Killian, Jill M.

Background: Contemporary data on trends in survival after incident atrial fibrillation (AF) are limited. Methods: Residents of a 27-county area in southern Minnesota and western Wisconsin with new-onset atrial fibrillation or atrial flutter between 2013 and 2023 were identified. An electronic algorithm requiring 1 inpatient code or 2 outpatient codes separated by >7 days but within 1 year was used to define AF. Patients were followed for all-cause mortality through March 31, 2025. Standardized mortality ratios of observed versus expected survival were calculated, and time trends in survival were examined using Cox regression adjusting for demographics, cardiovascular risk factors, comorbid conditions, and area-level measures of socioeconomic status and rurality. Results: There were 44,930 individuals identified with incident AF from 2013-2023 (56.4% male; mean (SD) age 72.8 (13.5) years; 95.8% were non-Hispanic white). Within the first 90 days, the risk of all-cause mortality was greatly elevated compared with individuals of a similar age and sex distribution in the general population (standardized mortality ratios 12.6, 95% CI, 12.1-13.0 and 3.8, 95% CI, 3.6-4.0 for the first 30 days and 31 to 90 days after diagnosis, respectively). This excess risk was observed for all age groups but was greatest in the youngest age group (standardized mortality ratios among 18-64 year olds for the first 30 days: 49.9, 95% CI, 44.6-55.7 and 31 to 90 days: 11.1, 95% CI: 9.4-13.1; Figure ). In the youngest age group, the excess risk persists through 5 years post AF, however, in the oldest age group the excess risk only persisted through 1 year. Survival within the first 90 days improved over the study period (adjusted hazard ratio [aHR], 0.88; 95% CI, 0.79-0.99 for 2023 vs 2013); likewise, among 90-day survivors, survival improved between 2013 and 2023 (aHR,0.82; 95% CI, 0.76-0.88). These trends were driven by improvements in the younger age groups, particularly for death among 90-day survivors (aHR for 18-64 years, 0.66, 95% CI, 0.52-0.83; 65-74 years: 0.77, 95% CI: 0.65-0.90; 75-84 years, 0.84, 95% CI: 0.75-0.95; 85+ years, 0.99, 95% CI: 0.98-1.01). Conclusion: In a Midwestern community, the excess risk of death is high within the first 90 days after incident AF. Furthermore, survival after AF has improved between 2013 and 2023, with the improvement greatest in younger age groups.

Background Area‐based deprivation indices have been linked to hypertension and diabetes outcomes, but limited information exists about their relative performance. We compared 2 area‐based deprivation measures (Area Deprivation Index and Yost Index) as risk factors for hypertension and diabetes control. Methods This cohort study identified adults with hypertension or diabetes in a 19‐county region of Southeast Minnesota covered by the Rochester Epidemiology Project. The deprivation indices were operationalized as quintiles for state and national ranks. We assessed agreement using the weighted kappa statistic. We used modified Poisson regression to evaluate associations of the deprivation indices with blood pressure or diabetes control in 2022. We compared relative model fit using the area under the receiver operating characteristic curve. Results We identified 67 386 individuals with hypertension and 30 435 with diabetes. There was moderate to substantial agreement between indices, but the agreement was higher for the state rank (weighted kappa 0.68 for both cohorts) than the national rank (0.54 for both). Although the indices were not associated with hypertension control, greater deprivation was associated with worse diabetes control for the Yost Index (relative risk [RR], 1.21 [95% CI, 1.07–1.38]) and Area Deprivation Index (RR, 1.39 [95% CI, 1.12–1.73]) national ranks. The full‐model area under the receiver operating characteristic curve was similar across indices but differed across cohorts with worse fit for hypertension (0.53 for both) than diabetes (0.63 for both). Conclusions Two common area‐based deprivation indices had similar strength of association with diabetes control, suggesting that either index would be appropriate for researching and developing interventions for diabetes control.

