Heart Failure and Atrial Fibrillation Stephen Wilton ACC Rockies - - PowerPoint PPT Presentation

▶
heart failure and atrial
SMART_READER_LITE
LIVE PREVIEW

Heart Failure and Atrial Fibrillation Stephen Wilton ACC Rockies - - PowerPoint PPT Presentation

Oct 04, 2023 44 likes •446 views

Heart Failure and Atrial Fibrillation Stephen Wilton ACC Rockies Banff March 15, 2016 Disclosures Research funding: St. Jude Medical Consulting / Honoraria Boehringer Ingelheim Arca Biopharma Key Points HF and AF are

slide-1
SLIDE 1

Heart Failure and Atrial Fibrillation

Stephen Wilton ACC Rockies Banff March 15, 2016

slide-2
SLIDE 2

Disclosures

  • Research funding:

– St. Jude Medical

  • Consulting / Honoraria

– Boehringer Ingelheim – Arca Biopharma

slide-3
SLIDE 3

Key Points

  • HF and AF are linked, and together are bad news
  • AF interferes with HF therapy
  • Rate or Rhythm Control for AF in patients with HF?
slide-4
SLIDE 4

The Heart Failure Epidemic

Annual Canadian Heart Failure Deaths

Heart and Stroke Foundation, 2016

slide-5
SLIDE 5

The AF Epidemic

Framingham

Lloyd-Jones, Circulation, 2004

slide-6
SLIDE 6

The AF Epidemic

Miyasaka, Circulation, 2006

slide-7
SLIDE 7

AF - Heart Failure Interaction

Maisel, Am J Cardiol, 2003

New York Heart Association Class

I II - III III-IV IV III II I

slide-8
SLIDE 8

HF AF

Fibrosis

Rapid rate Irregular rhythm No atrial systole ↑MR, TR

↑filling pressures Intracellular Ca++ dysregulation Neurohumoral activation

Structural Electrophysiologic

Ventricular remodeling

(response to↓CO)

Atrial remodeling

HTN DM Valvular HD OSA CAD

slide-9
SLIDE 9

HF AF

Fibrosis

Rapid rate Irregular rhythm No atrial systole ↑MR, TR

↑filling pressures Intracellular Ca++ dysregulation Neurohumoral activation

Structural Electrophysiologic

Ventricular remodeling

(response to↓CO)

Atrial remodeling Adapted from Anter, Circulation, 2009

slide-10
SLIDE 10

AF - Heart Failure Interaction

HF → AF AF → HF Framingham

Santhanakrishnan, Circulation, 2016

slide-11
SLIDE 11

We have a crisis

March 14, 2016

slide-12
SLIDE 12

Key Points

  • HF and AF are linked, and together are bad news
  • AF interferes with HF therapy
  • Rate or Rhythm Control for AF in patients with HF?
slide-13
SLIDE 13

SR AF

Kotecha, Lancet, 2014

slide-14
SLIDE 14

Beta-blockers for AF in HF

Miller, Canadian Cardiovascular Congress, 2014

Role of dose HFrEF HFpEF

slide-15
SLIDE 15

Beta-blockers for AF in HF

Miller, Canadian Cardiovascular Congress, 2014

Role of achieved heart rate HFrEF HFpEF

slide-16
SLIDE 16

Role of genotype-directed β-blockade

BEST Genetic substudy

Aleong, JACC HF, 2013

slide-17
SLIDE 17

AF interferes with HF therapy

Daubert, JACC, 2008; Poole, NEJM, 2008

ICDs

slide-18
SLIDE 18

AF interferes with HF Therapy

CRT

  • CRT works by:

– Optimizing atrioventricular timing – Biventricular pacing to resynchronize contraction

slide-19
SLIDE 19

AF interferes with HF therapy

Cardiac Resynchronization Therapy

  • 12-lead Holter analysis in 19 patients with AF, 9 responders
  • Only 9 had effective pacing (>90% paced)

Kamath, JACC, 2009

slide-20
SLIDE 20

AF and CRT - Evidence Gap

COMPANION CARE HF REVERSE MADIT CRT RAFT Euro CRT Survey* n 1212 412 419 1820 1798 2438 % AF 13 23

*Dickstein, EHJ, 2009

slide-21
SLIDE 21

CRT in AF vs. Sinus Rhythm

Death from any cause

Wilton, Heart Rhythm, 2011

N = 7,495 25.5% with AF F/U 33 months

Mortality

slide-22
SLIDE 22

CRT in AF

Role of AV node ablation

Wilton, Heart Rhythm, 2011

slide-23
SLIDE 23

Does CRT increase risk of AF?

Evidence from RAFT

Wilton et al, unpublished

Competing Risk HR: 1.20 (1.0-1.42; p = 0.045)

slide-24
SLIDE 24

Impact of new AF on CRT outcomes

Evidence from RAFT

Wilton et al, unpublished

slide-25
SLIDE 25

What about Digoxin?

