Atrial Fibrillation and Congestive Heart Failure:
the chicken or egg story
Luc DE ROY
The 30 most important diagnoses
pathology
ICD
-9-CM
Number of
admissions
%
admissions
mean
duration
(days)
4 Chronic IHD 4...
 Affects after the 40th year of life 26% of
men and 23% of all women
 Increases the risk for TIA/ CVA – HR: 3,9
 Causes...
AF begets HF and HF begets AFAF begets HF and HF begets AF
Fibrose met reentry ?
AF ontstaat bij een
belangrijke patiëntengroep
in de longvenen
Getriggerd ?
(bayes de luna ? – no - from Maurits Alessie)
(Wijffels, Alessie, Circulation 1995)
Atrial Fibrillation and congestive heart failure :
survival (cardiac death) according to treatment
adapted from Flaker, SP...
Klasse Ic Antiarrhythmic agents
AF + RBBB + LBBB
VT ?
Sinus
• What is known on the relationship of AF
and HF ?
• Is AF a marker of mortality ?
• What about the timing of onset of AF ?
1. Is upstream therapy useful ?
2.Should we aim for sinus rhythm
(i.e. drugs, cardioversion, ablation) ?
3. Should we use ...
Prognostic significance of AFPrognostic significance of AF
COMET: N= 3029 pts (20% with AF)
New Onset AF:New Onset AF: (mu...
EHS-HFEHS-HF
In-hospital mortality
7%7% 7%7% 12 %12 % 13 %13 %
P < 0.001P < 0.001 P < 0.001P < 0.001
No AF Previous AF New...
EHS-HF
No AF
(n=419)
Previous AF
(n=249)
New-onset AF
(n=123)
P-value
Worsening HF
Pulmonary oedema
Stroke
Other cardiovas...
Smit et al, Eur J HF 2012
Timing of AF in relation to HF
•AF patients developing HF seem to
have a better prognosis than HF
patients developing AF
•...
Upstream Therapy
• Renin-angiotensin-aldosterone
modulators
• Omega-3 fatty acids
• Statins
• Retrospective data better th...
Li D, Nattel et al. Circulation 2001
Control
5 Weeks
5 Weeks
+Enalapril
ACE inhibition reducesACE inhibition reduces
atria...
Amiodarone plus angiotensine I receptor blockers
maintain sinus rhythm
Madrid et al, 2002
dr
an
thy
hy
On
pr
ga
de
M
Th
th...
16-10-2001
ACE inhibitors and ARB`s
Savelieva I et al. Europace 2011;13:308-328
16-10-2001
Efficacy of statins in prevention of atrial fibrillation
Savelieva I et al. Europace 2011;13:308-328
16-10-2001
Upstream therapy after PVI in retrospective studies.
Savelieva I et al. Europace 2011;13:308-328
Maintaining sinus rhythm in CHF
• Why ?
• Drugs
• Cardioversion
• Ablation
DIAMONDDIAMOND
Pedersen et al. Circulation 2001;104:292
• 506 pts with LV dysfunction
• Randomized to Dofetilide or Placeb...
AFFIRMAFFIRM
JACC 2005;46:1891 / NEJM 2002;347:1825
- SR improves survival
- AAD increase (non-cardiac)
mortality
- SR imp...
Cardioversion and CHF
• Traditionally delayed, unless
• Tachycardiomyopathy or emergent
restoration of sinus rhythm necess...
Recent
onset
ESC guidelines 2012
CLINICAL RESEARCH
Cardioversion for Atrial Fibrillation
Clinical correlates of immediate success
and outcome at 1-year fol...
CCV ECV
Transient ischaemic attack 13 (1.3) 2 (0.3)
Non-haemorrhagic stroke 1 (0.1) 2 (0.3)
Pisters et al, Europace 2012
CCV ECV
Success 71% (IV) 88%
Complications 64/643 38/712
Transient ischaemic attack 13(1.3%) 2(0.3%)
Non-haemorrhagic stro...
