Gianluca Botto MD, FESC, FEHRA Electrophysiology Unit Sant Anna Hospital Como, Italy Antiarrhythmic drugs in AF Still a challenge When And How To Apply Rate Control Therapy
AFIB ESC/EACTS/EHRA GLs 2016 AFFIRM AF-CHF RACE II PALLAS Metanalysis BB in HFCG
Antiarrhythmic drugs in AF Still a challenge When and How To Apply Rate Control Therapy
AFIB ESC/EACTS/EHRA GLs 2016 Drugs for Rate Control in AF
AFIB ESC/EACTS/EHRA GLs 2016 Reccomendations for Rate Control
Targets of Rate Control The optimal HR target in AF pts is unclear Lienent rate-control is an acceptable initial approach, regardless of HF status, unless symptoms call for strict rate-control Restoration of SR is no longer the treatment objective for every pt presenting with AF
Atrial Fibrillation Definitions of Ventricular Rate Control in RCTs Study Resting rate Exercise rate (beats/min) (beats/min) AFFIRM <80 <110, with 6-min walk RACE <100 Not specified PIAF Not specified Not specified STAF Not specified Not specified AIRCRAFT <80 <150 at peak exercise PAF2 70, lower rate limit 130, upper rate limit RACE II < 110 NA Wood MA. Heart Rhythm 2004 (modif)
AFIB ESC/EHRA Guidelines 2010/16 Lienent HR <110 rest Lower (60-100) for HF pts* * 2016 GL-TF opinion Eur Heart J 2010: 31, 2369-2429 Strict HR <80 bpm rest HR <110 exercise
AF Rate-Control Across the Atlantic
Van Gelder IC. NEJM 2010 Primary outcome: composite of CV death, hospitalization for HF, and stroke, systemic embolism, bleeding, and life-threatening AEs
Symptoms of AF by Strategy Percentage of Pts with any Symptom: Data From the RACE II Stringency of HR control does NOT influence QoL Groenveld HF. JACC 2011; 58: 1795-803
Symptoms of AF by Strategy Data From the RACE II - Successful RC does NOT improve outcome - Lienent RC might be frontline therapy Groenveld HF. JACC 2013; 601: 741-8
AFIB ESC/EACTS/EHRA GLs 2016 Reccomendations for Rate Control
Antiarrhythmic drugs in AF Still a challenge When and How To Apply Rate Control Therapy
Permanent Atrial Fibrillation 24-hour Holter Monitoring Female, 72 y.o. No Drugs EHRA 2-3 Avg HR 101 bpm 80 157 65 Female 79 y.o. No Drugs EHRA 2 Avg HR 73 bpm 80 119 42
Acceptance of Rate Control As Default Strategy Pts who are truly asymptomatic in AF Pts who have adapted their lifestyle to became asymptomatic in AF Pts who do not realize (until cardioverted) that they have (had) AF-related symptoms Pts for whom the risk of rhythm control strategy outweight the apparent benefit of SR
AFFIRM Atrial Fibrillation Follow-up Investigation of Rhythm Management Subgroup Analysis Mortality from Any Cause N Engl J Med 2002; 347: 1825 Rhythm Control Better Rate Control Better
HR for rhythm vs rate (95% CI) Long-Term Rhythm Control May Lead to Lower Mortality Than Rate Control 1.4 Lower mortality with rate control 26.130 pts >66ys fquebec hosp with AF diagnosis from 99 to 07 who did not have AFrelated drug prescriptions in the year before the admission 1.2 1.0 0.8 0.6 Lower mortality with rhythm control No difference Treatment initiation 1 2 3 4 5 6 7 8 Years since initiation of AF treatment Ionescu-Ittu R. Arch Intern Med. 2012; 172: 997-1004.
Van Gelder IC. AHJ 2006 Van Gelder IC. NEJM 2010
Strict RC was no different compared to lienent strategy However, actual HR in both groups were similar Thus the trial was not that lienent Few pts had HR >100 bpm
Adequacy of RC hardly differed b/ween asympt e sympt pts AF-related symptoms reflect a suffering for AF per-se
Rate Control in AF Gaps in Evidence Areas such as rate-control are in dire need of better studies to underpin future GLs Need for studies comparing rate-control agents (RATE-AF) - potential benefit of different agents - adverse event profile of specific drugs in specific group of pts Role of catheter ablation - more data in adequately powered trials
Rate Control in AF Conclusion R-C strategy is widely utilized - really the best or maybe just easier? R-C optimization needs a taylored treatment by a very resolute and forbearing physician Many pts with apparently adequate RC still have significant symptoms and reduced QoL AF-ablation has a marginal role in pts with persistent/permanent AF but (because) better RCTs are needed
Rate Control in AF The Facts It is relatively easy to achieve in the elderly who commonly have reduced AV conduction It is often difficult to achieve w/out side effects in younger patients Many pts with apperently good rate control still have significant symptoms
Satisfaction with Treatment (%) Satisfaction With AF Treatments AF-AWARE Study 100 90 80 70 60 50 40 30 20 10 0 Overall Treatment For AF Medication for Rate Control Medication for Rhythm Control All P Value < 0.01 Medication for Anti- Thrombotic Treatment Patients Physicians Aliot E. Europace 2010; 12: 626-633