Heart Failure and Atrial Fibrillation. Stephen Wilton ACC Rockies Banff March 15, 2016
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1 Heart Failure and Atrial Fibrillation Stephen Wilton ACC Rockies Banff March 15, 2016
2 Disclosures Research funding: St. Jude Medical Consulting / Honoraria Boehringer Ingelheim Arca Biopharma
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?
4 The Heart Failure Epidemic Annual Canadian Heart Failure Deaths Heart and Stroke Foundation, 2016
5 The AF Epidemic Framingham Lloyd-Jones, Circulation, 2004
6 The AF Epidemic Miyasaka, Circulation, 2006
7 AF - Heart Failure Interaction New York Heart Association Class I II - III III-IV I II III IV Maisel, Am J Cardiol, 2003
8 HTN DM Valvular HD OSA CAD filling pressures Intracellular Ca ++ dysregulation Neurohumoral activation Atrial remodeling Structural Electrophysiologic HF Fibrosis AF Rapid rate Ventricular remodeling (response to CO) Irregular rhythm No atrial systole MR, TR
9 filling pressures Intracellular Ca ++ dysregulation Neurohumoral activation Atrial remodeling Structural Electrophysiologic HF Fibrosis AF Rapid rate Ventricular remodeling (response to CO) Irregular rhythm No atrial systole MR, TR Adapted from Anter, Circulation, 2009
10 AF - Heart Failure Interaction Framingham HF AF AF HF Santhanakrishnan, Circulation, 2016
11 We have a crisis March 14, 2016
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?
13 SR AF Kotecha, Lancet, 2014
14 Beta-blockers for AF in HF Role of dose HFrEF HFpEF Miller, Canadian Cardiovascular Congress, 2014
15 Beta-blockers for AF in HF Role of achieved heart rate HFrEF HFpEF Miller, Canadian Cardiovascular Congress, 2014
16 Role of genotype-directed β-blockade BEST Genetic substudy Aleong, JACC HF, 2013
17 AF interferes with HF therapy ICDs Daubert, JACC, 2008; Poole, NEJM, 2008
18 AF interferes with HF Therapy CRT CRT works by: Optimizing atrioventricular timing Biventricular pacing to resynchronize contraction
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
20 AF and CRT - Evidence Gap COMPANION CARE HF REVERSE MADIT CRT RAFT Euro CRT Survey* n % AF *Dickstein, EHJ, 2009
21 CRT in AF vs. Sinus Rhythm Death from any cause Mortality N = 7, % with AF F/U 33 months Wilton, Heart Rhythm, 2011
22 CRT in AF Role of AV node ablation Wilton, Heart Rhythm, 2011
23 Does CRT increase risk of AF? Evidence from RAFT Competing Risk HR: 1.20 ( ; p = 0.045) Wilton et al, unpublished
24 Impact of new AF on CRT outcomes Evidence from RAFT Wilton et al, unpublished
25 What about Digoxin? Bavishi, Int J Card, 2015
26 Digoxin - Power of Confounding Ziff, BMJ, 2015
27 Digoxin - Power of Confounding Ziff, BMJ, 2015
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?
29 Roy, NEJM, 2008 Pharmacologic Rhythm Control AF-CHF trial
30 Sinus Rhythm in follow-up (%) Why don t antiarrhythmic drugs work? Statistical arguments 80% 70% 60% 56% Rhythm Control Rate Control 62.6% Cross-over 12.2%, 29.2% 73% Cross-over 10%, 21% 66% 50% 28% 47% 40% 39% 34.6% 34% 30% 26% 20% 10% 10% 10% 8% 0% PIAF RACE AFFIRM STAF AF-CHF CAFÉ II Mean f/u 1 yr 2.3 yrs 3.5 yrs 1.2 yrs 3.1 yrs 1 yr 0%
31 Why don t antiarrhythmic drugs work? Clinical arguments Amiodarone in SCD-HeFT: NYHA 3 group Bardy, NEJM, 2005
32 Why don t antiarrhythmic drugs work? Clinical arguments Dronedarone in PALLAS (Permanent AF) Connolly, NEJM, 2011
33 What about AF ablation? Eliminate AF triggers, modify substrate Avoid long term drug toxicity Most studies include patients without heart failure Long term benefit unproven Superior to drugs for AF control
34 Change in LVEF 6 to 12 months post Wilton, Am J Cardiol, 2010
35 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: NCT / 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 Texas Cardiac Arrhythmia Institute at St. David s Medical Center, Austin, Texas, USA;; California Pacific Medical Center, San Francisco, California, USA; University of Kansas, Kansas City, USA; University of Sacred Heart, Rome, Italy; Late-breaking trials, ACC 2015, San Diego
36 AF Ablation for Heart Failure Kaplan Meier AATAC curves AF comparing Primary Endpoint success rate 70% in group 1, 34% patients in group 2 were recurrence-free with around 10% of Amio discontinuation due to side effect DiBiase, ACC 2015.
37 AF Ablation for Heart Failure AATAC AF Secondary Endpoints Over 2 years of follow-up, AF ablation group had: Fewer hospitalizations: 32% vs. 57%, p< Lower mortality: 8 vs. 18, p = DiBiase, ACC 2015.
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.
39 Ongoing Canadian Trials RAFT- Permanent AF Primary objective: To determine whether CRT will reduce allcause 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
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
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