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Aims: Heart failure (HF) and atrial fibrillation (AF) frequently coexist, exacerbate each other and are associated with increased morbidity and mortality. However, no previous study has specifically calculated the risk of experiencing either event following the occurrence of the other, considering also competing risks. The aim of the study was to examine the bi-directional relationship of AF and HF in a multi-ethnic population taking competing risks into account., Methods: Two Fine and Gray regression models of the sub-distribution functions were implemented to evaluate the bidirectional association between AF and HF and were adjusted for a common set of covariates. Competing events were defined as HF/AF and/or cardiac death versus non-cardiac death. For each model, common covariates for AF and HF were pre-identified in the literature, and either HF or AF was used as a time-dependent covariate., Results: In the Multi-Ethnic Study of Atherosclerosis (MESA), 4016 study participants (mean age 67.2±7.6 years and 48.8% male participants), free of clinically recognized cardiovascular disease at baseline, were assessed for AF and HF. After a median (IQR) follow-up of 6034 (3994-6313) days, 1044 incident AF, 302 incident HF, and 1298 events of deaths occurred. Deaths were distributed as 313 cardiac deaths and 985 non-cardiac deaths, and incidence of AF was about 3.5 higher than HF. We found that HF was associated with a composite outcome of AF and/or cardiac death (HR 2.91, 95%CI [2.49-3.40]; p<0.001), and that AF was associated with a composite outcome of HF and/or cardiac death (HR 2.05, 95%CI [1.79-2.35]; p<0.001)., Conclusion: Each of AF and HF exacerbate the incidence of each other and are strongly and independently associated, suggesting that their joint association should be taken into consideration in future studies. From a clinical perspective, the occurrence of either of these events greatly increases the risk for the other. (ClinicalTrials.gov Identifier: NCT00005487) LAY SUMMARY: This paper investigates the interplay of heart failure and atrial fibrillation, two types of heart disease. Several reports indicate that these conditions often happen together, make each other worse, and are linked to more illness and death, but their mutual influence has not been formally measured. We examined MESA participants free of heart disease before joining our study and evaluated the degree to which developing either heart failure or atrial fibrillation raises the chance of getting the other condition. We found that AF and HF exacerbate the respective incidence of each other and are strongly and independently associated, suggesting that both diseases should be taken into consideration together in future studies., Competing Interests: Declaration of competing interest The Authors declare that there is no conflict of interest. All authors declare that the submitted work is original and has not been published before (neither in English nor in any other language) and that the work is not under consideration for publication elsewhere. The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institutes of Health; or the U.S. Department of Health and Human Services., (Copyright © 2025. Published by Elsevier Inc.)

Aims: To evaluate whether myocardial fibrosis predicts cardiovascular events (CVEs) and mortality in the Multi-Ethnic Study of Atherosclerosis., Methods and Results: Cardiac magnetic resonance (CMR) T1 mapping with gadolinium administration for assessment of extracellular volume fraction (ECV) was performed in 1326 participants, in whom myocardial scar was assessed by late gadolinium enhancement (LGE). The clinical outcomes were defined as all-cause mortality, atherosclerotic CVEs, and incident heart failure (HF) during an average of 8 years of follow-up after the scan. Participants' mean native T1 time was 971 ms [standard deviation (SD) 45.5], ECV was 27 (SD 2.9), and 117 (8.8%) of them had LGE. At the time of the CMR exam, participant age was 68 years (SD 9) and 48% of them were women. Ideal cut-offs were identified using classification and regression trees accounting for time-to-event outcomes for ECV (30%) and native T1 time (954 ms). Over the follow-up period, 106 participants died, 78 developed CVE, and 23 developed HF. After adjustment for risk factors, ECV >30% was associated with death [hazard ratio (HR): 1.67, P < 0.05], incident CVE (HR: 2.02, P < 0.05), and incident HF (HR: 2.85, P < 0.05). After adjustments, native T1 >954 ms was associated with incident CVE (HR: 2.09, P < 0.05). Myocardial scar by LGE was not predictive of clinical outcomes after adjustments., Conclusion: ECV is an independent prognostic marker of incident HF, atherosclerotic CVEs, and all-cause mortality. ECV, with its ability to characterize both diffuse and focal fibrosis processes, better predicted incident events than regional myocardial abnormalities as visualized by LGE imaging in a large multi-ethnic population., Competing Interests: Conflict of interest: none declared., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.)

Aims: Longitudinal change in left atrial (LA) structure and function could be helpful in predicting risk for incident atrial fibrillation (AF). We used cardiac magnetic resonance (CMR) imaging to explore the relationship between change in LA structure and function and incident AF in a multi-ethnic population free of clinical cardiovascular disease at baseline., Methods and Results: In the Multi-Ethnic Study of Atherosclerosis (MESA), 2338 participants, free at baseline of clinically recognized AF and cardiovascular disease, had LA volume and function assessed with CMR imaging, at baseline (2000-02), and at Exam 4 (2005-07) or 5 (2010-12). Free of AF, 124 participants developed AF over 3.8 ± 0.9 years (2015) following the second imaging. In adjusted Cox regression models, an average annualized change in all LA parameters were significantly associated with an increased risk of AF. An annual decrease of 1-SD unit in total LA emptying fractions (LAEF) was most strongly associated with risk of AF after adjusting for clinical risk factors for AF, baseline LA parameters, and left ventricular mass-to-volume ratio (hazard ratio per SD = 1.91, 95% confidence interval = 1.53-2.38, P < 0.001). The addition of change in total LAEF to an AF risk score improved model discrimination and reclassification (net reclassification improvement = 0.107, P = 0.017; integrative discrimination index = 0.049, P < 0.001)., Conclusion: In this multi-ethnic study population free of clinical cardiovascular disease at baseline, a greater increase in LA volumes and decrease in LA function were associated with incident AF. The addition of change in total LAEF to risk prediction models for AF improved model discrimination and reclassification of AF risk., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.)