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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… • • • • 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 • • • • • Epidemiology Physiopathology Interactions Associations Outcomes Epidemiology: Facts about CHF • • • • • 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