Markers of high risk: all related to CHF
• Thrombi in LA / LAA
• Spontaneous echo contrast
• Flow velocity profile in the ...
Indications for TEE
• Problematic anticoagulation
• Valvular disease
• LVD
• Prior stroke
• Enlarged LA (> 5cm)
• All new ...
PVI ablation and CHF
• Normal anatomy ?
• Tachycardiomyopathy ?
• few data available…
Paroxysmal Persistent Permanent
ESC guidelines 2012
Endpoints: Ablation
success, LV function,
QOL, functional class
PV isolation & roof & PV-
MV lines. AADs
discontinued.
58 ...
Management of AF in HFManagement of AF in HF
NEJM 2004:351
• 58 pts
• HF and LVEF <45%
• FU= 12±7 m
• SR in 69 % at 12 mon...
Anselmino M et al; JCE 2013
Ablation in left ventricular dysfunctionAblation in left ventricular dysfunction
CRT and AF
• AF patients were excluded from
the first studies
• new data available…
CRT and AF
• Assess % BV pacing
• Ablation of the AV node…
• new data available…
Figure 3
Effect of AV nodal ablation in patients with IHD versus DCM and a BV ICD
Sohinki et al, Eurpace 2013, in press
• Upstream therapy with ACE inhibitors
might be useful
• Cardioversion carries a higher risk for
emboli than is generally ...
Conclusions
treat both conditions,
and as early as possible
Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)
Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)
Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)
Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)
Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)
Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)
Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)
Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)
Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)
Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)
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Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)

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  • Efficacy of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in prevention of atrial fibrillation compared with placebo, no treatment, or alternative drug therapies in five meta-analyses (point estimate 95% confidence interval). Note that several studies have not been included in these meta-analyses. CHF, congestive heart failure; HTN, hypertension; MI, myocardial infarction. Asterisk indicates post-cardioversion studies; dagger indicates medical therapy studies. See the text for details.
  • Efficacy of statins in prevention of atrial fibrillation compared with placebo, no treatment, or altenative drug therapies in five meta-analyses (point estimate ±95% confidence intervals). HTG, hypothesis-testing studies; HTS, hypothesis-testing studies; OS, observational studies; RCTs, randomized controlled studies. See the text for details. Updated from Savelieva et al.94
  • The effects of therapy with renin-angiotensin system inhibitors and statins on the recurrence of atrial fibrillation after pulmonary vein ablation in retrospective studies. ACEI, angiotensin converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin receptor blocker.
  • Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)

    1. 1. Atrial Fibrillation and Congestive Heart Failure: the chicken or egg story Luc DE ROY
    2. 2. The 30 most important diagnoses pathology ICD -9-CM Number of admissions % admissions mean duration (days) 4 Chronic IHD 414 21996 1,35 9,2 12 Arrhythmias 427 17129 1,05 10,5 14 Angina pectoris 413 16798 1,03 8,2 16 AMI 40 15881 0,98 13 17 CHF 428 15869 0,98 18,8
    3. 3.  Affects after the 40th year of life 26% of men and 23% of all women  Increases the risk for TIA/ CVA – HR: 3,9  Causes myocardial dysfunction  Worsens heart failure Atrial fibrillation
    4. 4. AF begets HF and HF begets AFAF begets HF and HF begets AF
    5. 5. Fibrose met reentry ?
    6. 6. AF ontstaat bij een belangrijke patiëntengroep in de longvenen Getriggerd ?
    7. 7. (bayes de luna ? – no - from Maurits Alessie)
    8. 8. (Wijffels, Alessie, Circulation 1995)
    9. 9. Atrial Fibrillation and congestive heart failure : survival (cardiac death) according to treatment adapted from Flaker, SPAF study 1992 0 90 180 270 360 450 540 630 720 Time in SPAF (days) 0 20 40 60 80 100 % Def CHF, on AAD Def CHF, off AAD
    10. 10. Klasse Ic Antiarrhythmic agents AF + RBBB + LBBB VT ? Sinus
    11. 11. • What is known on the relationship of AF and HF ? • Is AF a marker of mortality ? • What about the timing of onset of AF ?
