Rung nhĩ ở người bệnh suy tim điều trị năm 2014 có gì mới

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

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

• 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

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

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

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