Management of atrial fibrillation in patients with heart failure: What's new in 2014?

 Management of atrial fibrillation in 
patients with heart failure: 
what's new in 2014? 
 Dr. Reginald Liew 
MA, MBBS (Hons), PhD (Lond), FRCP (UK), FESC, FACC 
Senior Consultant Cardiologist, Gleneagles Hospital 
Asst. Prof. Duke-NUS Graduate Medical School, Singapore 
No conflict of interests to disclose 
Outline of talk 
• Incidence/ Pathophysiology of AF in patients with 
heart failure 
• Rate versus rhythm control 
• AVN ablation and PPM/ CRT insertion 
• Catheter ablation of AF in heart failure patients 
• HF with impaired LV function 
• HF with preserved EF 
Outline of talk 
• Incidence/ Pathophysiology of AF in patients with 
heart failure 
• Rate versus rhythm control 
• AVN ablation and PPM/ CRT insertion 
• Catheter ablation of AF in heart failure patients 
• HF with impaired LV function 
• HF with preserved EF 
Prevalence of AF in patients enrolled 
in HF studies 
• AF is very common in patients with heart failure 
• Incidence is around 20-50% from heart failure studies 
Hazard ratios of shared risk factors in 
patients with AF and heart failure 
Trulock et al. JACC. 2014; vol. 64, no. 7 
Pathophysiological relationship between 
AF and heart failure 
Trulock et al. JACC. 2014; vol. 64, no. 7 
Treatment options for AF in patients 
with heart failure 
1. Control ventricular rate 
• Beta-blockers, Ca- channel blockers, digoxin 
2. AVN ablation and insertion of PPM/ CRT device 
3. Restore SR (if persistent AF) with DC 
cardioversion + AAD 
4. Catheter ablation of AF 
• Stroke prevention with oral anticoagulation 
Outline of talk 
• Incidence/ Pathophysiology of AF in patients with 
heart failure 
• Rate versus rhythm control 
• AVN ablation and PPM/ CRT insertion 
• Catheter ablation of AF in heart failure patients 
• HF with impaired LV function 
• HF with preserved EF 
Rate v Rhythm control in heart failure 
patients with AF 
• No study has shown an overall survival benefit of either strategy 
– e.g. RACE, AF-CHF, ANDROMEDA, AFFIRM, DIAMOND, CAFÉ II 
• However, the trials tested treatment strategies and not true rate v rhythm 
control 
– Substantial cross-over between treatment arms 
– Improved QoL in patients who remained in SR 
• Newer drugs are being studied (e.g. ranolazine- Na Channel blocker) and 
possible future role for genetic test in best choice of drug (e.g. genotype-
directed bucindolol therapy in HF and AF). 
• Pts with AF and structural heart disease have limited choice of AAD due to 
toxicities and risk of TdP 
Lenient v strict rate control in AF 
Van Gelder et al. NEJM 2010; 
362(15):1363-73 • 614 pts with permanent AF 
randomly assigned to: 
• Lenient rate control (<110bpm 
at rest) 
• Strict rate control (<80bpm at 
rest; <110bpm during 
moderate exercise) 
• Easier to achieve target HR in 
lenient group 
• No difference between 
symptoms and adverse 
outcomes between the two 
groups 
• Post-hoc analysis of RACE II in heart failure patients (LVEF<40%): stringency of rate 
control has no effect on cardiovascular morbidity and mortality, symptoms or QoL 
• Mulder et al. Eur J Heart Fail 2013; 15(11): 1311-8 
Meta-analysis of beta-blocker for rate 
control in heart failure patients with AF 
• Large meta-analysis of data from 10 RCTs (18,254 pts) 
• Beta-blockers have no survival advantage or benefits on reduced hospital 
admissions in HF pts with AF, unlike their beneficial effects in HF patients in SR 
Kotecha et al. Lancet 2014 (in press) 
HF and SR HF and AF 
Outline of talk 
• Incidence/ Pathophysiology of AF in patients with 
heart failure 
• Rate versus rhythm control 
• AVN ablation and PPM/ CRT insertion 
• Catheter ablation of AF in heart failure patients 
• HF with impaired LV function 
• HF with preserved EF 
Major studies of AVN ablation and 
CRT for patients with heart failure 
Ganesan et al. JACC 2012, vol 59: 719-26 
Major studies of AVN ablation and 
CRT for patients with heart failure 
Ganesan et al. JACC 2012, vol 59: 719-26 
Improved survival in pts who 
underwent AVN ablation and CRT 
Ganesan et al. JACC 2012, vol 59: 719-26 
All- cause mortality Cardiovascular mortality 
Improvement in NYHA class in patients 
undergoing AVN ablation and CRT 
Ganesan et al. JACC 2012, vol 59: 719-26 
Outline of talk 