    12. 12. 1. Is upstream therapy useful ? 2.Should we aim for sinus rhythm (i.e. drugs, cardioversion, ablation) ? 3. Should we use CRT ?
    13. 13. Prognostic significance of AFPrognostic significance of AF COMET: N= 3029 pts (20% with AF) New Onset AF:New Onset AF: (multivariate) RR=1.90(multivariate) RR=1.90 Eur Heart J 2005;26:1303 c Stopped prior to study start. Figure 1 All-cause mortality by baseline atrial fibrillat ion.
    14. 14. EHS-HFEHS-HF In-hospital mortality 7%7% 7%7% 12 %12 % 13 %13 % P < 0.001P < 0.001 P < 0.001P < 0.001 No AF Previous AF New onset AF 13 %13 % 19 %19 % Rivero-Ayerza et al. Eur Heart J, 2008 EuroHeart Failure - MortalityEuroHeart Failure - Mortality In-hospital mortality 12 week mortality
    15. 15. EHS-HF No AF (n=419) Previous AF (n=249) New-onset AF (n=123) P-value Worsening HF Pulmonary oedema Stroke Other cardiovasc. Non-cardiovascular 141 (34%) 99 (24%) 17 (4%) 79 (19%) 71 (17%) 71 (29%) 58 (23%) 27 (11%) 35 (14%) 40 (16%) 42 (34%) 34 (28%) 8 (7%) 27 (22%) 25 (20%) 0.551 0.794 0.014 0.298 0.768 Mode of Death ?Mode of Death ? Rivero-Ayerza et al. Eur Heart J, 2008
    16. 16. Smit et al, Eur J HF 2012
    17. 17. Timing of AF in relation to HF •AF patients developing HF seem to have a better prognosis than HF patients developing AF •Development of AF in patients with HF may be a sign of worsening HF
    18. 18. Upstream Therapy • Renin-angiotensin-aldosterone modulators • Omega-3 fatty acids • Statins • Retrospective data better than prospective …
    19. 19. Li D, Nattel et al. Circulation 2001 Control 5 Weeks 5 Weeks +Enalapril ACE inhibition reducesACE inhibition reduces atrial fibrosis in a heart failure modelatrial fibrosis in a heart failure model
    20. 20. Amiodarone plus angiotensine I receptor blockers maintain sinus rhythm Madrid et al, 2002 dr an thy hy On pr ga de M Th tha lon hig aro pa Figure2. Kaplan-Meier estimates of the percentage of patients remaining free from recurrence of atrial fibrillation. Time to first ECG-documented recurrence of atrial fibrillation since random- ization. Days of follow-up (days), timed after cardioversion. Madrid et al
    21. 21. 16-10-2001 ACE inhibitors and ARB`s Savelieva I et al. Europace 2011;13:308-328
    22. 22. 16-10-2001 Efficacy of statins in prevention of atrial fibrillation Savelieva I et al. Europace 2011;13:308-328
    23. 23. 16-10-2001 Upstream therapy after PVI in retrospective studies. Savelieva I et al. Europace 2011;13:308-328
    24. 24. Maintaining sinus rhythm in CHF • Why ? • Drugs • Cardioversion • Ablation
    25. 25. DIAMONDDIAMOND Pedersen et al. Circulation 2001;104:292 • 506 pts with LV dysfunction • Randomized to Dofetilide or Placebo • No effect on mortality • Effect of SR on mortality RR 0.44 (0.30-0.64) Survival according to Rx Survival according to rhythm
    26. 26. AFFIRMAFFIRM JACC 2005;46:1891 / NEJM 2002;347:1825 - SR improves survival - AAD increase (non-cardiac) mortality - SR improved functional class
    27. 27. Cardioversion and CHF • Traditionally delayed, unless • Tachycardiomyopathy or emergent restoration of sinus rhythm necessary • few data available…
    28. 28. Recent onset ESC guidelines 2012
