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Atrial Arrhythmia Management
in Advanced Heart Failure
Patients
Eric E. Johnson, MD, FACC, FHRS
The Stern Cardiovascular
Foundation
Baptist Memorial Hospital-Memphis
Disclosures
Medtronic advisory board,
speaking engagements, clinical
research support.
Speaker for BMS, Pfizer.
Cheney Recovering at Home After Being
Treated for Irregular Heartbeat
MONDAY, NOVEMBER 26, 2007
Question 1: How would you manage AF in this patient?
1.) Rate control and anticoagulate
2.) Anticoagulate and begin amiodarone
3.) Cardiovert
4.) No change in therapy
5.) Go on hunting trip and not worry
Dick Cheney
Cheney has a long history of cardiovascular disease
He had his first of five heart attacks in 1978, at age 37. Subsequent attacks
resulted in moderate left ventricular dysfunction.
He underwent four-vessel coronary artery bypass grafting in 1988, coronary
artery stenting in November 2000, urgent coronary balloon angioplasty in
March 2001
He underwent implantation of an implantable cardioverter-defibrillator in June,
2001.
CBS News reported that during the morning of November 26, 2007, Cheney
was diagnosed with atrial fibrillation and underwent treatment that afternoon.
In July 2010, Cheney was outfitted with a left-ventricular assist device (LVAD)
at Inova Fairfax Heart and Vascular Institute to compensate for worsening
congestive heart failure.
On March 24, 2012, Cheney underwent a seven-hour heart transplant
procedure at Inova Fairfax Hospital in Falls Church, Virginia, at the age of
71.
From Wikipedia
Introduction
• Atrial fibrillation begets atrial fibrillation. AF
begets heart failure. HF begets AF.
• RATE CONTROL & ANTICOAGULATION
(AFFIRM) What about CHF? (AF-CHF)
• Underlying substrate - optimize meds for HTN,
HF
• Device therapy: pacing - selective site, multiple
site, minimize ventricular pacing, atrial therapies,
CRT
• Catheter Ablation - AVN RF & AF ablation (PVI)
• AF in LVAD AND HT patients
• Review of guidelines
• AF is associated with increased risk of stroke,
HF, and all-cause mortality
• Mortality rate with AF is double that of patients in
SR and linked to severity of underlying disease
– SOLVD mortality 34% AF vs 23% SR
• Difference in deaths due to HF rather than thromboembolism
– COMET
• No difference in all-cause mortality with AF at entry
• Mortality increased if AF developed during follow-up
• HF promotes AF, AF aggravates HF, and
individuals who develop alternate condition
share poor prognosis.
From: Rhythm Control in Heart Failure Patients With Atrial Fibrillation: Contemporary Challenges Including the
Role of Ablation
J Am Coll Cardiol. 2014;64(7):710-721. doi:10.1016/j.jacc.2014.06.1169
Figure Legend:
The Physiological Relationship
Between Atrial Fibrillation and Heart
Failure
Action potential duration
heterogeneity includes spatial and
temporal nonuniformities (36). This
mechanistic hypothesis has fallen out
of favor with recent evidence (33).
Date of download:
2/1/2015
Copyright © The American College of Cardiology.
All rights reserved.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
AFFIRM
Primary Endpoint – Total Mortality
Mortality (%)
30
25
Rhythm
Rate
20
15
p = 0.078 unadjusted
p = 0.068 adjusted
10
5
0
3
2
5
4
Time (Years)
No difference between strategies, but a late mortality advantage
for rate control starting at about 2 years after randomization.
0
1
Implications of AFFIRM
• Rate control is appropriate primary therapy
• Anticoagulation for all with one or more risk
factors for stroke
• What therapies are under-represented?
– Non-pharmacologic therapies
• Who is under-represented in AFFIRM?
–
–
–
–
Young patients
Paroxysmal atrial fibrillation
Disabling symptoms of AF
CHF
Rhythm Control Drugs in HF
•
What drug(s) are indicated for HF
patients?
1.
2.
3.
4.
5.
6.
Propafenone
Amiodarone
Sotalol
Dofetilide
1&3
2&4
AF-CHF Trial
AF-CHF Study Design
Strategy Algorithm
Baseline Characteristics
Medical Therapy at 12 Months
Primary Endpoint:
Cardiovascular Death
Secondary Endpoints
AF-CHF Conclusions
AF Ablation: Pulmonary Vein
Isolation (PVI)
QuickTime™ and a
MS-MPEG4 v2 decompressor
are needed to see this picture.
