Impact de la pression artérielle et influence de l’insuffisance cardiaque systolique sur le contrôle de la fibrillation auriculaire et la survie
Blood pressure may have a major impact on the evolution of AF and heart failure; nonetheless optimal management of blood pressure in these patients remains uncertain. Sinus rhythm maintenance has only moderate efficacy in abrogating AF and the potential role of blood pressure and its impact on risks of arrhythmia recurrence are unknown. Moreover, in patients with heart failure, blood pressure may affect prognosis in a non-linear fashion, where high blood pressure and also low blood pressure may increase mortality. The aim of this research was to evaluate the impact of blood pressure on the efficacy of sinus rhyhtm maintenance and mortality in patients with AF and to assess the potential role of ejection fraction and heart failure on this interaction. We conducted a post hoc combined analysis on pooled data from AFFIRM and AF-CHF trials. Patients were first classified according to LVEF (>40%, ≤40%) and we then assessed the impact of a baseline SBP (<120 mmHg, 120-140 mmHg, >140 mmHg) on outcomes. Firstly, in a total of 2715 patients randomized to rhythm control, 68±8 years and followed for 41±17 months, we assessed time to first AF recurrence according to SBP. Secondly, in all 5436 patients from both source studies, we assessed mortality according to SBP. In patients with LVEF >40%, baseline SBP did not influence any of the outcomes in multivariate Cox regression analyses. In contrast, in patients with LVEF ≤40%, the AF recurrence rate was higher in those with a SBP <120 mmHg and a SBP >140 mmHg compared to SBP 120-140 mmHg [HR 1.15; 95% CI (0.92-1.43)] and [HR, 1.47; 95% CI (1.12-1.93)], respectively. Mortality was also modulated by blood pressure in patients with LVEF ≤40% : SBP <120 mmHg and SBP >140 mmHg were both associated with increased death rate compared to SBP 120-140 mmHg [HR 1.75; 95% CI (1.41 to 2.17)] and [HR 1.40; 95% CI (1.04 to 1.90)], respectively. In conclusion, AF recurrence and mortality are influenced by SBP in patients with AF and depressed ejection fraction but not in patients with normal ejection fraction. A “U-shaped” pattern was identified where lower (<120 mmHg) and higher (>140 mmHg) SBP lead to worse outcomes.
Hypertension Heart failure Blood pressure Atrial fibrillation Mortality