• Incidence/ Pathophysiology of AF in patients with 
heart failure 
• Rate versus rhythm control 
• AVN ablation and PPM/ CRT insertion 
• Catheter ablation of AF in heart failure patients 
• HF with impaired LV function 
• HF with preserved EF 
Catheter ablation of AF in HF 
Advantages 
– Alters atrial substrate to treat disease 
– Improvement in quality of life and 
symptoms 
– More effective than AADs; may be 
able to come off AADs 
Disadvantages 
– Invasive with 2-4% complication rate 
– Long procedure 
– May require multiple procedures 
– Pts often have multiple co-morbidities 
– May not be cost-effective 
Approaches to catheter ablation in 
AF and heart failure 
Trulock et al. JACC. 2014; vol. 64, no. 7 
AP n PA View of Ablation Spots on PV veins and Roof 
CFAE lesions in yellow 
RIPV isolation 
Major trials of AF ablation in patients 
with heart failure 
Trulock et al. JACC. 2014; vol. 64, no. 7 
Major trials of AF ablation in patients 
with heart failure 
Trulock et al. JACC. 2014; vol. 64, no. 7 
Jones et al. JACC, vol 61, no. 18, 2013 
Primary endpoint 
Significant improvement 
in peak VO2 (measure of 
exercise capacity) in 
ablation group after 12 
months follow up 
Jones et al. JACC, vol 61, no. 18, 2013 
Secondary endpoints 
Jones et al. JACC, vol 61, no. 18, 2013 
Meta-analysis of AF ablation in pts with 
heart failure and LV systolic dysfunction 
Anselmino et al. Circulation Arr and Electro. 
2014 (in press) 
Change in LVEF and NT-proBNP post ablation 
Anselmino et al. Circulation Arr and Electro. 
2014 (in press) 
• Single centre, cohort study 
• AF ablation performed in 74 consecutive patients with 
compensated HFPEF (LVEF>50%) 
• LV strain and strain rate assessed by echo at baseline and over 
12 months post ablation 
• 34 +/1 16 month f/u 
• Overall success rate of 73% 
• LV systolic and diastolic indices improved only in patients who 
maintained SR at f/u 
Tomoko Machino-Ohtsuka et al. JACC 2013, 
vol 62: 1857-65 
 Tomoko Machino-Ohtsuka et al. JACC 2013, 
vol 62: 1857-65 
Tomoko Machino-Ohtsuka et al. JACC 2013, 
vol 62: 1857-65 
Indices of 
systolic 
function 
Indices of 
diastolic 
function 
Summary points- management of AF in 
patients with heart failure 
• Best management strategy of patients with AF and heart failure is still not 
fully resolved 
• If asymptomatic, treatment of heart failure and rate control may be 
sufficient 
• If symptomatic and/or AF is thought to be contributing to heart failure, 
restoration of sinus rhythm should be considered 
– Trial of DC cardioversion and anti-arrhythmic drug 
– Catheter ablation of AF (evidence in favor of benefits, but associated risks) 
– Better success in patients without IHD / less atrial scar/ smaller atrial sizes 
Gleneagles Hospital, 
#03-37C, Annexe Block 
6A Napier Road, Singapore 
T +65 6472 3703 
Email: reginald.liew@hscs.com.sg 
www.theharleystreetclinicsingapore.com 
Mount Elizabeth Novena Specialist Centre 
#07-41, 38 Irrawaddy Road, 
Singapore 
T +65 6694 0050 
AFFIRM anti-arrhythmic drug substudy 
Wyse et al. NEJM 2002; 347(23): 1825-33 
• 58 patients with CHF (LVEF<45%) undergoing catheter ablation 
for AF compared with 58 matched patients without CHF 
undergoing catheter ablation 
• Non- randomized study, but first high impact proof of concept 
paper that showed LVEF could be improved with catheter 
ablation of AF 
• Only 9-21% of patients had IHD 
Hsu LF et al. NEJM, vol 351, no. 23, 2004 
 Hsu LF et al. NEJM, vol 351, no. 23, 2004 
Ongoing studies of AF ablation in patients 
with heart failure 
• CASTLE-AF (Catheter ablation versus standard conventional treatment 
in patients with LV dysfunction and AF): 
– Prospective randomized multi-centre study comparing catheter ablation to 
conventional treatment in HF patients with AF 
– Pts enrolled: LVEF≤35%, NYHA≥II, pts with dual chamber ICD with home 
monitoring capabilities 
– 1ry endpoint: all-cause mortality or worsening HF 
– Due to be completed in 2015 
• RAFT-AF (Rate versus catheter ablation rhythm control in 
patients with HF and high burden AF 
– Large, prospective, multi-centre, randomized trial comparing catheter 
ablation for AF with rate control 
– NYHA II-III, OMT, increased NT-proBNP 
– 1ry endpoint: cardiovascular mortality 
– Currently recruiting; due to be completed in 2016