Rate Control versus Rhythm Control in NSTEMI

Transcription

1 Rate Control versus Rhythm Control in NSTEMI Gulmira Kudaiberdieva, MD, FESC Adana, Turkey Conflict of interest: None to declare Istanbul

2 OUTLINE Significance of AF in ACS Prognostic value of AF in NSTEMI Rate vs rhythm control in AF Rate vs rhythm control in ACS/NSTEMI ESC AF 2010 guideline`s recommendations

3 Significance of AF in ACS AF is a frequently encountered arrhythmia in the setting of ACS Population-based studies demonstrated that the incidence of AF in the setting of AMI and ACS tended to increase up to 13.3% during last decade Incidence of AF in the setting of NSTE-ACS varies between 6.2 and 7.9% and it has a worse impact on the clinical course and prognosis of the disease Appropriate treatment strategies of AF in the setting of ACS might modify its unfavorable impact on prognosis

4 Atrial Fibrillation in NSTEMI RCT/META-ANALYSIS REGISTRY/SURVEY PURSUIT Gusto IIB IMPACT II PARAGON Meta-analysis (Lopes et al. Heart 2008) GRACE registry RICO PRAXIS ACACIA FAST-MI

5 Study PROGNOSTIC SIGNIFICANCE OF AF IN NSTEMI Study type/ Population AF End-point Outcome GRACE (Am J Cardiol 2003;92: ) Registry ACS pts New -6.2% Prior-7.9% In-hospital Death OR 1.65 ( ) - PURSUIT - (Am J Cardiol 2001; 88: 76-9.) RCT 9432 pts, NSTEMI New 6.4% Death 30-d 6-m HR 7.01 ( ) HR 4.46 ( ) Lopez et al (Heart 2008) Meta-analysis (PURSUIT, PARAGON, Gusto II B, SYNERGY) NSTE-ACS pts Any AF 6.4% <7-d 1-year - HR 1.67 ( ) ACACIA Lau et al. (Am J Cardiol 2009;104: ) Registry STEMI HR NSTE ACS 1942 IR NSTE-ACS -696 New AF 6.5% 4.6% 1.6% 1-year Comp: death, MI, stroke HR 1.1 ( ) HR 2.0 ( ) HR 3.9 ( ) RICO (Heart 2005;91:369-70) Survey, prospective NSTEMI 504 pts AF<24h In hospital Death/VA OR 2.2, p<0.001 PRAXIS (Am J Cardiol 2012;110: ) ACS 2335 pts Prev known AF: Perm pers- parox New-onset: Admission In-hospital 6.4% 2.3% 2.3% 7.88% 10-year Mortality 78% 69% 68% 53.2

6 Adj ORs for in-hospital events in ACS pts with new onset and prior AF GRACE Registry (Am J Cardiol 2003;92: )

7 Survival of patients with NSTEMI and AF PURSUIT RCT (Am J Cardiol 2001; 88: 76-9)

8 Type of ACS and 1-year outcome of patients with new onset AF (Am J Cardiol 2009;104: )

9 Multivariate predictors of new-onset AF in ACS GRACE registry (Am J Cardiol 2003;92:1031 6) - Older age (per 10-year increase, OR 1.58 (1.49 to 1.67) - Female gender OR 1.24 (1.07 to 1.45) - STEMI OR 2.08 (1.74 to 2.49) - NSTEMI OR 1.85 (1.55 to 2.22) - HT OR 1.34 (1.17 to 1.53) - HR per 30 beats/min increase, OR 1.65 (1.53 to 1.79) - BP per 20 mm Hg decrease OR 1.16 (1.12 to 1.21) - Cardiac arrest on presentation OR 1.65 (1.17 to 2.34) - Killip class II or higher OR 1.36 (CI 1.17 to 1.57) -Initial serum creatinine OR 1.07 (1.01 to 1.15)

