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Atrial Fibrillation Management in Heart

Failure patients

Dr Teo Wee Siong MBBS (S’pore), M Med (Int Med), FAMS, MRCP (UK), FRCP (Edin), FACC, FHRS

Director of Electrophysiology and Pacing

National Heart Centre

Singapore

Mt Elizabeth Hospital

Singapore

Management depends on:

 New onset, paroxysmal , persistent, long standing persistent, permanent or unknown

 Devices – pacemakers, Atrial defibrillators, ICDs, CRT

 Ablation – AV node ablation, AF ablation

 Upstream therapy - ACE inhibitors, ARB, Statins

 Devices – atrial pacing, minimal ventricular pacing

Rate vs Rhythm control for AF in HF pts

AF in HF is a/w increased mortality

Maintenance of sinus rhythm

improved survival ?

AF-CHF Study - Rhythm Control versus Rate Control for

Atrial Fibrillation and Heart Failure

Roy D et al N Engl J Med 2008;358:2667-2677

Kaplan-Meier Estimates of Death from Cardiovascular Causes (Primary Outcome)

In pts with AF and congestive heart failure, a routine strategy of rhythm control does not reduce the rate of death from cardiovascular causes, as compared with a rate-control strategy

? Conversion to sinus rhythm

improves suvival

amiodarone showed a significantly better 4 year

survival compared with non-converters (P=0.04)

Deedwania PC, et al

Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation: observations from the Veterans Affairs Congestive Heart Failure Survival Trial of Antiarrhythmic Therapy (CHF STAT)

Circulation.1998;98:2574-2579

Rate vs Rhythm Control

applicable to older pts with minimal symptoms

better

symptomatic pts especially when there is suggestion that the rapid AF causes tachycardia cardiomyopathy

Rate control for AF in HF pts

tachycardia cardiomyopathy and rapid deterioration in preexisting heart failure

Rate controls results in improved LV function

Drugs for rate control

RACE II - Lenient vs strict rate control

Van Gelder IC et al N Engl J Med 2010;362:1363-1373

Nonpharmacological rate control

Rhythm control for AF in HF pts

symptomatic despite rate control

TEE or after initiating anticoagulation

Maintainace of sinus rhythm

Amiodarone – most effective drug

Touboul P et al Eur HJ 2003;24:1481 Singh BN et al NEJM 2007;357:987

Dronedarone provides Rhythm control

Hohnloser SH, et al N Engl J Med 2009; 360:668-678

Recent sub group analysis suggest reduction in stroke as well

Kober L et al NEJM 2008;358:2678

Dronedarone in stable HF pts

 AF and stable CHF (NYHA Class II and III), dronedarone did not increase mortality and showed a reduction of CV

hospitalization or death similar to the overall population A

primary outcome event occurred in 59/114 placebo patients

compared with 42/95 dronedarone patients (HR 0.78, 95% CI

= 0.52–1.16)

 However, in the light of the ANDROMEDA study,

dronedarone should be contraindicated in patients with NYHA class IV or unstable NYHA classes II and III CHF

Honhloser SH et al Dronedarone in patients with congestive heart failure: insights from ATHENA

Eur H J 2010;31:1717-1721

Role of specific drug therapies

Role of antiarrhythmic drugs for AF in

Class 1 antiarrhythmic drugs

a/w excess mortality in pts with a h/o CHF and are thus contraindicated

antiarrhythmic drugs had a relative mortality risk

of 4.7 compared with pts treated without

antiarrhythmic drugs

Flaker GC, et al

Antiarrhythmic drug therapy and cardiac mortality in atrial fibrillation

J Am Coll Cardiol 1992; 20:527-32

Role of beta blockers in AF and HF

improve morbidity and mortality in HF patients with

AF

Insufficiency Bisoprolol Study II) and MERIT-HF

(Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure) studies were not able to

demonstrate that beta-blockers decreased morbidity

and mortality in HF patients that had AF

Role of beta blockers in AF and HF

beta-blockers improve morbidity and

mortality in HF patients with AF

(The Cardiac Insufficiency

Bisoprolol Study II) and MERIT-HF

(Metoprolol CR/XL Randomized

Intervention Trial in Congestive

Heart Failure) studies were not able

to demonstrate that beta-blockers

decreased morbidity and mortality in

HF patients that had AF

Carvedilol and digoxin combination

lowered the ventricular rate on 24-h ambulatory

electrocardiographic monitoring (p < 0.0001) and

during submaximal exercise (p < 0.05), whereas LVEF (p < 0.05) and symptom score (p < 0.05) improved

patients switched from combination therapy to

carvedilol alone

Carvedilol alone or in combination with digoxin for the management of atrial fibrillation in patients with heart failure?

Aleem U Khand, Andrew C Rankin, William Martin, Jacqueline Taylor, Islay Gemmell and John G F Cleland

J Am Coll Cardiol 2003;42:1944-1951.

shown not to increase the risk of death among

AF pts with heart failure

Amiodarone Trials Meta-Analysis Investigators

Effect of prophylactic amiodarone on mortality after acute myocardial infarction and in congestive heart failure: meta-analysis of individual data from 6500 patients in randomised trials Lancet 1997;350:1417-24

ESC AF Guidelines 2010

Substrate modification – ACE inhibitors

with the ACE inhibitor trandolapril reduced the risk of developing AF after myocardial infarction

in pts with LV dysfunction by 55% during term follow-up

long-Pedersen OD, Bagger H, Kober L, Torp-long-Pedersen C

Trandolapril reduces the incidence of atrial fibrillation after acute myocardial infarction in patients with left ventricular dysfunction Circulation 1999;100:376-80

Substrate modification - ARB

 Ibersartan in combination with amiodarone had a lower incidence of AF recurrence that amiodarone alone

 Madrid et al studied 154 pts undergoing cardioversion of

persistent AF.

