Background Contemporary data are lacking on the prognostic importance of heart failure (HF) after myocardial infarction (MI). We evaluated the prognostic impact of HF post MI according to preserved/reduced ejection fraction (EF) and the timing of its occurrence. Methods and Results All Olmsted County, Minnesota residents (n=2,596) with incident MI diagnosed in 1990-2010 and no prior HF were followed through March 2013. Cox models were used to examine (1) the hazard ratios (HRs) for death associated with HF type and timing; and (2) secular trends in survival by HF status. During a mean follow-up of 7.6 years, there were 1116 deaths, 634 in the 902 patients who developed HF (70%), and 482 in the 1694 patients who did not develop HF (28%). After adjustment for age and sex, HF as a time-dependent variable was strongly associated with mortality (HR=3.31, 95% confidence interval [CI]: 2.93-3.75), particularly from cardiovascular causes (HR=4.20, 95% CI: 3.50-5.03). Further adjustment for MI severity and comorbidity, acute treatment, and recurrent MI moderately attenuated these associations (HR=2.49 and 2.94 for all-cause and cardiovascular mortality, respectively). Mortality did not differ by EF, but was higher for delayed- vs. early-onset HF (p for heterogeneity=0.002). The age- and sex-adjusted 5-year survival estimates in 2001-2010 vs. 1990-2000 were 82% and 81% among HF-free and 61% and 54% among HF patients, respectively (p for heterogeneity of trends=0.05). Conclusions HF markedly increases the risk of death after MI. This excess risk is similar regardless of EF but greater for delayed- vs. early-onset HF. Mortality after MI declined over time, primarily as a result of improved HF survival.

BACKGROUND Contemporary data on temporal trends in incidence and survival after atrial fibrillation are scarce. METHODS Olmsted County, MN residents with a first-ever atrial fibrillation or atrial flutter event between 2000–2010 were identified. Age- and sex-adjusted incidence rates were standardized to the 2010 US population and the relative risk of AF in 2010 vs. 2000 was calculated using Poisson regression. Standardized mortality ratios of observed vs. expected survival were calculated, and time trends in survival were examined using Cox regression. RESULTS We identified 3344 incident atrial fibrillation/atrial flutter events (52% male, mean age 72.6, 95.7% white). Incidence did not change over time (age- and sex-adjusted rate ratio (95% CI): 1.01 (0.91–1.13) for 2010 vs. 2000). Within the first 90 days, the risk of all-cause mortality was greatly elevated compared to individuals of a similar age and sex distribution in the general population (standardized mortality ratios (95% CI): 19.4 (17.3–21.7) and 4.2 (3.5–5.0) for the first 30 days and 31–90 days after diagnosis, respectively). Survival within the first 90 days did not improve over the study period (adjusted hazard ratio (HR) (95% CI): 0.96 (0.71–1.32) for 2010 vs. 2000); likewise, no difference in mortality between 2010 and 2000 was observed among 90 day survivors (HR (95% CI): 1.05 (0.85–1.31)). CONCLUSIONS In the community, atrial fibrillation incidence and survival have remained constant over the last decade. A dramatic and persistent excess risk of death was observed in the 90 days after atrial fibrillation diagnosis, underscoring the importance of early risk stratification.

Major changes have recently occurred in the epidemiology of myocardial infarction (MI) that could possibly affect outcomes such as heart failure (HF). Data describing trends in HF after MI are scarce and conflicting and do not distinguish between preserved and reduced ejection fraction (EF). We evaluated temporal trends in HF after MI. All residents of Olmsted County, Minnesota (n = 2,596) who had a first-ever MI diagnosed in 1990-2010 and no prior HF were followed-up through 2012. Framingham Heart Study criteria were used to define HF, which was further classified according to EF. Both early-onset (0-7 days after MI) and late-onset (8 days to 5 years after MI) HF were examined. Changes in patient presentation were noted, including fewer ST-segment-elevation MIs, lower Killip class, and more comorbid conditions. Over the 5-year follow-up period, 715 patients developed HF, 475 of whom developed it during the first week. The age- and sex-adjusted risk declined from 1990-1996 to 2004-2010, with hazard ratios of 0.67 (95% confidence interval (CI): 0.54, 0.85) for early-onset HF and 0.63 (95% CI: 0.45, 0.86) for late-onset HF. Further adjustment for patient and MI characteristics yielded hazard ratios of 0.86 (95% CI: 0.66, 1.11) and 0.63 (95% CI: 0.45, 0.88) for early- and late-onset HF, respectively. Declines in early-onset and late-onset HF were observed for HF with reduced EF (<50%) but not for HF with preserved EF, indicating a change in the case mix of HF after MI that requires new prevention strategies.

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