Background Multimorbidity is common in patients with atrial fibrillation (AF); however, the impact of the number and type of comorbid conditions on outcomes remains uncertain. Methods This cohort study included patients with new‐onset AF from a Midwest region between 2013 and 2017. Eighteen chronic conditions at the time of AF were classified into groups: cardiometabolic, other somatic, and mental health. Cox regression determined associations between the number of each condition type with death, ischemic stroke/transient ischemic attack, and congestive heart failure, stratified by age. Results Among 16 509 patients with AF (mean age, 74 years; 43% women), the mean number of cardiometabolic, other somatic, and mental health conditions was 2.7, 1.4, and 0.5, respectively. The number and type of conditions had a varying impact on outcomes and differed by age. A higher number of cardiometabolic conditions were associated with increased risk of death within 90 days only in people aged ≥85 years (≥4 conditions versus 0: hazard ratio [HR], 1.74 [95% CI, 1.05–2.87]), whereas for death after 90 days, associations were strongest in the youngest age group (<65 years: HR, 1.83 [95% CI, 1.35–2.46]; 65–74 years: HR, 1.34 [95% CI, 1.04–1.73]; 75–84 years: HR, 1.32 [95% CI, 1.09–1.60]; ≥85 years: HR, 1.14 [95% CI, 0.96–1.35]). Associations with outcomes were generally strongest in the youngest age group and attenuated with older age for higher number of other somatic conditions, whereas the pattern was less consistent for mental health conditions. Conclusions Along with cardiometabolic‐related conditions, other somatic and mental health conditions are important predictors of outcomes in AF, with effects differing by age, and should be considered when caring for these patients.

Background: Atrial fibrillation (AF) is the most common sustained arrhythmia with prevalence increasing over the last decade. However, data on recent temporal trends in incidence of AF have been inconsistent, with some reports of increasing trends over time and others indicating no change in incidence over time. Therefore, we aimed to determine how the incidence of AF has changed over the last decade in a community in the Midwest USA. Methods: Between 2013 and 2023, adults (aged 18 and older) with incident AF were identified in a 27-county region in the Midwest. AF was identified using diagnostic codes by employing an electronic algorithm requiring 1 inpatient code or 2 outpatient codes separated by >7 days but within 1 year. For total rates, age - and sex-adjusted incidence rates were standardized to the 2010 US total population. Poisson regression was used to calculate the incidence rate ratio of AF for 2023 vs 2013. Results: We identified 44,930 individuals with incident AF from 2013 to 2023. Of these, 56.4% were male, the mean (SD) age was 72.8 (13.5) years, and 95.8% were non-Hispanic white. The age-and sex-adjusted incidence rates (per 1,000) and 95% confidence intervals standardized to the 2010 US total population were 5.24 (5.07-5.41) in 2013, 5.73 (5.56-5.91) in 2018, and 5.44 (5.28-5.61) in 2023. Although a drop in incidence was observed corresponding to the COVID-19 pandemic, a small increase in the overall incidence of AF was observed over time. The overall incidence rate ratio (95% CI) for 2023 vs 2013 was 1.07 (1.02-1.11), P=0.003. The incidence rates were higher in men compared to women and increased with older age ( Figure 1 ). However, differences in AF incidence by sex were greatest in the youngest age group and attenuated with older age (incidence rate ratio (95% CI): 2.18 (2.10-2.28) for ages 18-64 years, 1.76 (1.70-1.83) for ages 65-74 years, 1.38 (1.33-1.42) for ages 75-84 years, and 1.23 (1.18-1.28) for ages 85 years and older). Conclusion: In this 27-county region in the Midwest, although small in magnitude, a statistically significant increase in AF incidence was observed over time from 2013 to 2023. Furthermore, the incidence of AF was higher in men compared with women, especially in younger age groups.

Background Valvular heart disease contributes to symptomatic heart failure, but its prevalence and prognostic significance in advanced heart failure is not well understood. Methods This retrospective population‐based cohort study included adult residents of Olmsted County, Minnesota, with advanced heart failure (2007–2018). Patients were classified by echocardiographic regurgitation and stenosis of aortic, mitral, tricuspid, and pulmonic valves at the time of advanced heart failure. We examined the associations of aortic stenosis, mitral regurgitation, and tricuspid regurgitation with risks of cardiovascular and all‐cause death through 2023 using Cox proportional hazards models. Results There were 936 patients with advanced heart failure (mean age, 76.9 years; 44.5% women, 43.4% with heart failure with preserved ejection fraction). Moderate or greater regurgitation was observed in 2.8% (n=26) of aortic, 26% (n=244) of mitral, 42% (n=389) of tricuspid, and 4.3% (n=40) of pulmonic valves, while moderate or greater stenosis was observed in 9.7% (n=91) of aortic and 1.8% (n=17) of mitral valves. No patients had clinically significant tricuspid or pulmonic stenosis. After adjustment for age, sex, left ventricular ejection fraction, right ventricular function, serum sodium, Charlson comorbidity index, body mass index, and systolic blood pressure, moderate and severe aortic stenosis were associated with increased cardiovascular death compared with patients without aortic stenosis (hazard ratio [HR], 1.42 [95% CI, 1.01–2.01]; and HR, 1.55 [95% CI, 1.02–2.36]), respectively. Conclusions Tricuspid regurgitation, mitral regurgitation, and aortic stenosis were the most observed valvular pathologies of moderate or greater severity in advanced heart failure. Only moderate or greater aortic stenosis was independently associated with cardiovascular death in advanced heart failure.

