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Background  Atrial fibrillation ( AF ) has been objectively associated with exercise intolerance in patients with heart failure with reduced ejection fraction; however, its impact in patients with heart failure with preserved ejection fraction has not been fully scrutinized.    Methods and Results  We identified 1744 patients with heart failure and ejection fraction ≥50% referred for cardiopulmonary stress testing at the Cleveland Clinic (Cleveland, OH), 239 of whom had  AF . We used inverse probability of treatment weighting to balance clinical characteristics between patients with and without  AF . A weighted linear regression model, adjusted for unbalanced variables (age, sex, diagnosis, hypertension, and β‐blocker use), was used to compare metabolic stress parameters and 8‐year total mortality (social security index) between both groups. Weighted mean ejection fraction was 58±5.9% in the entire population. After adjusting for unbalanced weighted variables, patients with  AF  versus those without  AF  had lower mean peak oxygen consumption (18.5±6.2 versus 20.3±7.1 mL/kg per minute), oxygen pulse (12.4±4.3 versus 12.9±4.7 mL/beat), and circulatory power (2877±1402 versus 3351±1788 mm Hg·mL/kg per minute) ( P <0.001 for all comparisons) but similar submaximal exercise capacity (oxygen consumption at anaerobic threshold, 12.0±5.1 versus 12.4±6.0mL/kg per minute;  P  =0.3). Both groups had similar peak heart rate, whereas mean peak systolic blood pressure was lower in the  AF  group (150±35 versus 160±51 mm Hg;  P <0.001). Moreover,  AF  was associated with higher total mortality.    Conclusions  In the largest study of its kind, we demonstrate that  AF  is associated with peak exercise intolerance, impaired contractile reserve, and increased mortality in patients with heart failure with preserved ejection fraction. Whether  AF  is the primary offender in these patients or merely a bystander to worse diastolic function requires further investigation.

journal of the american heart association

Impact of Atrial Fibrillation on Exercise Capacity and Mortality in Heart Failure With Preserved Ejection Fraction: Insights From Cardiopulmonary Stress Testing