Download Ventricular rate profiles during atrial fibrillation in heart failure patients

Ventricular rate profiles
during atrial fibrillation in
heart failure patients
Fabrizio Oliva
Niguarda Ca’ Granda Hospital, Milano
on behalf of the cardiological centres
participating to the ClinicalService® Project.
Disclosure Information: No conflict of interest to declare
Epidemiology: HF & AF
Atrial fibrillation is
frequent in heart
failure patients.

Framingham study :
15% of patients with
HF show AF
AF prevalence
increases with
worsening HF
status
AF & HF: a big question
Who’s born before?
AF & HF
Heart failure
Atrial Fibrillation
Worsening HF may be lead to AF episodes
&
AF may cause worsening HF events.
AF and HF are strongly
correlated to prognosis.
All cause mortality
AF in HF patients is
associated to higher
mortality (HR=1.34)
Driers et al, JACC 1998 (SOLVD trial)
HF: CRT guidelines
Cardiac Resynchronisation Therapy
Class I Indication
Synus Rhythm, Reduced EF ( 35%)
Ventricular Dyssynchrony (QRS > 120ms)
NYHA III-IV (ambulatory); Optimal Medical Therapy
Synus Rhythm, Reduced EF ( 35%)
Ventricular Dyssynchrony (QRS > 150ms)
NYHA II; Optimal Medical Therapy
Class I pacemaker indication;
Reduced EF ( 35%); Ventricular Dyssynchrony (QRS > 120ms)
NYHA III-IV
Class II Indications
Permanent atrial fibrillation;
AV-nodal ablation-induced pacemaker dependence or
slow ventricular rate and >95% pacing frequency;
Reduced EF ( 35%); Ventricular Dyssynchrony (QRS > 130ms)
NYHA class III-IV; Optimal Medical Therapy
Class I pacemaker indication;
Reduced EF ( 35%); Ventricular Dyssynchrony (QRS <120ms)
NYHA II-III-IV
CRT AF & HF: Background
Benefits of CRT have been demonstrated also in patients with AF
In 86 pts with AF vs 209 pts in SR
Among 86 pts with AF 66 had permanent AF and 20 paroxismal AF
Khadjooi et al., Heart 2008
CRT AF & HF: real world data
AF prevalence:
0% in clinical trial
(exclusion criteria)
ESC survey
23% in the real world
Pre CRT data
AF prevalence: 17%
Niguarda series
(597 patients)
CRT & monitoring: is it helpful?
AF monitoring is important in patients with a CRT device because
AF-induced high ventricular rate (VR) may cause loss of CRT
Aims
To evaluate the association between different profiles of
AF and uncontrolled ventricular rate (VR) in a cohort of
HF patients who need continuous biventricular pacing to
achieve cardiac resynchronization
Each patient was assigned a specific AF profile according to duration
of the longest AF episode of that patient (device derived data):
AF >10 minutes,
AF >6 hours,
AF >24 hours,
AF >7 consecutive days -
Persistent AF
AF >6 consecutive months - Permanent AF
Results
1404 patients implanted with CRT-D
NYHA≥II, LVEF≤35%, QRS ≥120ms
Median follow-up 18 months AF detected in 32%
AF profile
N. patients
10 min≤AF<6 hours
115 (26%)
6 hours ≤AF<24 hours
70 (16%)
24 hours ≤AF<7 days
57 (13%)
7 days ≤AF<6 months -PERSISTENT
154 (35%)
AF≥6 months –PERMANENT
47 (10%)
Overall
443 (100%)
Results
Mean VR during AF (average of each patient mean VR): 86±10bpm
Maximum VR during AF (average of each patient max VR): 115±15 bpm.
Optimal VR control during AT/AF :
VR≤80 bpm during resting 12-lead ECG
VR≤110 bpm during a 6-minute walking test
maximum VR
mean VR
Uncontrolled VR :
mean VR>80 and max VR>110 bpm
(device stored data)
Results
Distribution of daily mean VR during AF
Normalized distribution for the 5 specified AF profiles.
In paroxysmal AF profiles VR distribution seems to be wider and
shifted toward high rates;
In persistent or permanent AF profiles VR is normally distributed
and ranges between 50 and 100 bpm
Conclusions
The question remains big
but...now we know more:
These findings underscore the importance of research on
real-world HF patients treated by CRT devices;
VR during AF had a specific profile according to AF type;
 Improved rate control in CRT patients with uncontrolled
VR during AF is a clinically relevant target;
Conclusions
The question remains big
but... now we know more:
VR control may not be achieved in a significant proportion of patients
due to lack of information about AF occurrence.
This has important clinical implications since it has been shown that
patients with new-onset AF are less prone to respond to CRT.
 Our findings suggests that continuous monitoring of AF and related
VR could allow to appropriately choose and pursue rate or rhythm
control strategies.