10 RCTs rate vs. rhythm control in AF Study Patients Rate Rhythm End-points/ follow-up RACE (NEJM 2002: 347; ) AFFIRM (NEJM 2002: 347; ) STAF (JACC 2003; 41:1690 6) 522pts Persistent AF <1 y History AF recurrence after of at least 1 ECV 4060 pts With 1RF for stroke or death Recurrent AF 200 pts High-risk AF recurrence: AF>4 weeks and <2 years, LAD>45mm, LVEF<45%, NYHA>II, >1 ECV and AF recurrence 256 pts Digitalis, BBl, CCB, comb, AVN abl.+pace +anticoag Bbl, CCB, digoxin, comb 100 BBl, digitalis, CCB, AVN abl/mod with or w/o PM 266 pts ECV+sotalol/ flecainide/propafeno ne/amiodarone + anticoagulation (b.a. 4 weeks, aspirin) 2033 ECV, amiodarone, disopyramide, flecainide, moricizine, procainamide, propafenone, quinidine, sotalol, comb. 100 No CAD, no LVD ECV +class 1 AAD/ sotalol CAD or LVD ECV+amiodarone CEP CV death HF Thromboemb. events Bleeding Pacemaker Adverse effects 24 mo Primary mortality CEP- death, stroke, bleeding, cardiac arrest 5y Primary - CEP: death, stroke/ TIA, CPR, syst.embolism Sec. bleeding, QoL, echo, HR, SRm 3y Outcome 17.22% vs 22.6% -5.4 (-11.0 to 0.4) Women 10.5% vs 32% (-30.8 to -12.1) HT 17.3% vs 30.8% (-22.2 to -4.9) SRm - 39% RhythmC Death adj HR 1.18 (0.99 to 1.41, p=0.07). CHF. CAD, >65y risk death with RhythmC Adv.E: Pulm, Qtprol, Tdp, brady with RhythmC Hosp. 73% vs 80.1%, p<0.001 CEP- 5.54%/y vs 6.09%/y, p=0.99 Hosp: 54 vs 24, p<0.001 SRm 23% vs 0%

11 Study Pts Rate Rhythm End-points/ follow-up Outcome PIAF (Lancet 2000; 356: ) 252 pts Symptomatic, persistent AF>7d and <360d 125 Diltiazem 127 ECV amiodarone Primary: symptom impr Secondary: HR, Srm, Ex.toler, QoL, Hosp. Follow-up: 1y Symtpoms impr- NS SRm -56% vs 10%, p<0.001 Ex.toler. with RhythmC Hosp. 69%vs 24%,p=0.001 Adv. E 14%vs 25%, p<0.05 HOT CAFE (Chest 2004; 126:476 86) 205 pts 1st persistent AF episode, required ECV, duration >7 d and <2 y 101 pts 24-h Holter ECG BBl, CCB, digoxin or comb, ECV and AVN abl. with PM 104 pts ECV stepwise AADs - disopyramide, propafenone, sotalol, and amiodarone Primary: CEP death, Thromboembolic ev. (ischemic stroke) and major bleeding Sec. EP: HRm, SRm, Ex. toler, Hosp., proarrhythmia, CHF, hemorrhage Mean follow-up 1.7y CEP: 1.98 (0.28 to 22.3). Secondary: SRm 63.5% Hospit. 8 vs 32, p<0.05 Ex. toler., FS in RhythmC CAFÉ II (Heart 2009: 95; pts HF and persistent AF (mean 14m) 31pts guidelines 30 pts Guidelines Amiodarone 3m prior ECV and after, BBL or digoxin Symtpoms, NYHA, 6MWT, QoL, LVF, NT-proBNP, Follow-up 1y NYHA, 6MWT NS LVF and QoL and NT-proBNP with Rhythm C SRm 66%, HRm- 90% AF-CHF (NEJM 2008; 357; ) 1376 pts LVEF<35%, or NYHA II-IV CHF, parox or persist AF 694 pts Bbl, digoxin, AVNabl PM 682 pts ECV, amiodarone, sotalol, dofetilide Primary: CV death Secondary: any death, stroke, HF worsen CEP: CV death, stroke, HF worsen Follow-up 12 mo (up 74mo) CV death Adj HR1.05 ( ) Secondary and CEP - NS J-RHYTHM (Circ J 2009: ) 823 pts Paroxysmal AF 404 Bbl, CCB, digoxin 423 Guideline treatment Primary: CEP- mortality, cerebral infarct, bleed, hosp,, HF, syst. emb, disability Sec: QoL, effic, safety AADs Follow-up 578d Event free survival RhythmC HR ( ) Rhythm C better in >65y, male, HT, no history CHF, QoL

12 META- ANALYSIS 5 RCTS AFFIRM, RACE, STAF, PIAF, HOT-CAFÉ 5239 pts with persistent AF or at high-risk for AF recurrence End-points: - all-cause mortality - Stroke Rate C with antic. is equivalent to RhythmC in terms of all-cause mortality and ischemic stroke, RhythmC may be favorable in selected patients (De Denus et al Arch Intern Med. 2005) A) Odds ratios for all-cause mortality B) Odds ratios for ischemic stroke

13 META- ANALYSIS 5 RCTS AFFIRM, RACE, STAF, PIAF, HOT-CAFÉ 5239 pts with persistent AF or at highrisk for AF recurrence Follow-up: years End-points: - CEP all cause death and thromboembolic stroke - Major bleeding - NS - Systemic emboli NS Rate C strategy is associated with significant reduction of CEP (all-cause death and thromboembolic events) as compared with RhythmC strategy, especially in older population with persistent AF or at high risk for AF reoccurrence and longer follow-up (Testa et al. Eur Heart J, 2005) A) Odds Ratios for CEP Rate C vs RhythmC groups B) Odds ratios for CEP in subgroups of pts 65y C) Odds ratios for CEP in subgroups of pts 65y and >20mo follow-up