Bavishi, Int J Card, 2015

slide-26
SLIDE 26

Digoxin - Power of Confounding

Ziff, BMJ, 2015

slide-27
SLIDE 27

Digoxin - Power of Confounding

Ziff, BMJ, 2015

slide-28
SLIDE 28

Key Points

  • HF and AF are linked, and together are bad news
  • AF interferes with HF therapy
  • Rate or Rhythm Control for AF in patients with HF?
slide-29
SLIDE 29

Pharmacologic Rhythm Control

  • AF-CHF trial

Roy, NEJM, 2008

slide-30
SLIDE 30

Why don’t antiarrhythmic drugs work?

56% 39% 62.6% 34% 73% 66% 10% 10% 34.6% 8% 26% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80%

PIAF RACE AFFIRM STAF AF-CHF CAFÉ II Rhythm Control Rate Control

28% 47%

Mean f/u 1 yr 2.3 yrs 3.5 yrs 1.2 yrs 3.1 yrs 1 yr Cross-over 12.2%, 29.2% Cross-over 10%, 21%

Statistical arguments

Sinus Rhythm in follow-up (%)

slide-31
SLIDE 31

Why don’t antiarrhythmic drugs work?

Clinical arguments Amiodarone in SCD-HeFT: NYHA 3 group

Bardy, NEJM, 2005

slide-32
SLIDE 32

Why don’t antiarrhythmic drugs work?

Clinical arguments Dronedarone in PALLAS (Permanent AF)

Connolly, NEJM, 2011

slide-33
SLIDE 33

What about AF ablation?

  • Eliminate AF

triggers, modify substrate

  • Avoid long term

drug toxicity

  • Superior to drugs

for AF control

  • Most studies

include patients without heart failure

  • Long term benefit

unproven

slide-34
SLIDE 34

Change in LVEF

6 to 12 months post

Wilton, Am J Cardiol, 2010

slide-35
SLIDE 35

’ ; ’ ; ôpit Lévêque é

Ablation vs. Amiodarone for Treatment of Atrial Fibrillation in Patients with Congestive Heart Failure and an Implanted ICD/CRTD (AATAC-AF in Heart Failure) ClinicalTrials.gov Identifier: NCT00729911/ P.I. Andrea Natale

Luigi Di Biase, Prasant Mohanty, Sanghamitra Mohanty, Pasquale Santangeli, Chintan Trivedi, Dhanunjaya Lakkireddy, Madhu Reddy,Pierre Jais, Sakis Themistoclakis, Antonio Dello Russo, Michela Casella, Gemma Pelargonio, Maria Lucia Narducci, Robert Schweikert, Petr Neuzil, Javier Sanchez, Rodney Horton, Salwa Beheiry, Richard Hongo, Steven Hao, Antonio Rossillo, Giovanni Forleo, Claudio Tondo, J. David Burkhardt, Michel Haissaguerre, Andrea Natale

Late-breaking trials, ACC 2015, San Diego

slide-36
SLIDE 36

AF Ablation for Heart Failure

DiBiase, ACC 2015.

AATAC AF – Primary Endpoint

–

70% in group 1, 34% patients in group 2 were recurrence-free with around 10% of Amio discontinuation due to side effect

slide-37
SLIDE 37

AF Ablation for Heart Failure

  • Over 2 years of follow-up, AF ablation

group had:

– Fewer hospitalizations: 32% vs. 57%, p<0.0001

  • Lower mortality:

– 8 vs. 18, p = 0.037

DiBiase, ACC 2015.

AATAC AF – Secondary Endpoints

slide-38
SLIDE 38

Ongoing Canadian Trials

RAFT-AF

  • International, Canadian-led RCT (A. Tang, G.

Wells, PIs)

  • CIHR funding for 5 years
  • Primary hypothesis:
  • Catheter ablation-based atrial fibrillation rhythm

control as compared with rate control in patients with heart failure of either impaired LV function (LVEF ≤ 45%) or preserved LV function (LVEF > 45%) will reduce all cause mortality or heart failure hospitalization.

slide-39
SLIDE 39

Ongoing Canadian Trials

RAFT- Permanent AF

  • Primary objective:
  • To determine whether CRT will reduce all-

cause mortality or hospitalization for heart failure in patients with permanent AF, mild to moderate heart failure, left ventricular systolic dysfunction, and prolonged QRS duration, when compared to implantable cardioverter defibrillator (ICD) therapy alone

slide-40
SLIDE 40

Key Points

  • HF and AF are linked, and both together is bad
  • AF interferes with HF therapy
  • Best management of AF in patients with HF is

unknown

  • Ongoing clinical studies may provide clarity