Management of Atrial Fibrillation in Heart Failure

Transcription

1 Disadvantages of AV Junction Ablation Persistent AFib- no AV synchrony Ongoing risk of thromboembolism Life-long dependency on pacemaker Comparison of LA Ablation vs. AVN Ablation LA Ablation AVN Ablation SAE 1-2% 1-2% 1-year efficacy 70-80% 100% Re-do rate 20-50% 1-2% EF (if RVR) QoL CHF & AF that is not adequately managed with pharmacologic therapy AVN Ablation/Pacemaker versus Left Atrial Ablation to Eliminate the AF ICD versus No ICD Factors that favor AVN ablation in CHF patients Long-lasting persistent AF LA diameter >55-60 mm LA thrombus Very elderly, frail Bradycardia indication for pacemaker Factors that favor LA ablation in CHF patients Paroxysmal AF Reasons to Implant ICD in CHF Patient With AF Cardiomyopathy preceded onset of AF History sustained VT, VF Reasons to possibly defer ICD and reevaluate after AF has been eliminated or rate-controlled AF precedes onset of CHF Borderline EF criterion for ICD: ~30-35% 17

2 CAFÉ-II Study: Randomized Study of Rate vs. Rhythm Control in Persistent AF and Heart Failure Shelton, et al, Heart 2009;95: patientswith persistent AF & HF Randomized to: Amiodarone + DCCV- 30 Rate control- 31 HR target t <80 at rest & <110 with walking 1 year f/u CAFÉ-II: Outcomes at 1 Year NSR in 66% of rhythm-control t group Successful rate control in 90% of rate-control group Significantly better outcomes with rhythm control: LV function NT-proBNP QoL Greatest improvements in patients who were in SR at 1 year Shelton, et al Heart, 2009 CAFÉ-II: QoL Over 1 Yr: Pts in SR vs Pts With Adequate Rate Control Heart Rhythm, May, 2010 RF Ablation of the AV Node Beneficial Effects of AV Junction Ablation in Patients with Atrial Fibrillation & Rapid Rate Improvement in symptoms & QOL Increase in functional capacity Increase in LV ejection fraction Decreased utilization of health-care resources 16

3 Catheter Ablation of AF in CHF: Efficacy RFCA of AF in CHF: Effect on LVEF 20% re-do rate Freedom from AF at 6 months: 71% off drugs 88% on drugs RFCA of AF in CHF: Effect on 6-Minute Walk RFCA of AF in CHF: Effect on QOL Catheter Ablation of AF in CHF: Conclusions In patients with HF and AF, RF catheter ablation of the AF results in better left ventricular function, functional capacity, andqol than AVNAbl plus biventricular i pacing. Post-Ablation Follow-Up Discharged 1 day post-ablation on usual meds and amiodarone 200 mg/day NSR at 3-month visit- amio d/c ed NYHA class I Echo- EF 40% 30-day auto-trigger monitor at 6 months- no AF Maintained on warfarin because CHADS=2 & no clear awareness of AF 15

4 ACC/AHA Practice Guidelines: Maintenance of Sinus Rhythm Heart Failure Amiodarone Dofetilide Catheter Ablation JACC, 8/06 Catheter Ablation For AF in CHF Hsu et al, NEJM, 12/04 The patient was treated with amiodarone for 6 weeks then underwent DC cardioversion, i with successful conversion to NSR. When seen 1 week later in clinic, i he was again in AF. Reportedimproved d effort tolerance for 1 st 4 days post-cardioversion. HR 75 at rest, 115/min after 1 min. stair-stepping i What Next? A. Ablation of AF B. Rate control strategy C. Ablation of AF + ICD D. Rate-control strategy + ICD 58 pts with CHF and LVEF <40% AF, persistent or permanent in 91% 78% had NSR at 1 year after RF ablation (69% in NSR off antiarrhythmic drugs) NSR associated with improved EF, LV dimensions, exercise capacity, symptoms, QOL Benefit of RFA of AF in Patients With & Without Adequate Rate Control Pre-RFA (n=29) (n=24) Catheter Ablation of AF in CHF 81 pts with AF, CHF, EF 40% Randomized: PV isolation ± ablation lines, CFAE ablation AV node ablation + BiV ICD Followed for 6 months after last procedure Weekly event monitor transmissions End points: EF, 6-min walk test, QoL Hsu et al, NEJM, 12/

5 Drug Therapy at 12 Months Drug Rhythm Control Rate Control Amiodarone 82% 7% * Sotalol 2% <1% * Beta-blocker 80% 88% * Digoxin 51% 75% * ACEI/ARB 94% 94% Aldo antagonist 47% 49% Warfarin 88% 92% ASA 34% 31% Statin 44% 46% Outcomes With Rhythm-Control vs. Rate-Control Strategies No significant differences in: Cardiovascular mortality(8%/yr) y) All-cause mortality (10%/yr) Stroke rate (~1-2%/yr) Worsening CHF (~7-8%/yr) Outcomes With Rhythm-Control vs. Rate-Control Strategies Rhythm Control Points to Consider Rate Control Hosp. in 1 st Yr 46% 39% * Hosp. for AF 14% 9% * Hosp. for Brady 6% 3% * DC Cardioversion 59% 9% * The study compared 2 strategies, not NSR vs AF Many pts in rhythm control arm had AF Some pts in rate control arm had no AF Benefits of NSR may have been negated by harmful effects of rhythm-control drugs End points such as LVEF, LV dilatation, functional capacity not examined Rhythm Control vs. Rate Control for AF in CHF Roy, et t al, l NEJM, 6/19/08 Conclusions A rhythm-control strategy does not improve outcomes compared to a rate-control strategy in pts with AF and CHF A rate-control strategy reduces the need for DCCV & hospitalization and should be considered the 1 approach for pts with AF & CHF ACC/AHA/ESC AF Practice Guidelines Fuster, et al JACC, 8/15/06 Includes heart failure 13

6 Management of AF in Patients With Heart Failure Fred Morady, MD University of Michigan Case Study: Treatment of AF in CHF 55 y/o man with persistent AF s/p MI & CABG NYHA functional class II-III on beta-blocker, dig, ACEI, aldo antagonist, t warfarin Exam- BP 110/70, HR 80, no overt CHF Electrolytes, BUN/creat, TFT WNL Nuclear stress- large scar, no ischemia, i EF0.28 Echo- LA 46 mm, EF 30% What is the most appropriate approach to therapy for this patient? A. Rhythm control strategy B. Rate control strategy C. Rhythm control strategy + ICD D. Rate-control strategy + ICD Heart Failure & Atrial Fibrillation 10-50% of pts with CHF have AF AF may be the cause of HF Even when HF is the cause of AF, the AF often aggravates the HF Reasons Rapid rate Irregular rhythm Loss of AV synchrony AF is independent d predictor ofdeath in HF Rhythm Control vs. Rate Control for AF in Heart Failure 1,376 pts with AF and CHF (CAD in 48%) Mean age 67 yr, mean EF 27% AF persistent in 68% Randomization Rhythm control: 682 Rate control: 694 Mean f/u 37 months Rhythm Control vs. Rate Control for AF in CHF Target heart rates in the rate-control arm: <80 bpm at rest <110 bpm during 6-minute walk 12