Background Heart failure self‐care can contribute to a high daily workload and treatment burden. The goal of this cohort study was to assess the characteristics and outcomes associated with burden of treatment (BoT). Methods Surveys comprising validated instruments to measure BoT and other constructs were mailed to patients with heart failure in Southeastern Minnesota. Participants were divided into tertiles by BoT scores. Associations of clinical variables with BoT were examined using multinomial logistic regression. Associations of BoT with mortality and hospitalizations were examined using Cox proportional hazard regression and Andersen–Gill models, respectively. Results A total of 609 participants (mean age 76.3 years, 60.3% men, 55.2% urban, 64.3% preserved ejection fraction) completed surveys. Higher BoT was associated with worse health status, more depressive symptoms, lower resilience, less social support, lower medication adherence, and worse health literacy. Mean±SD follow‐up was 14.4 (4.1) months. Estimated 1‐year mortality (8.3% [95% CI, 4.3%–12.1%], 11.0% [95% CI, 6.5%–15.2%], 16.0% [95% CI, 10.8%–21.0%]) and 1‐year mean cumulative hospitalizations (0.57 [95% CI, 0.45–0.72], 0.83 [95% CI, 0.66–1.05], 1.15 [95% CI, 0.93–1.42]) increased across patients reporting low, medium, and high BoT, respectively. Adjustment for health status eliminated any significant association of BoT with risks of death and hospitalization (adjusted hazard ratio [HR], 1.10 [95% CI, 0.58–2.07] and 1.09 [95% CI, 0.74–1.61], respectively, highest versus lowest BoT tertile). Conclusions BoT in heart failure varies by clinical and psychosocial factors. Higher BoT identifies patients at increased risk of adverse health outcomes due to their worse health status. These findings can serve as a foundation for interventions to minimize workload and improve quality of life.

Objective Patients with heart failure (HF) perform a variety of self-care activities to control symptoms and minimise the risk of HF decompensations. The objective of this study was to understand how patients build capacity and manage the work of living with HF. Design A qualitative study using semi-structured telephone interviews. The interview guide was informed by the Cumulative Complexity Model, a conceptual framework that focuses on a patient’s workload and their capacity to manage that work. Interview transcripts were analysed using a mixed inductive and deductive coding approach with organisation into larger thematic categories. Setting Southeastern Minnesota USA (11 counties) with capture of data from local community healthcare providers under the auspices of the Rochester Epidemiology Project. Participants Intentional sampling of local patients with HF (n=24, median age 69.5 years, 54% women, 63% rural, 54% preserved ejection fraction) who reported high treatment burden and/ or poor health status on a questionnaire. Results Three major themes emerged: using capacity to manage workload, disruptions resulting in workload exceeding capacity and regaining workload-capacity balance. Participants described routinising the daily tasks associated with living with HF to minimise the associated burden and identified disruptions to their routines, including hospitalisations, emergency room visits, worsening health status and changes in healthcare access. To accommodate disruptions and regain workload-capacity balance, participants decreased workload and/or transferred tasks to others to maximise capacity. Conclusions Participants with HF described managing patient workload in times of stable health, but they sometimes struggled to accommodate disruptions and worsening health status. These findings can inform the design of interventions to minimise workload, maximise capacity and improve quality of life for patients with HF.

