Introduction

Investigation of the overlap between atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) is of increasing interest and both phenotypes share common pathophysiology in aspects. The EMPEROR-Preserved and DELIVER trials demonstrated beneficial effects of SGLT2-inhibitor (SGLT2i) therapy in patients with HFpEF regardless of the presence of diabetes. First clinical subanalysis demonstrated potential antiarrhythmic effects of SGLT2i. Our aim was to assess the eligibility for SGLT2i treatment in a contemporary cohort of patients with atrial fibrillation.

Methods

Data basis for this investigation is the all-comer TRUST registry (“Longterm Outcome and Predictors for Recurrence after Medical and Interventional Treatment of Arrhythmias at the University Heart Center Hamburg”) which is prospectively and consecutively recruiting patients with heart rhythm disorders at a large tertiary-care center in Hamburg since 03/2021. Most patients in TRUST are seen for ablation procedures. All participants undergo deep phenotyping, including transthoracic echocardiography (TTE), interviews conducted by trained personnel and systematic follow-up. We applied the inclusion criteria of EMPEROR-Preserved and DELIVER on the clinical, laboratory and imaging baseline characteristics assessed in TRUST.

Results

We will report more complete data at the time of presentation. As of today, complete data is available in 319/1023 TRUST patients referred for AF ablation (FirstDo/ReDo). Median age was 67 (IQR 59;75) years, 117 (37 %) were female. Median left ventricular ejection fraction (LVEF) was 55.0 % (IQR 47 %;59 %); ≤ 40 %: 45/319, 14,1 %; 41-49 %: 42/319, 13,2 %; 50-59 %: 157/319, 49,2 %; ≥ 60 %: 75/319, 23,5 %), NT-proBNP was 703 mg/dl (IQR 179 mg/dl;1782 mg/dl), mean GFR was 72.3±19.4 ml/min and 9,7 % were diagnosed with diabetes mellitus (I or II). 142 (44.5 %) patients reported NYHA II dyspnea, 63 (19,8%) of NYHA III and 1 (0,3 %) had dyspnea at rest (NYHA IV).

81/319 patients (25,4 %) and 93/319 (29,2 %) met the inclusion criteria for DELIVER and EMPEROR-Preserved, respectively. 30/81 (37 %) “DELIVER-candidates” and 32/93 (34%) “EMPEROR-Preserved-candidates” had HFpEF in their medical record at baseline. By combination of both groups, 101/319 (31,6%; median age 70 (IQR 62;77) year; 46 (46 %) female) of enrolled, record-completed AF patients were eligible for SGLT2i therapy regarding HFpEF. Median LVEF was 53 % (IQR 45%;57%), NT-proBNP was 1574 mg/dl (IQR 988 mg/dl;2263 mg/dl) and mean GFR was 68±21 ml/min. 75/319 patients (23,5 %) met the inclusion criteria of both trials. 

At baseline, 10,1% of 319 patients were already taking SGLT2i, 14,3% of the combined SGLT2i-eligible group (14/101; DELIVER or EMPEROR-Preserved). 

Conclusion

Approximately one-third of unselected patients referred for atrial fibrillation ablation met the inclusion criteria of DELIVER or EMPEROR-Preserved and are therefore eligible for an additive SGLT2i therapy. Initiation of SGLT2i therapy in this population may prevent recurrent AF and improve other cardiovascular outcomes. This should be studied in future research.