Atrial fibrillation (AF) is common in heart failure with preserved ejection fraction (HFpEF); However, the prognostic impact of AF on HFpEF patients has not been fully elucidated.

A literature search of the PubMed and EMBASE databases on literature published through April 2019 was undertaken. Combined hazard ratio (HR) estimates and 95% confidence intervals (CIs) were calculated using fixed-effects or random-effects models, depending on the heterogeneity. Subgroup analyses, sensitivity analysis and meta-regression analyses were also performed.

Fourteen (14) eligible studies with 1,948,923 patients with HFpEF were included in the analysis. Atrial fibrillation was associated with an 11% increased risk of all-cause mortality in patients with HFpEF (HR 1.11, 95% CI 1.09–1.12). Sensitivity analysis confirmed the stability of the results. The stratification of studies by controlled or uncontrolled confounding factors affected the final estimate (confounder-controlled HR 1.21, 95% CI 1.12–1.30; confounder-uncontrolled HR 1.13, 95% CI 0.96–1.31). In addition, AF was an independent predictor of hospitalisation for heart failure (HR 1.32, 95% CI 1.15–1.52), cardiovascular death (HR 1.38, 95% CI 1.01–1.89) and stroke (HR 1.87, 95% CI 1.54–2.27).

Atrial fibrillation was associated with worse clinical outcomes in patients with HFpEF. Further investigation is required to see whether AF is the primary offender in these patients or merely a bystander to worse diastolic function.