How do you decide on rate versus rhythm control?

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1 Heart Rhythm Congress 2014 How do you decide on rate versus rhythm control? Dr Ed Duncan Consultant Cardiologist & Electrophysiologist

2 Define Rhythm Control DC Cardioversion Pharmacological AFFIRM study 2002 RACE study 2002 Catheter ablation CABANA trial Define outcome measure Symptomatic benefit Mortality or morbidity reduction

3 A COMPARISON OF RATE CONTROL AND RHYTHM CONTROL IN PATIENTS WITH ATRIAL FIBRILLATION 14 (0.006%) of 2033 in the rhythm control group underwent catheter ablation SR conferred a 53% mortality reduction AAD conferred a 49% mortality increase The AFFIRM investigators; N Engl J Med, Vol. 347, No. 23

4 A COMPARISON OF RATE CONTROL AND RHYTHM CONTROL IN PATIENTS WITH RECURRENT PERSISTENT ATRIAL FIBRILLATION The RACE study group Van Gelder et al N Engl J Med 2002;347:

5 Maintenance of Sinus Rhythm with an ablation strategy in patients with AF is associated with a lower risk of stroke and death Hunter et Al, Heart 2011

6 Asymptomatic persistent AF and outcome: Results of the RACE study Rienstra et al, Heart Rhythm, Vol 11, June 2014

7 Nice 2014: When to offer rate or rhythm control? Offer rate control in people with AF except where: There is a reversible cause Heart failure is felt secondary to AF New onset AF Atrial flutter For whom a rhythm control strategy is deemed more suitable based upon clinical judgement

8 June 2014

9 ESC guidelines ESC Guidelines for the management of atrial fibrillation Europace (2010)

10 Long term follow up after ablation of longstanding PsAF Rostock et al, Heart Rhythm Vol 9, 2011 Tilz et al, Jacc Vol 60; 2012

11 For whom a rhythm control strategy is deemed more suitable based upon clinical judgement Who benefits most from rhythm control? Procedural risk Redo procedures When is catheter ablation most successful? PsAF Symptom benefit Reduction in co-morbidity Patient choice Who is at most risk during catheter ablation? PsAF

12 Clinical characteristics of patients with persistent atrial fibrillation successfully treated by left atrial ablation Takahashi Y et al Circ Arrhythmia Electrophysiol 2010;3:

13 Long-term single- and multiple-procedure outcome and predictors of success after catheter ablation for persistent atrial fibrillation AF duration Male Gender Heart failure Rostock et al, Heart Rhythm Vol 9, 2011

14 Which are the most reliable predictors of recurrence of atrial fibrillation after transcatheter ablation? a meta-analysis D Ascenzo et al; International Journal of Cardiology 167 (2013)

15 The impact of age on the efficacy and safety of catheter ablation for longstanding persistent atrial fibrillation Xiao-Dong Zhang et al; International Journal of Cardiology 168 (2013)

16 16 Obstructive Sleep Apnoea (OSA) 720 consecutive pts Treated OSA was > 4hrs CPAP AF recurrence seen in: - 51% OSA vs 30% no OSA (p<0.0001) - 68% untreated vs 35% treated (p<0.0001) Neilan G et al. Effect of Sleep Apnea and Continuous Positive Airway Pressure on Cardiac Structure and Recurrence of Atrial Fibrillation. JAHA 2013.

17 Long-term follow-up after atrial fibrillation ablation in patients with impaired left ventricular systolic function: The importance of rhythm and rate control Nedios et al Heart Rhythm 2014;11:

18 A Randomized Controlled Trial of Catheter Ablation Versus Medical Treatment of Atrial Fibrillation in Heart Failure (The CAMTAF Trial) Ejection fraction NYHA class Hunter et al. Circ Arrhythm Electrophysiol. 2014;7:31-38.

19 Catheter Ablation of Atrial Fibrillation in Patients with Left Ventricular Systolic Dysfunction: A Systematic Review and Meta- Analysis 1838 patients Mean EF 40% Anselmino et al; Circ Arrhythm Electrophysiol. Epub Sept 28, 2014;

20 Predictors of complications after AF Examples: ablation Female gender Increasing age HCM Institutional experience Bohnen M et al Heart Rhythm Nov;8(11): Hoyt et al Heart Rhythm Dec;8(12): Shah RU et al. J Am Coll Cardiol Jan 10;59(2) Inoue K, Heart Rhythm Aug 15

21 June 2014

22 How do you decide on rate versus rhythm control? i.e. who do you want to ablate? Highly symptomatic secondary to AF Short duration of AF Long duration of SR post DCCV Structurally normal heart Exceptions: young heart failure patients

23 Questions?

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