrosy
authors.forename: Muthiah
authors.initials: M
authors.lastname: Vaduganathan
authors.forename: Christopher M
authors.initials: CM
authors.lastname: O'Connor
authors.forename: Karl
authors.initials: K
authors.lastname: Swedberg
authors.forename: Faiez
authors.initials: F
authors.lastname: Zannad
authors.forename: Marvin A
authors.initials: MA
authors.lastname: Konstam
authors.forename: Aldo P
authors.initials: AP
authors.lastname: Maggioni
mesh_terms: D000368:Aged; D065092:Antidiuretic Hormone Receptor Antagonists; D001146:Arrhythmia, Sinus / Q000175:diagnosis* / Q000503:physiopathology; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000503:physiopathology; D001282:Atrial Flutter / Q000175:diagnosis* / Q000503:physiopathology; D015331:Cohort Studies; D004311:Double-Blind Method; D004562:Electrocardiography; D005260:Female; D006333:Heart Failure / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D017483:Receptors, Vasopressin / Q000627:therapeutic use; D012189:Retrospective Studies; D013318:Stroke Volume / Q000502:physiology*; D016896:Treatment Outcome
chemical_list: D065092:Antidiuretic Hormone Receptor Antagonists; D017483:Receptors, Vasopressin