Download Atrial Fibrillation and Heart failure: Good Old Friends

Atrial Fibrillation and Heart failure:
Good Old Friends
Adrian Baranchuk MD FACC FRCPC
Associate Professor of Medicine
Director, EP Training Program
Queen’s University
International Session: Asia Pacific Society of Cardiology,
Inter-American Society of Cardiology and
American College of Cardiology
San Diego, ACC.15
Conflict of Interest
•  Unrestricted Grant from Bayer
•  Unrestricted Grant from
Medtronic
•  Honorarium to deliver
conferences for Bayer,
Boehringer Ingelheim, Medtronic,
St Jude
•  No conflict of interest for this
specific talk
Good Old Friends:
What does it mean?
Old Friends Can Be Good
Friends…but not necessarily…
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Are AF and CHF Good friends?
Are they always together?
How do they treat each other?
Do they make favors to each
other?
•  Are they the ONLY good friends in
this story?
The Three Stooges: AF-CHF-OSA
AF
CHF
OSA
Overview
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Epidemiology
Physiopathology
Interactions
Associations
Outcomes
Epidemiology:
Facts about CHF
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CHF affects 5,000,000 people in US
>550,000 new cases every year
12-15 million visits per year
6,5 million hospital/days per year
In 2007: 33 billion dollars
Epidemiology:
Facts about AF
•  AF is the most common arrhythmia in
daily practice
•  2.3 million people in NA
•  In the last 20 years, admission due to
AF increased by 66%
•  By 2050, 5,6 million may have AF in NA
Physiopathology
Physiopathology
CHF
AF
↑ cardiac filling pressures, Ca++ dysregulation, ANS
CHF
AF
dysfunction, neuroendocirne imbalance, dispersion of
refractoriness, interstitial fibrosis
Increased HR, shorter diastolic filling pressure, ↓ CO,
irregularity of ventricular response, loss of atrial kick,
Tachy-induced CM, impact of AAD
AF
CHF
Interactions:
Prognostic factor
A role for a trio rather
than a duo?
CHF
AF
OSA
•  OSA aggravates the course of CHF
•  OSA and AF are associated
•  AF and CHF are associated
•  The presence of OSA turns difficult the
treatment of AF &CHF
Stroke
Tachyarrhythmias
•  Atrial Fibrillation
•  Ventricular arrhythmia
Bradyarrhythmias
Sleep Apnea
Autonomic dysfunction
Atrial overdrive
pacing
Heart failure
•  Systemic hypertension
•  Pulmonary hypertension
•  Supra/ventricular arrhythmia
•  ? CRT
Baranchuk et al. Europace 2008; 10(6):666-667
Challenges for treatment
•  OSA: no treatment implies more AF and
CHF, but treatment may be deleterious
in CHF (Canpap Study)
•  CHF: Treatment is mandatory to
decrease both OSA & AF (Role of CRT)
•  AF: Treatment is beneficial to control
physiopathological aspects, but maybe
deleterious for CHF (AAD) + Poor
impact on mortality. Role for Pace/
ablate and for CRT/ablate
Rhythm control or Rate
control for AF in patients with
CHF?
NEJM 2008
Invasive rate-control
•  PACE-Ablate: in patients with low LVEF
it may aggravate CHF due to
dyssynchrony
•  CRT-Ablate: as patients becomes
dependent, CRT maybe beneficial to
control for CHF (CERTIFY Study)
DOWNFALL: AF attenuates the benefit of CRT!!!
PRO: Collateral benefit of CRT on OSA!!!!
“CRT reduces AHI in patients with Central SA but not in OSA”
Lamba, Baranchuk et al. Europace 2011
Invasive rhythm-control
•  PVI: Initial LVEF improvement, but
the benefit depends on ability to
stay in NSR without AAD
•  RAFT-AF Study: Ongoing
(3 groups: AF ablation-267-, No AF ablation-1068-, No AF-1068)
Bunch TJ. JCE 2014
Conclusions
•  More questions than answers
despite >100 metaanalysis
•  AF-CHF-OSA are frequently
associated
•  Selecting appropriate therapy is
key
•  Controlling for impacting the
other factor is also key
Conclusions (cont)
•  ADD can be deleterious for CHF
•  Pace-ablate in systolic
dysfunction should be abandoned
•  Consider CRT-Ablate
•  Consider PVI as rhythm-control