Background Multimorbidity is common in patients with atrial fibrillation (AF), yet comorbidity patterns are not well documented. Methods The prevalence of 18 chronic conditions (6 cardiometabolic, 7 other somatic, 5 mental health) was obtained in patients with new-onset AF from 2013-2017 from a 27-county region and controls matched 1:1 on age, sex, and county of residence. For AF patients and controls separately, clustering of conditions and co-occurrence beyond chance was estimated (using the asymmetric Somers’ D statistic), overall and for ages <65, 65-74, 75-84, and ≥85 years. Results Among 16,509 patients with AF (median age 76 years, 57% men), few (4%) did not have any of the 18 chronic conditions, whereas nearly one-quarter of controls (23%) did not have any chronic conditions. Clustering of cardiometabolic conditions was common in both AF patients and controls, but clustering of other somatic conditions was more common in AF. Although the prevalence of most condition pairs was higher in AF patients, controls had a larger number of condition pairs occurring together beyond chance. In persons aged <65 years, AF patients more frequently exhibited concordance of condition pairs that included either pairs of somatic conditions or a combination of conditions from different condition groups. In persons aged 65-74 years, AF patients more frequently had pairs of other somatic conditions. Conclusion Patterns of co-existing conditions differed between patients with AF and controls, particularly in younger ages. A better understanding of the clinical consequences of multimorbidity in AF patients, including those diagnosed at younger ages, is needed.

Introduction: Psychological resilience is the ability to adapt to significant adversity. Higher resilience has been associated with better quality of life in HF, but its association with outcomes is not known. Herein, we characterize resilience and its association with outcomes in HF. Research Questions/Hypothesis: Greater resilience is associated with better health status and outcomes in high-risk HF. Methods: In a prospective study, adult residents of 11 counties in Southeastern Minnesota with HF who had been hospitalized with decompensated HF or ventricular arrhythmia (“high-risk HF”) in the preceding 1 year were mailed a survey that included questionnaires to assess resilience (Connor Davidson resilience scale, CD-RISC2), health status (KCCQ-12), and other psychosocial constructs in March 2022. Patients were divided into tertiles by resilience scores, and association with outcomes (survival and hospitalization) were examined using Cox proportional hazard regression and Andersen-Gill models, respectively. Results: Among 649 respondents (mean age 76 ± 11.5 years, 40% women, 64.3% HFpEF), patients with greater resilience were older ( p=0.015 ), had lower BMI ( p=0.003 ) and were more often retired or employed (vs disabled or unemployed, p<0.001 ). Greater resilience was moderately correlated with better health status (r=0.33), social support (r=0.27), and health literacy (r=-0.30); and lower treatment burden (r=-0.42), symptom burden (r=-0.41), and fewer depressive symptoms (r=-0.41) ( p<0.001 for all ). At 1-year follow up, patients with the lowest resilience (lowest tertile) were at a significantly increased risk for HF hospitalizations (adjusted HR 2.09, 95% CI 1.06-4.11) and CV mortality (adjusted HR 1.90, 95% CI 1.01-2.57) compared to those with highest resilience. There was no statistically significant association of resilience with risks of all-cause mortality or all-cause hospitalizations after adjustment ( Figures 1A-D ). Conclusion: Higher resilience is associated with better health status and psychosocial profile. Patients with low resilience are at increased risk for HF hospitalizations and CV mortality. Impact of resilience on long term outcomes and response to interventions must be tested in future studies.

Background The epidemiology and pathophysiology of heart failure (HF) differ in women and men. Whether these differences extend to the subgroup of patients with advanced HF is not well defined. Methods and Results This is a retrospective cohort study of all adult Olmsted County, Minnesota residents with advanced HF (European Society of Cardiology criteria) from 2007 to 2017. Differences in survival and hospitalization risks in women and men following advanced HF development were examined using Cox proportional hazard regression and Andersen‐Gill models, respectively. Of 936 individuals with advanced HF, 417 (44.6%) were women and 519 (55.4%) were men (self‐reported sex). Time from development of HF to advanced HF was similar in women and men (median 3.2 versus 3.6 years). Women were older at diagnosis (mean age 79 versus 75 years), less often had coronary disease and hyperlipidemia, but more often had hypertension and depression ( P <0.05 for each). Advanced HF with preserved ejection fraction was more prevalent in women than men (60% versus 30%, p<0.001). There were no differences in adjusted risks of all‐cause mortality (hazard ratio [HR], 0.89 [95% CI, 0.77–1.03]), cardiovascular mortality (HR, 0.85 [95% CI, 0.70–1.02]), all‐cause hospitalizations (HR, 1.04 [95% CI, 0.90–1.20]), or HF hospitalizations (HR, 0.91 [95% CI, 0.75–1.11]) between women and men. However, adjusted cardiovascular mortality was lower in women versus men with advanced HF with reduced ejection fraction (HR, 0.72 [95% CI, 0.56–0.93]). Conclusions Women more often present with advanced HF with preserved ejection fraction and men with atherosclerotic disease and advanced HF with reduced ejection fraction. Despite these differences, survival and hospitalization risks are largely comparable in women and men with advanced HF.