 75 pts were randomised to amiodarone only and 79 were randomised to amiodarone plus irbesartan At two months, 85% of pts were still in sinus rhythm on combination therapy compared with 63% in the amiodarone only group

Madrid AH, Bueno MG, Rebollo J et al

Use of irbesartan to maintain sinus rhythm in pts with long lasting persistent AF:

a prospective and randomized study Circulation 2002:106:331-6

Effect of statins

 GISSI Heart-Failure (GISSI-HF) trial

of atrial fibrillation

moderate significance (p=0.038) only after statistical

adjustment for concomitant medications and a long list

of clinical features and laboratory results

Maggioni AP, Fabbri G, Lucci D, et al Effects of rosuvastatin on atrial fibrillation occurrence:

Ancillary results of the GISSI-HF trial Eur Heart J 2009

Score Stroke rate

Gage et al JAMA 2001;285:2864-2870.

CHADS2 scoreCombination of AFI and SPAF schemes

1 Congestive Heart Failure

ESC AF Guidelines 2010

RELY- Cumulative Hazard Rates for the Primary Outcome of Stroke or Systemic Embolism,

According to Treatment Group

Connolly SJ et al N Engl J Med 2009;361:1139-1151

Nonpharmacological therapy for AF pts with HF not responding to drugs

 AV node ablation + CRT

 ICD for HF with LVEF < 35%

open heart surgery

Pacing in AF pts - ? Proarrhythmic

effect of ventricular pacing

pts with normal baseline QRSd

versus VVIR pacing in SND.

in both groups (DDDR, HR 1.36 [95% CI, 1.09, 1.69]; VVIR, HR 1.21 [95% CI 1.02, 1.43], for each 25% increase in Cum%VP)

Michael O Sweeney et al for the MOde Selection Trial (MOST) Investigators

Adverse Effect of Ventricular Pacing on Heart Failure and Atrial Fibrillation Among Patients With Normal Baseline QRS Duration in a Clinical Trial of Pacemaker Therapy for Sinus Node Dysfunction

Circulation 2003;107:2932

ICD for AF and HF pts

Role of CRT in AF and HF

 CRT indicated for pts with rapid AF who need AV node

ablation + pacing RV pacing alone may be deleterious

 CRT may help prevent AF or reduce AF burden

 CRT indicated in pts with HF and QRS > 120 ms even in AF Improvement in hemodyanamics, functional class, reverse

remodelling, reduce hospitalization

 Spontaneous conversion to sinus rhythm possible when HF improves after CRT (hence insert atrial lead as well)

 CRT-D – prevents SCD

CRT important in AF pts with

impaired LV function

CRT post AV node ablation

– 184 pts requiring AV node ablation

randomized to biventricular pacing (n=

103) or a right ventricular pacing system

(n= 81)

• At 6 months post ablation,

– Six minute walk test - Pts treated with CRT

improved to a greater degree compared

with pts treated with RV pacing (31%

above baseline vs 24% above baseline,

P=0.04)

– Pts treated with CRT had significantly

greater improvement in LVEF compared

with pts who received RV pacing (46% vs

41%, p=0.03)

• No significant difference in quality of

life was observed.

Doshi RH et al J Cardiovasc Electrophysiol 2005;16:1160-5

40.7

44.9

46.0 45.6

38 39 40 41 42 43 44 45 46 47

PAVE: Changes in LVEF

Spontaneous conversion to SR after CRT

reported in CRT pts

 Kies, Leclercq Heart 2006;92:490-4

 Saxon L Cardiovasc Electrophysiol 2006;17:520-5

Management of AF in CRT pts

 Loss of AV synchrony

 Reduce biventricular pacing

 Consistent biV capture – eliminated fusion

 Eliminates risk of uncontrolled ventricular rate

 Regularizes the ventricular rate

 Possible discontinuation of drugs which can further impair

LV function negatively affecting morbitidy and mortalithy

CRT pts who develop AF –

AVN ablation may be needed

Role of Ablation

AVN ablation for rapid AV and HF

 Advantage

 Disadvantage

– No severe heart disease

Hsu LF… Haissaiguerre M NEJM 2004

PABA CHF

Composite Primary End Point of Ejection Fraction, 6-Minute Walk Distance, and Score on the Minnesota Living with Heart Failure Questionnaire at 6 Months

Khan MN et al N Engl J Med 2008;359:1778-1785

 PABA-CHF Conclusion

 Pulmonary-vein isolation was superior to atrioventricular-node ablation with biventricular pacing in patients with heart failure who had drug-refractory atrial fibrillation

Remote magnetic Navigation - Stereotaxis – Value for complex ablation

 Integration with C ARTO Electro-Anatomical

Navigation System

 Precise Tip Control – can move by mm precision

Safety of GentleTouch Catheters

 Consistent Contact

 Reproducible navigation of ablation catheter

 Can reach sites that cannot or rarely be reached

by conventional techniques

 Reduced Patient X-Ray Exposure

 Reduce X-ray exposure of Medical personnel

Loss of PV potentials during ablation

ESC AF Guidelines 2010

AF and CHF in 2010

antithrombotic drugs may make it safer and easier

approach especially in the elderly with more severe HF and long standing persistent AF

with significant symptoms

of pts