Temporal trends in mortality, heart failure hospitalization, and stroke in heart failure patients with and without atrial fibrillation: A nationwide study from 1997-2018 on 152,059 patients

Background:It remains unknown how the prognosis has changed for patients with heart failure (HF) and concomitant atrial fibrillation (AF), which is why we aimed to investigate temporal trends in clinical outcomes from 1997 to 2018. Methods:From Danish nationwide registries, we identified 152,059 patients with a first-time HF-diagnosis from 1997 to 2018. Patients were grouped according to year of new-onset HF and AF-status: Prevalent AF (n=34,734), New-onset HF (n=12,691), and No AF (n=104,634). Outcomes of interest were the five-year risk of all-cause mortality, HF-hospitalization, and stroke. Results:Between 1997 and 2018, the proportion of patients with prevalent or new-onset AF increased from 24.7% (n=9256) to 35.8% (n=14,970). The five-year risk of all-cause mortality decreased from 69.1% (95% CI): 67.9%-70.2%) to 51.3% (49.9%-52.7%), 62.3% (60.5%-64.4%) to 43.0% (40.5%-45.5%), and 61.9% (61.3%-62.4%) to 36.7% (35.9%-37.6%) for the prevalent AF, new-onset AF, and no AF group, respectively. Minimal changes were observed in the risk of HF-hospitalization. The five-year risk of stroke decreased from 8.5% (7.8%-9.1%) to 5.0% (4.4%-5.5%) in the prevalent AF group, 8.2% (7.2%-9.2%) to 4.6% (3.7%-5.5%) in the new-onset AF group, and 6.3% (6.1%-6.6%) to 4.9% (4.6%-5.3%) in the no AF group. Simultaneously, patients prescribed anticoagulant therapy within 90 days after HF-onset increased from 42.7% to 93.1% in patients with prevalent AF and 41.9% to 92.5% in patients with new-onset AF. Conclusion:From 1997 to 2018, we observed an increase in patients with HF and coexisting AF. Mortality and stroke risk decreased across all patient groups regardless of AF-status. Anticoagulation therapy increased, and stroke risk in patients with HF and AF was reduced to similar levels as HF patients without AF at the end of the study period. ### Competing Interest Statement M.E.M. reports grants from CARDIO-HGH Foundation, Herlev-Gentofte University Hospital and Danish Cardiovascular Academy, unrelated to the submitted work. C.H.G reports personal fees from lectures honorarium from Astra Zeneca, unrelated to the submitted work. J.B.O reports speaker honorarium or consultancy fees from Bayer, Bristol-Myers Squibb, and Pfizer, unrelated to the submitted work. E.F. declares an independent research grant related to valvular heart disease and endocarditis from the Novo Nordisk Foundation and the Danish Heart Association, unrelated to submitted work. L.Ø. declares an independent research grant related to research in mitral valve regurgitation from the Novo Nordisk Foundation, unrelated to the submitted work. L.K reports speaker honorarium from Novo Nordisk, AstraZeneca, Novartis, and Boehringer Ingelheim, unrelated to the submitted work. M.S reports lecture fees from Novartis, Boehringer-Ingelheim, Astra Zeneca and Novo Nordisk, unrelated to the submitted work. The other authors report no conflicts. ### Funding Statement Hospital grants, Department of cardiology, Herlev-Gentofte Hospital ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Data for this study were approved for use by Statistics Denmark. Ethical approval was not necessary according to the Danish regulations regarding observational retrospective register-based studies. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data for this study were obtained from Dansih Nationwide Registers, and approved for use by Statistics Denmark.