AHA Scientific Sessions 2026 Abstract · Nov 2, 2026
Post-Event Mortality After Stroke or Major Bleeding Across the Ejection Fraction Spectrum in Acute Heart Failure with Atrial Fibrillation
By YAMAMOTO J, nakamura K, Enomoto Y et al.
Background: Patients hospitalized with acute heart failure (AHF) and atrial fibrillation (AF) face competing risks of ischemic stroke, major bleeding, and death. Whether the mortality impact of post-stroke and post-bleeding states differs across the left ventricular ejection fraction (LVEF) spectrum, including preserved or supranormal ranges, remains uncertain. Objective: To assess post-stroke and post-bleeding mortality across LVEF in hospitalized AHF with AF. Methods: We retrospectively analyzed 716 patients hospitalized with AHF and AF in a multicenter Japanese registry. Follow-up was truncated at 3 years. Patients moved from a no-event-yet state to an after-stroke or after-bleeding state at the first qualifying event. Simon-Makuch curves and time-dependent Cox models assessed all-cause and cardiovascular death, adjusted for age, sex, New York Heart Association class, estimated glomerular filtration rate, hemoglobin, HAS-BLED score, and direct oral anticoagulant use. Effect modification was assessed by LVEF categories (<40%, 40-49%, and >=50%) and exploratory restricted cubic spline models. Results: Mean age was 79±11 years, 49% were women, and median follow-up was 1.4 years. Overall, 53 patients developed ischemic stroke, 89 developed major bleeding, 160 died, and 106 died of cardiovascular causes. The LVEF complete-case cohort included 688 patients: 249 with LVEF <40%, 126 with LVEF 40-49%, and 313 with LVEF >=50%. First qualifying events were stroke-first in 34 patients and bleeding-first in 74. Three-year all-cause survival was 69.1% in the no-event-yet state, 36.3% after stroke, and 33.1% after bleeding. Major bleeding was associated with higher all-cause death (hazard ratio [HR] 2.00, 95% confidence interval [CI] 1.22-3.28; p=0.007), whereas stroke was not (HR 1.35, 95% CI 0.67-2.70; p=0.395). In preserved LVEF, post-bleeding status was strongly associated with all-cause death (HR 2.65, 95% CI 1.31-5.34), while post-stroke status was not (HR 0.93, 95% CI 0.26-3.32). Exploratory spline analysis showed a J-shaped relation between continuous LVEF and the mortality impact of major bleeding, with risk lowest around 40-45% and rising again in the preserved range, whereas the post-stroke association weakened at higher LVEF. In a 90-day landmark analysis of 527 event-free survivors, the post-bleeding association persisted (HR 1.98, 95% CI 1.05-3.71), whereas post-stroke status remained non-significant. Conclusions: In AHF with AF, transition to a post-bleeding state was more consistently associated with subsequent all-cause mortality than transition to a post-stroke state. Bleeding-related vulnerability was evident in preserved LVEF and persisted in landmark analysis, supporting bleeding-risk mitigation alongside stroke prevention across the LVEF spectrum.