Treatment of atrial fibrillation in patients with advanced heart failure - Rhythm or rate control: how to decide?

Transcription

1 Treatment of atrial fibrillation in patients with advanced heart failure - Rhythm or rate control: how to decide? Uta C. Hoppe Dep. of Internal Medicine III University of Cologne No conflict of interest

2 Prevalence of AF (%) Atrial fibrillation in heart failure - Prevalence NYHA - class I II-III III-IV IV

3 Mortality (%) Mortality (%) Heart Failure: AF & All-cause Mortality (alle pts.: RRR 40%, ARR 13.4%, p<0.0001) Medical therapy Medical therapy + CRT no AF AF no AF AF Hoppe et al. Circulation 2006;114:18

4 Vicious cycle: Atrial fibrillation & Heart Failure Heart Failure - enlarges atria (increased filling pressure) - augments sympathetic nerve activity - deregultates intracellular Ca 2+ handling - progresses fibrosis promote each other Atrial fibrillation - rapid/irregular heart rate - loss of atrial contraction - mitral/tricuspid valve regurgitation

5 Atrial fibrillation Rhythm versus Rate Control - PIAF - STAF - AFFIRM (only one with mortality data) - RACE - HOT-CAFE No superiority of one strategy over another

6 Mortality (%) AFFIRM - Study n=4060; >65 years; 71% BP, 38% CAD, 65% LA dilation p= % systolic LV dysfunction Rhythm control Rate control Years Wyse et al. NEJM 2002;347:1825

7 Patients (n) Patients (n) AFFIRM - Study Rate control Torsade de piontes Rhythm control Ischemic Stroke p= ,4% Sotalol p= Warfarin 70 % >85 % Wyse et al. NEJM 2002;347:1825

8 AFFIRM-Study n=4060; >65 years; 71% BP, 38% CAD, 65% LA dilation On-treatment analysis: Survival benefit of SR Epstein et al. Circulation 2004;109:1509

9 Survival Distribution Function STAT-CHF trial Spontaneous conversion of AF to SR using Amiodarone Converters 0.6 p = Nonconverters Follow-up (months) Deedwania et al. Circulation 1998;98:2574

10 Atrial fibrillation & Heart Failure Conversion to sinus rhythm: - may be a marker of less advanced disease - may improve prognosis

11 Rhythm control vs. Rate Control for Atrial fibrillation and Heart Failure (AF-CHF) n = 1376 patients Ejection fraction 27±6 %; NYHA III/IV 31% Paroxysmal AF 31%, persistent AF 69% Mean follow-up 37 months Rhythm control (82% Amiodarone) Rate control (<80 bpm) Roy et al. N Engl J Med 2008;358:2667

12 Rhythm control vs. Rate Control for Atrial fibrillation and Heart Failure (AF-CHF) n=1376, EF 27±6 %, NYHA III/IV 31%, parox. AF 31%, persist. AF 69% Survival Rate (%) Cardiovascular Mortality 100 Rate control 80 Rhythm control p= Months of Follow-up Roy et al. N Engl J Med 2008;358:2667

13 AF-CHF trial n=1376, EF 27±6 %, NYHA III/IV 31%, parox. AF 31%, persist. AF 69% All-cause Mortality Stroke ~ 90% on Warfarin in both groups Roy et al. N Engl J Med 2008;358:2667

14 AF-CHF trial n=1376, EF 27±6 %, NYHA III/IV 31%, parox. AF 31%, persist. AF 69% All-cause Mortality Stroke Worsening Heart Failure ~ 90% on Warfarin in both groups ~ 10% cross-over from rate-control to rhythm-control due to worsening HF Roy et al. N Engl J Med 2008;358:2667

15 AF-CHF trial n=1376, EF 27±6 %, NYHA III/IV 31%, parox. AF 31%, persist. AF 69% All-cause Mortality Stroke Worsening Heart Failure Hospitalization Rhythm-control 64% Rate-control 59% P = 0.06 Roy et al. N Engl J Med 2008;358:2667

16 Patients with Atrial Fibrillation (%) AF-CHF trial n=1376, EF 27±6 %, NYHA III/IV 31%, parox. AF 31%, persist. AF 69% Prevalence of AF at each Follow-up Visit 100 Rhythm control Rate control BL 3 Wk Months Roy et al. N Engl J Med 2008;358:2667

17 Survival Rate Survival Rate AF-CHF trial n=1376, EF 27±6 %, NYHA III/IV 31%, parox. AF 31%, persist. AF 69% On-treatment analysis Cardiovascular Mortality Total Mortality 100 High prevalence sinus rhythm 100 High prevalence sinus rhythm Low prevalence sinus rhythm 50 Low prevalence sinus rhythm 25 p = p = Months of follow-up Months of follow-up Talajic et al. JACC 2010;55:1796

18 AF-CHF trial n=1376, EF 27±6 %, NYHA III/IV 31%, parox. AF 31%, persist. AF 69% Medical Therapy at 12 Months Roy et al. N Engl J Med 2008;358:2667

19 AF-CHF trial n=1376, EF 27±6 %, NYHA III/IV 31%, parox. AF 31%, persist. AF 69% Medical Therapy at 12 Months Roy et al. N Engl J Med 2008;358:2667

20 Amiodarone: Potential effect on all-cause mortality n=3029, EF <35%, carvedilol or metoprolol (COMET-Study) All-cause Mortality Torp-Pedersen et al. J Card Fail 2007;13:340

