Prognostic importance of a restrictive transmitral filling pattern in patients with symptomatic congestive heart failure and atrial fibrillation Jakob Raunsø, MD, a Jacob Eifer Møller, MD, DmSci, b Jesper Kjaergaard, MD, PhD, b Dilek Akkan, MD, b Christian Hassager, MD, DmSci, b Christian Torp-Pedersen, MD, DmSci, a and Lars Køber, MD, DmSci b on behalf of the EchoCardiography and Heart Outcome Study (ECHOS) investigators Copenhagen, Denmark Background Restrictive diastolic filling pattern is associated with increased mortality in patients with myocardial infarction and heart failure. Most studies have excluded patients with atrial fibrillation. The aim of the present study was to assess the prognostic value of a restrictive filling pattern in patients with atrial fibrillation. Methods Doppler echocardiography including pulsed wave Doppler assessment of transmitral flow was performed in 880 patients with a clinical diagnosis of heart failure on hospital admission. Filling was considered restrictive when the mitral deceleration time ≤140 milliseconds. Results On admission, 337 (39%) of the patients had atrial fibrillation. Among patients in atrial fibrillation, 170 (50%) had a restrictive filling; and in patients in sinus rhythm, 256 (47%) had restrictive filling (P = .34). During follow-up of median 6.7 years (range 5.3-7.8), 564 patients died (64%). Mortality was significantly higher in patients with a restrictive filling pattern irrespective of atrial fibrillation or sinus rhythm (P b .001). In a multivariable model only including patients in atrial fibrillation, a restrictive filling pattern remained a significant predictor of all-cause mortality (hazard ratio 1.79, 95% CI 1.24- 2.58, P =.002). Conclusions In a heterogeneous population hospitalized for symptomatic heart failure, a restrictive transmitral filling pattern during hospitalization is an ominous prognostic sign also in patients presenting with atrial fibrillation. (Am Heart J 2009;158:983-8.) Noninvasive estimates of left ventricular (LV) diastolic function pressure have emerged as important predictors of morbidity and mortality in patients with heart failure as well as acute coronary syndrome. 1-4 Most of these variables, which are derived from Doppler echocardio- graphic assessment of blood flow velocities across the mitral valve and the velocities of the mitral annulus motion during diastole, act as surrogate markers of increased LV filling pressure. 5,6 One of the most extensively investigated and robust markers of increased filling pressure is a short mitral deceleration time that consistently has been associated with poor outcome in heart failure and acute myocardial infarction. 1-4 The mitral filling pattern is determined by multiple factors including active ventricular relaxation, chamber compli- ance, and myocardial ischemia, but also by heart rate and rhythm, all characteristics of patients with irregular R-R intervals. 7-9 Most studies have therefore studied patients in sinus rhythm, excluding patients in atrial fibrillation. In the case of heart failure, this will potentially exclude between 30% and 40% of patients presenting with acute decompensated heart failure. 10 The aim of the present study was therefore, in a large unselected population presenting to hospital with decompensated heart failure, to assess the prognostic importance of a restrictive mitral filling pattern (RFP), defined as an abnormally short mitral deceleration time of b140 milliseconds. We hypothesized that the prognostic impact of RFP on mortality of all causes is independent of the presence of atrial fibrillation. Methods Study population This study was based on 880 patients participating in the Echocardiography and Heart Outcome Study (ECHOS). 11 ECHOS was a prospective, double-blind, randomized, From the a Department of Cardiology, Copenhagen University Hospital, Gentofte Hospital, Copenhagen, Denmark, and b Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. Submitted February 2, 2009; accepted September 29, 2009. Reprint requests: Jakob Raunsø, Post 67, Department of Cardiology, Copenhagen University Hospital, Gentofte Hospital, Niels Andersens Vej 65, 2900 Hellerup, Denmark. E-mail: jrj@heart.dk 0002-8703/$ - see front matter © 2009, Mosby, Inc. All rights reserved. doi:10.1016/j.ahj.2009.09.013