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