- Atrial fibrillation & HFpEF Dipak Kotecha, MD PhD FESC FHEA - - PowerPoint PPT Presentation

Dipak Kotecha, MD PhD FESC FHEA

Novel concepts and treatments of comorbidities in Heart Failure with Preserved Ejection Fraction

• Atrial fibrillation & HFpEF

Groningen HF Symposium, Vienna 2018

No conflicts of interest

• r financial disclosures.

Historical grants, personal fees and consultancy: Menarini (unrestricted research grant), AtriCure (lecture fees), Daiichi Sankyo (professional development). Funding: National Institute for Health Research - Career Development Fellowship (UK Department of Health).

Disclosures

Trends in heart failure

HF hospital admissions at Mayo Clinic (n=6076, 1987-2001)

Owan: N Engl J Med 2006; 355:251-259

Lane / Kotecha: J Am Heart Assoc. 2017;6:e005155

Incident AF in 57,818 patients in United Kingdom 1998-2010

Prevalenc valence Mortali tality ty Incidenc dence

per 1000

p<0.001 p=0.84

AF increasing rapidly and mortality high in elderly

Heart failure

AF

33-56%

Kotecha & Piccini: Eur Heart J. 2015;36:3250-3257 Chiang: Circ Arrhythm EP. 2012;5:632-639 (adapted)

Clinical heart failure Mean LVEF

RealiseAF registry: 9816 AF patients from 26 countries

High rates

• f HF in AF

Heart failure

AF

33-56% 30-41%

Santhanakrishnan: Circulation. 2016;133:484-492

Framingham Heart Study USA: New-onset AF (n=1737) or HF (n= 1166) 1980-2012

Prevalent and future AF common in HF

Kotecha & Piccini: Eur Heart J. 2015;36:3250-3257

Kotecha/Lam/Rienstra et al: JACC 2016;68:2217

Other precipitating conditions

Chicken

• r Egg?

Summary

• 1. HFpEF and AF are increasingly common, with linked pathophysiology

Meta-analysis of published studies:

Comparing AF + HFpEF vs AF + HFrEF

Kotecha et al: Int J Cardiol. 2016;214:516-7

Different types of HF affect

• utcomes

in AF

Kotecha et al: Int J Cardiol. 2016;203:660-6

? ?

Echo in AF and HF

Kotecha et al: Europace. 2017;19:1427-1438

? ?

Study (year) n Parameter Correlation with invasive filling pressure

Kusunose (2009) 56 E/e’ r = 0.57** Li (2010) 49 E/e’ E/e’ Lateral: r = 0.49* E/e’ Septal: r = 0.40* Senechal (2008) 24 E/e’ E/e’ Lateral: r = 0.47* E/e’ Septal: r = 0.46* Sohn (1999) 27 E/e’ r = 0.79*** Wada (2012) 45 E/e’ r = 0.57 *** Oyama (2004) 68 E/Vp r = 0.63** Nagueh (1996) 30 E/Vp IVRT r = 0.65*** r = -0.76*** Temporelli (1999) 35 DT IVRT r = -0.79** r = -0.95*** Matsukida (2001) 37 DT r = -0.65*** Traversi (2001) 51 DT r = -0.60*** Chirillo (1997) 35 DT r = -0.50 Diwan (2005) 13 IVRT r = -0.92**

Kotecha et al: Europace. 2017;19:1427-1438

Diastolic function in AF

Improving assessment

• f function

in AF

1 2 3 4 5 6 7 8 9 10

Coefficient of variation (%)

Index beat method: Two preceding RR intervals are similar and equivalent heart rate is <100 bpm

Bunting / Kotecha (unpublished)

n=20 Mitral E

Current guidelines still recommend standard ECG for diagnosis “Irregular RR intervals and no distinct p waves for at least 30 seconds” * New technologies mean that diagnosis in the future may be very different…

* Kirchhof, Benussi, Kotecha, et al: Eur Heart J. 2016;37:2893-2962

Novel AF detection methods

Kotecha et al: Europace 2018;20:395-407

Kotecha et al: Europace 2018;20:395-407

AFNET & EHRA Consensus Conference 2017

Guidance

• n AF

detection

Kotecha/Lam/Rienstra et al: JACC 2016;68:2217

Diagnosis

• f AF

and HFpEF

Summary

• 1. HFpEF and AF are increasingly common, with linked pathophysiology
• 2. Outcomes depend on type of HF, but diagnosis can be challenging
• 3. Novel methods of detecting AF have already arrived

Ponikowski et al: Eur Heart J 2016;37:2129-2200

Lack

• f effective

treatment

• ptions

Beta-blockers & efficacy according to LVEF

Cleland/Kotecha: Eur Heart J 2018;39:26

Beta-blockers in Heart Failure Collaborative Group

Individual patient data from n=11 double-blind, placebo-controlled randomised trials

Beta-blockers & change in LVEF

Cleland/Kotecha: Eur Heart J 2018;39:26

n=4601

Beta-blockers in Heart Failure Collaborative Group

Individual patient data from n=11 double-blind, placebo-controlled randomised trials

n=996

• 1. Aldosterone antagonists
• 2. ARNI
• 3. Anti-diabetic therapies
• 4. Implanted devices (ICD/CRT)
• 5. AF ablation
• 6. Non-pharmacology interventions

Un- answered questions in AF + HFpEF

Kotecha/Lam/Rienstra et al: JACC 2016;68:2217

AF + HFpEF treatment

• ptions

Summary

• 1. HFpEF and AF are increasingly common, with linked pathophysiology
• 2. Outcomes depend on type of HF, but diagnosis can be challenging
• 3. Novel methods of detecting AF have already arrived
• 4. Treatment trials in HFpEF have had disappointing results; prognostic

effects of AF treatment in HFpEF under evaluation

Kirchhof, Bennussi, Kotecha et al: Eur Heart J 2016:37:2893

ESC 2016 AF Guidelines

Improving management by better phenotyping

Kotecha et al: Europace 2018;20:395-407

AFNET & EHRA Consensus 2017

Improving management by better phenotyping

Re-define AF / HF and AF + HF

www.bigdata-heart.eu Eur Heart J. 2018;39:1481-95

Summary

• 1. HFpEF and AF are increasingly common, with linked pathophysiology
• 2. Outcomes depend on type of HF, but diagnosis can be challenging
• 3. Novel methods of detecting AF have already arrived
• 4. Treatment trials in HFpEF have had disappointing results; prognostic

effects of AF treatment in HFpEF under evaluation

• 5. Better phenotyping offers a new perspective and stratified

(personalised) treatment options for patients with AF + HFpEF