14 Rate vs Rhythm control in pts with HF and AF Meta-analysis AF in CHF Meta-analysis 2012 updated 2425 pts in 3 RCT AFFIRM, RACE, AF-CHF Hospitalizations: due to AF and bradyarrhythmias 9% vs 14%, p=0.001 and 3% vs 6%, p=0.02 (Caldeira et al. Eur J Int Med 2011: 22; ) 8 RCTs- STAF, PIAF, HOT-CAFÉ, AFFIRM, RACE, CAFÉ II, CHF-AF, J-RHYTHM 7499 pts Follow-up: y End-points: all-cause mortality, CV mortality, arrhythmic/scd mortality, ischemic stroke, systemic embolism, major bleeding No significant difference between both arms RateC and RhythmC in all analyzed end-points Subgroup analysis: RCTs >50% pts with HF 5 RCTs STAF, AFFIRM, CAFÉ-II, CHF-AF, RACE HOT-CAFÉ Systemic embolism : 0.43 [ ] in favor of Rate C strategy

15 RATE Control versus RHYTHM Control in NSTEMI - There are no clinical trials on comparison of rate and rhythm control strategies in pts with ACS - There are few retrospective analyses of rhythm and rate control therapies in ACS

16 Beta-blockers and AF in ACS CAPRICORN 1959 pts, 3-21 d post-mi with LVD 984 pts - placebo 975 pts carvedilol Outcome: atrial or ventricular arrhythmias Follow-up average 1.3 y Any AF -22/975 (2.3%) vs 53/984 (5.4%) HR 0.41 ( ), p= New AF 16/894 (1.8%) vs 31/895 (3.5%) HR 0.51 ( ), p=0.02 (JACC 2005: 45; ) Survival free of atrial fibrillation

17 Rhythm Control in ACS STEMI- GUSTO 30-day mortality III study analysis Unadjusted (Heart 2002;88: ) Adjusted for baseline characteristics* Adjusted for baseline characteristics and pre-af complications** Amiodarone 1.23 (0.81 to 1.87) 1.21 (0.77 to 1.90) 1.08 (0.68 to 1.74) DCC 1.22 (0.75 to 2.01) 1.24 (0.73 to 2.10) 1.16 (0.66 to 2.03) 1-year mortality Amiodarone 1.12 (0.78 to 1.63) 1.14 (0.75 to 1.73) 1.03 (0.67 to 1.57) DCC 1.24 (0.81 to 1.91) 1.33 (0.82 to 2.16) 1.27 (0.78 to 2.09) *Adjusted for grouping of atrial fibrillation (AF) including paroxysmal AF, chronic AF, and no previous AF; pulse rate; systolic blood pressure; age; history of myocardial infarction; angina; percutaneous transluminal coronary angioplasty; Killip class; and smoking class (previous, current, never). **In addition to the above demographics, adjusted for significant pre-af complications including worsening heart failure, shock, acute ventricular septal, defect, and stroke.

18 RHYTHM VS RATE CONTROL IN ACS STEMI and LVD/HF VALIANT (Heart 2010: 96; ) -Retrospective analysis pts post-mi with LVD/HF -760 pts Rate C BBL 84.7%, digoxin 43.8% -371 pts RhythmC amiodarone 87.3% and other AADs 14.8% -End-points: mortality and stroke days and days -Stroke NS -Mortality 0-45d 12.4% vs 6.1% Adj HR 1.9 ( ), p= Mortality d 30.9% vs 29.0% -Adj HR 1.1 ( ), p> % of death in pts on amiodarone

19 ESC Guidelines 2010 on the management of AF

20 ESC Guidelines 2010 on the management of AF

21 ESC AF GUIDELINES 2012 UPDATE Updates on RATE and RHYTHM CONTROL Vernakalant contraindication for patients with ACS Dronedarone Catheter ablation

22 CONCLUSIONS Current evidence for treatment of AF in ACS is based on retrospective analyses of trials in patients with ACS Acute management of arrhythmia -ESC guideline recommendation - special populations AF in ACS Treatment of underlying disease, ischemia and comorbidities Proper antithrombotic therapy Upstream therapy After stabilization choice of rate or rhythm control strategy should be done as recommended for patients with CAD based on presence of symptoms, special considerations, safety and efficacy of AADs, benefit of each strategy There is a need for prospective clinical trials on rhythm and rate control management of AF in patients with NSTEMI/ACS