    29. 29. CLINICAL RESEARCH Cardioversion for Atrial Fibrillation Clinical correlates of immediate success and outcome at 1-year follow-up of real-world cardioversion of atrial fibrillation: the Euro Heart Survey Ron Pisters1,2*, Robby Nieuwlaat 3, Martin H. Prins4, Jean-Yves Le Heuzey5, Aldo P. Maggioni6, A. John Camm 7, and Harry J.G.M. Crijns1,2 for the Euro Heart Survey Investigators 1 Department of Cardiology, Maastricht University Medical Centre, The Netherlands; 2 Cardiovacular Research Institute Maastricht, Maastricht, The Netherlands; 3 Department of Cardiology, Population Health Research Institute, Hamilton, Canada; 4 Department of Clinical Epidemiology, Maastricht University Medical Centre, The Netherlands; 5 Department of Cardiology, Georges Pompidou Hospital, Rene´ Descartes University, Paris, France; 6 ANMCO Research Centre, Florence, Italy; and 7 Division of Clinical Sciences, St George’s University, London, UK Received 17 October 2011; accepted after revision 1 December 2011; online publish-ahead-of-print 5 January 2012 A im s In atrial fibrillation (AF) cardioversion is the cornerstone of the rhythm management strategy despite the lack of contemporary dataon acute and long-term success. We aim to describe present-day cardioversion of AFand identify Europace (2012) 14, 666–674 doi:10.1093/europace/eur406 http://europace.oxfordDownloadedfrom
    30. 30. CCV ECV Transient ischaemic attack 13 (1.3) 2 (0.3) Non-haemorrhagic stroke 1 (0.1) 2 (0.3) Pisters et al, Europace 2012
    31. 31. CCV ECV Success 71% (IV) 88% Complications 64/643 38/712 Transient ischaemic attack 13(1.3%) 2(0.3%) Non-haemorrhagic stroke 1(0.1%) 2(0.3%) Pisters et al, Europace 2012
    32. 32. Markers of high risk: all related to CHF • Thrombi in LA / LAA • Spontaneous echo contrast • Flow velocity profile in the LAA • Low LA emptying velocity • Dilatation above 6 sq cm
    33. 33. Indications for TEE • Problematic anticoagulation • Valvular disease • LVD • Prior stroke • Enlarged LA (> 5cm) • All new cases (duration < 1 month)
    34. 34. PVI ablation and CHF • Normal anatomy ? • Tachycardiomyopathy ? • few data available…
    35. 35. Paroxysmal Persistent Permanent
    36. 36. ESC guidelines 2012
    37. 37. Endpoints: Ablation success, LV function, QOL, functional class PV isolation & roof & PV- MV lines. AADs discontinued. 58 pts NYHA Class ≥ II, LVEF < 45% referred for ablation 58 controls matched for age, sex, & AF class Hsu et al; NEJM 2004;351:2373-2383
    38. 38. Management of AF in HFManagement of AF in HF NEJM 2004:351 • 58 pts • HF and LVEF <45% • FU= 12±7 m • SR in 69 % at 12 months • LVEF improved 21±13 % • Improved exercise capacity, symptoms, and QOL
    39. 39. Anselmino M et al; JCE 2013 Ablation in left ventricular dysfunctionAblation in left ventricular dysfunction
    40. 40. CRT and AF • AF patients were excluded from the first studies • new data available…
    41. 41. CRT and AF • Assess % BV pacing • Ablation of the AV node… • new data available…
    42. 42. Figure 3 Effect of AV nodal ablation in patients with IHD versus DCM and a BV ICD Sohinki et al, Eurpace 2013, in press
    43. 43. • Upstream therapy with ACE inhibitors might be useful • Cardioversion carries a higher risk for emboli than is generally accepted • PVI is useful in selected HF patients • AV nodal ablation has a role in CRT, especially in DCM Conclusions
    44. 44. Conclusions treat both conditions, and as early as possible
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