Atrial Fibrillation and Congestive Heart Failure: the chicken or egg story

Luc DE ROY

The 30 most important diagnoses

pathologyICD

-9-CMNumber of admissions

% admissions

mean duration (days)

4 Chronic IHD 414 21996 1,35 9,2

12 Arrhythmias 427 17129 1,05 10,5

14Angina pectoris

413 16798 1,03 8,2

16 AMI 40 15881 0,98 13

17 CHF 428 15869 0,98 18,8

Affects after the 40th year of life 26% of men and 23% of all women

Increases the risk for TIA/ CVA – HR: 3,9

Causes myocardial dysfunction

Worsens heart failure

Atrial fibrillation

AF begets HF and HF begets AFAF begets HF and HF begets AF

Fibrose met reentry ?

AF ontstaat bij een belangrijke patiëntengroepin de longvenen

Getriggerd ?

(bayes de luna ? – no - from Maurits Alessie)

(Wijffels, Alessie, Circulation 1995)

Atrial Fibrillation and congestive heart failure :survival (cardiac death) according to treatment

adapted from Flaker, SPAF study 1992

0 90 180 270 360 450 540 630 720

Time in SPAF (days)

0

20

40

60

80

100%

Def CHF, on AAD

Def CHF, off AAD

Klasse Ic Antiarrhythmic agents

AF + RBBB + LBBB

VT ?

Sinus

• What is known on the relationship of AF and HF ?

• Is AF a marker of mortality ?

• What about the timing of onset of AF ?

1. Is upstream therapy useful ?

2.Should we aim for sinus rhythm

(i.e. drugs, cardioversion, ablation) ?

3. Should we use CRT ?

Prognostic significance of AF Prognostic significance of AF

COMET: N= 3029 pts (20% with AF)

New Onset AF: New Onset AF: (multivariate) RR=1.90 (multivariate) RR=1.90 Eur Heart J 2005;26:1303

EHS-HFEHS-HF

7%7% 7%7% 12 %12 % 13 %13 %

P < 0.001P < 0.001 P < 0.001P < 0.001

No AF Previous AF New onset AF

1313 % % 19 %19 %

Rivero-Ayerza et al. Eur Heart J, 2008

EuroHeart Failure - Mortality EuroHeart Failure - Mortality

In-hospital mortality 12 week mortality

EHS-HF

No AF(n=419)

Previous AF(n=249)

New-onset AF(n=123)

P-value

Worsening HF

Pulmonary oedema

Stroke

Other cardiovasc.

Non-cardiovascular

141 (34%)

99 (24%)

17 (4%)

79 (19%)

71 (17%)

71 (29%)

58 (23%)

27 (11%)

35 (14%)

40 (16%)

42 (34%)

34 (28%)

8 (7%)

27 (22%)

25 (20%)

0.551

0.794

0.014

0.298

0.768

Mode of Death ?Mode of Death ?

Rivero-Ayerza et al. Eur Heart J, 2008

Smit et al, Eur J HF 2012

Timing of AF in relation to HF

•AF patients developing HF seem to have a better prognosis than HF patients developing AF

•Development of AF in patients with HF may be a sign of worsening HF

Upstream Therapy • Renin-angiotensin-aldosterone

modulators

• Omega-3 fatty acids

• Statins

• Retrospective data better than prospective …

Li D, Nattel et al. Circulation 2001

Control

5 Weeks

5 Weeks +Enalapril

ACE inhibition reduces ACE inhibition reduces atrial fibrosis in a heart failure modelatrial fibrosis in a heart failure model

Amiodarone plus angiotensine I receptor blockersmaintain sinus rhythm

Madrid et al, 2002

16-10-2001

ACE inhibitors and ARB`s

Savelieva I et al. Europace 2011;13:308-328

16-10-2001

Efficacy of statins in prevention of atrial fibrillation

Savelieva I et al. Europace 2011;13:308-328

16-10-2001

Upstream therapy after PVI in retrospective studies.

Savelieva I et al. Europace 2011;13:308-328

Maintaining sinus rhythm in CHF

• Why ?

• Drugs

• Cardioversion

• Ablation

DIAMONDDIAMOND

Pedersen et al. Circulation 2001;104:292

• 506 pts with LV dysfunction

• Randomized to Dofetilide or Placebo

• No effect on mortality

• Effect of SR on mortality RR 0.44 (0.30-0.64)

Survival according to Rx

Survival according to rhythm

AFFIRMAFFIRM

JACC 2005;46:1891 / NEJM 2002;347:1825

- SR improves survival

- AAD increase (non-cardiac) mortality

- SR improved functional class

Cardioversion and CHF• Traditionally delayed, unless

• Tachycardiomyopathy or emergent restoration of sinus rhythm necessary

• few data available…

Recent onset

ESC guidelines 2012

CCV ECV

Transient ischaemic attack 13 (1.3) 2 (0.3)

Non-haemorrhagic stroke 1 (0.1) 2 (0.3)

Pisters et al, Europace 2012

CCVECV

Success 71% (IV) 88%

Complications 64/643 38/712

Transient ischaemic attack 13(1.3%) 2(0.3%)

Non-haemorrhagic stroke 1(0.1%) 2(0.3%)

Pisters et al, Europace 2012

Markers of high risk: all related to CHF

• Thrombi in LA / LAA

• Spontaneous echo contrast

• Flow velocity profile in the LAA

• Low LA emptying velocity

• Dilatation above 6 sq cm

Indications for TEE

• Problematic anticoagulation

• Valvular disease

• LVD

• Prior stroke

• Enlarged LA (> 5cm)

• All new cases (duration < 1 month)

PVI ablation and CHF• Normal anatomy ?

• Tachycardiomyopathy ?

• few data available…

Paroxysmal Persistent Permanent

ESC guidelines 2012

Endpoints: Ablation success, LV function, QOL, functional class

PV isolation & roof & PV-MV lines. AADs discontinued.

58 pts NYHA Class ≥ II, LVEF < 45%

referred for ablation

58 controls matched for age,

sex, & AF class

Hsu et al; NEJM 2004;351:2373-2383

Management of AF in HFManagement of AF in HF

NEJM 2004:351

• 58 pts

• HF and LVEF <45%

• FU= 12±7 m

• SR in 69 % at 12 months

• LVEF improved 21±13 %

• Improved exercise capacity, symptoms, and QOL

Anselmino M et al; JCE 2013

Ablation in left ventricular dysfunctionAblation in left ventricular dysfunction

CRT and AF• AF patients were excluded from

the first studies

• new data available…

CRT and AF• Assess % BV pacing

• Ablation of the AV node…

• new data available…

Effect of AV nodal ablation in patients with IHD versus DCM and a BV ICD

Sohinki et al, Eurpace 2013, in press

• Upstream therapy with ACE inhibitors might be useful

• Cardioversion carries a higher risk for emboli than is generally accepted

• PVI is useful in selected HF patients

• AV nodal ablation has a role in CRT, especially in DCM

Conclusions

Conclusions

treat both conditions, and as early as possible