From: Rhythm Control in Heart Failure Patients With Atrial Fibrillation: Contemporary Challenges Including the
Role of Ablation
J Am Coll Cardiol. 2014;64(7):710-721. doi:10.1016/j.jacc.2014.06.1169
Figure Legend:
Approaches to Catheter Ablation in AF and HF
CFAE = complex fractionated atrial electrogram; PV = pulmonary vein; PVI =
pulmonary vein isolation; other abbreviations as in Figure 1.
Date of download:
2/1/2015
Copyright © The American College of Cardiology.
All rights reserved.
AV Node Ablation
• Does not eliminate AF
• Effective in controlling ventricular
rate
• Improves:
– QOL
– Exercise tolerance
– Left ventricular function
• No deleterious effect on survival
From: Rhythm Control in Heart Failure Patients With Atrial Fibrillation: Contemporary Challenges Including the
Role of Ablation
J Am Coll Cardiol. 2014;64(7):710-721. doi:10.1016/j.jacc.2014.06.1169
Table Title:
Key Questions Specific to Catheter Ablation of AF in Patients With HF
Date of download:
2/1/2015
Copyright © The American College of Cardiology.
All rights reserved.
Clinical Impact of AF in Patients
with LVAD
• AF develops in up to 50% of patients with
LVADs
• PAF is not associated with worse
outcomes in patients with HMII LVAD
• Persistent AF may be associated with
increased mortality and HF hospitalization
• Patients with AF may have
thromboembolic events at higher INR
levels
JACC. 2014;64(18):1883-1890
AF post-heart transplantation
QuickTime™ and a
decompressor
are needed to see this picture.
J Am Heart Assoc. 2012 Apr; 1(2): e001461.
Published online 2012 Apr 24.
2014 AHA/ACC/HRS Guideline for the
Management of Patients with AF and CHF
•
Class I
1. In the absence of pre-excitation, intravenous betablocker administration is recommended to slow the
ventricular response to AF in the acute setting, with
caution needed in patients with overt congestion,
hypotension, or HF with reduced EF
2. In the absence of pre-excitation, intravenous digoxin
or amiodarone is recommended to control heart rate
acutely in patients with HF
3. Digoxin is effective to control resting heart rate in
patients with HF with reduced EF
JACC. 2014;64(21):2246-2280
Guideline: AF and CHF
•
Class IIa
1. A combination of digoxin and a beta blocker is
reasonable to control resting and exercise heart rate
in patients with AF
2. It is reasonable to perform AV node ablation with
ventricular pacing to control heart rate when
pharmacological therapy is insufficient or not
tolerated
3. Intravenous amiodarone can be useful to control
heart rate in patients with AF when other measures
are unsuccessful or contraindicated
JACC. 2014;64(21):2246-2280
Guideline: AF and CHF
•
Class IIa
4. For patients with AF and rapid ventricular response
causing tachycardia-induced cardiomyopathy, it is
reasonable to achieve rate control by either AV
nodal blockade or a rhythm-control strategy
5. For patients with chronic HF who remain
symptomatic from AF despite a rate-control
strategy, it is reasonable to use a rhythm-control
srategy
JACC. 2014;64(21):2246-2280
Guideline: AF and CHF
•
Class IIb
1. Oral amiodarone may be considered when
resting and exercise heart rate cannot be
adequately controlled using a beta blocker
or digoxin, alone or in combination
2. AV node ablation may be considered when
the rate cannot be controlled and
tachycardia-mediated cardiomyopathy is
suspected
JACC. 2014;64(21):2246-2280
•
Guideline: AF and CHF
Class III:Harm
1. AV node ablation should not be performed
without a pharmacological trial to achieve
ventricular rate control
2. For rate control, intravenous
nondihydropyridine calcium channel
antagonists, intravenous beta blockers, and
dronedarone should not be administered to
patients with decompensated HF
JACC. 2014;64(21):2246-2280
Increased Mortality Associated with Digoxin
in Patients with AF: The TREAT-AF Study
• Digoxin is widely used to control the ventricular rate in
patients with AF, but evidence supporting safety and
efficacy are limited
• In patients with recently identified AF, treatment with
digoxin was associated with an increased risk of death,
independent of kidney function or cardiovascular
comorbidities
• Consider alternatives to digoxin in managing AF
• Prospective studies are needed to confirm findings and
explore mechanisms for increased mortality
TREAT-AF (The Retrospective Evaluation and
Assessment of Therapies in AF)
JACC 2014;64(7):660-668
Conclusions
1.) Increasing evidence of interaction AF
and HF
2.) Rhythm control and anticoagulation
appropriate primary therapy for most
patients
3.) Management of underlying substrate
and device therapy when appropriate
4.) Evolving role of atrial fibrillation ablation