21 Amiodarone: Potential effect on all-cause mortality n=3029, EF <35%, carvedilol or metoprolol (COMET-Study) Sudden death Death due to circulatory failure Torp-Pedersen et al. J Card Fail 2007;13:340

22 AF-CHF trial n=1376, EF 27±6 %, NYHA III/IV 31%, parox. AF 31%, persist. AF 69% Rhythm control group: - Significantly lower use of beta-blockers - High percentage of amiodarone might negate potential survival benefit of sinus rhythm

23 before after 1 week 1 month 6 months before after 1 week 1 month 6 months LVEF % Peak VO 2 (ml/kg/min) Heart Failure: Cardioversion of Atrial Fibrillation Improvement of EF and Peak VO 2 in Sinus rhythm Ejection fraction max. O 2 -Uptake van Gelder et al., 1993

24 Effect of Rate vs. Rhythm control on LV function n=335, follow-up 2 years Fractional shortening (%) RACE Fractional shortening * * * * * baseline 12 months 24 months Rate Rhythm Rhythm AF at 2 years Rhythm SR at 2 years Hagens et al. Heart Rhythm 2005;2:19

25 LV EF (%) LV End-Diastolic Diameter (mm) Atrial fibrillation: Ablation in Heart Failure n=58, EF<45%, 78% Sinus rhythm after 1 year (69% no AA) Ejection fraction LVEDD p<0.001 p<0.001 p<0.001 p< p=0.001 p=0.03 p=0.02 p= Months Months Hsu et al. NEJM 2004;351:2373

26 LV Ejection Fraction (%) Atrial fibrillation: Ablation in Heart Failure Inadequate Rate control p = p < 0.01 Adequate Rate control Months Hsu et al. NEJM 2004;351:2373

27 Rate vs. Rhythm Control for Atrial fibrillation and Heart Failure (CAFÉ-II Study) n = 61 patients Systolic LV dysfunction 57% at least moderate systolic dysfunction NYHA II 80%, NYHA III 20% Persistent AF Rhythm control (82% Amiodarone) Rate control (<80 bpm) Shelton et al. Heart 2009;95:924

28 Percentage CAFÉ-II Study n=61, 57% at least moderate systolic dysfunction, NYHA II 80%, persistent AF Percentage of pts. in sinus rhythm within the rhythm control group Baseline 4 months 8 months 12 months Shelton et al. Heart 2009;95:924

29 CAFÉ-II Study n=61, 57% at least moderate systolic dysfunction, NYHA II 80%, persistent AF Change in quality of life (QoL) scores over 1 year SF-36 vii p = SF-36 vii (mental) p = SF-36 vii (physical) p = MLWHF p = Rate Rhythm QoL worse QoL better Shelton et al. Heart 2009;95:924

30 CAFÉ-II Study Change in quality of life (QoL) scores over 1 year Comparison only of those who maintained SR in the rhythm control group with those achieving adequate rate control in rate control group SF-36 vii p = SF-36 vii (mental) p = SF-36 vii (physical) MLWHF p = p = Rate Rhythm QoL worse QoL better Shelton et al. Heart 2009;95:924

31 Distance (metres) CAFÉ-II Study n=61, 57% at least moderate systolic dysfunction, NYHA II 80%, persistent AF Six-minute walk test distance 500 p = p = Rate Rhythm Log-NT-proBNP decrease Rate control Rhythm control 0 Baseline One year p = Shelton et al. Heart 2009;95:924

32 Atrial fibrillation and heart failure Rhythm or rate control: how to decide? - Anticoagulation independent of strategy - Worsening HF related to AF despite adequate rate control effort to restore/maintain SR indicated - Mild to moderate AF-related symptoms one attempt to restore/maintain SR warranted (early) given modest benefit no repeated cardioversions - No AF-related symptoms Rate control

33 Treatment of atrial fibrillation in patients with advanced heart failure - Rhythm or rate control: how to decide? Uta C. Hoppe Dep. of Internal Medicine III University of Cologne

34 AF-CHF trial n=1376, EF 27±6 %, NYHA III/IV 31%, parox. AF 31%, persist. AF 69% Cardiovascular Mortality: Cross-Over excluded Talajic et al. JACC 2010;55:1796

35 Anteil % Asymptomatisches Vorhofflimmer-Rezidiv n=110; follow-up 19 Mo.; SM-Impl.; Z.n. AFli; optimale AA-Therapie % 80 42% % 38% nach >3 Mo 20 16% 0 AF im EKG AF im SM AF >48h asympt. AF >48h asympt. Israel et al. JACC 2004;43:47

36 AFFIRM - Studie jüngere Patienten Alter <65 J (n=969) >65 J (n=3091) Hazard Ratio Alle (n=4060) Rhythmus-Kontrolle besser Frequenz-Kontrolle besser Wyse et al. NEJM 2002;347:1825

37 Atrial Fibrillation and Congestive Heart Failure AF-CHF Studie % Patienten p= % 25.2% 31.8% 32.9% Rhythmus-Kontrolle Frequenz-Kontrolle 27.6% 30.8% Kardiovaskulärer Tod (prim. EP) Gesamt- Sterblichkeit p=ns 2.6% 3.6% Schlaganfall CHF- Verschlechterung n=1.376; EF 35%, mean follow-up 37 Mo Roy et al. N Engl J Med 2008;358:2667

38 FAZIT Rhythmus- vs. Frequenzkontrolle Sinusrhythmus anstreben bei: - jüngeren hochsymptomatischen Patienten - Patienten mit Herzinsuffizienz bei älteren oligosymptomatischen Patienten: - Rhythmus- & Frequenzkontrolle vergleichbar

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