Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)
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Transcript of Insuffisance cardiaque et fibrillation auriculaire - l'oeuf ou la poule (Pr L. Jordaens)
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Atrial Fibrillation and Congestive Heart Failure: the chicken or egg story
Luc DE ROY
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The 30 most important diagnoses
pathologyICD
-9-CMNumber of admissions
% admissions
mean duration (days)
4 Chronic IHD 414 21996 1,35 9,2
12 Arrhythmias 427 17129 1,05 10,5
14Angina pectoris
413 16798 1,03 8,2
16 AMI 40 15881 0,98 13
17 CHF 428 15869 0,98 18,8
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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
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AF begets HF and HF begets AFAF begets HF and HF begets AF
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Fibrose met reentry ?
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AF ontstaat bij een belangrijke patiëntengroepin de longvenen
Getriggerd ?
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(bayes de luna ? – no - from Maurits Alessie)
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(Wijffels, Alessie, Circulation 1995)
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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
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Klasse Ic Antiarrhythmic agents
AF + RBBB + LBBB
VT ?
Sinus
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• What is known on the relationship of AF and HF ?
• Is AF a marker of mortality ?
• What about the timing of onset of AF ?
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1. Is upstream therapy useful ?
2.Should we aim for sinus rhythm
(i.e. drugs, cardioversion, ablation) ?
3. Should we use CRT ?
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Prognostic significance of AF Prognostic 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
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EHS-HFEHS-HF
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
1313 % % 19 %19 %
Rivero-Ayerza et al. Eur Heart J, 2008
EuroHeart Failure - Mortality EuroHeart Failure - Mortality
In-hospital mortality 12 week mortality
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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
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Smit et al, Eur J HF 2012
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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
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Upstream Therapy • Renin-angiotensin-aldosterone
modulators
• Omega-3 fatty acids
• Statins
• Retrospective data better than prospective …
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Li D, Nattel et al. Circulation 2001
Control
5 Weeks
5 Weeks +Enalapril
ACE inhibition reduces ACE inhibition reduces atrial fibrosis in a heart failure modelatrial fibrosis in a heart failure model
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Amiodarone plus angiotensine I receptor blockersmaintain sinus rhythm
Madrid et al, 2002
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16-10-2001
ACE inhibitors and ARB`s
Savelieva I et al. Europace 2011;13:308-328
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16-10-2001
Efficacy of statins in prevention of atrial fibrillation
Savelieva I et al. Europace 2011;13:308-328
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16-10-2001
Upstream therapy after PVI in retrospective studies.
Savelieva I et al. Europace 2011;13:308-328
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Maintaining sinus rhythm in CHF
• Why ?
• Drugs
• Cardioversion
• Ablation
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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
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AFFIRMAFFIRM
JACC 2005;46:1891 / NEJM 2002;347:1825
- SR improves survival
- AAD increase (non-cardiac) mortality
- SR improved functional class
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Cardioversion and CHF• Traditionally delayed, unless
• Tachycardiomyopathy or emergent restoration of sinus rhythm necessary
• few data available…
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Recent onset
ESC guidelines 2012
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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
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CCVECV
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
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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
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Indications for TEE
• Problematic anticoagulation
• Valvular disease
• LVD
• Prior stroke
• Enlarged LA (> 5cm)
• All new cases (duration < 1 month)
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PVI ablation and CHF• Normal anatomy ?
• Tachycardiomyopathy ?
• few data available…
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Paroxysmal Persistent Permanent
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ESC guidelines 2012
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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
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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
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Anselmino M et al; JCE 2013
Ablation in left ventricular dysfunctionAblation in left ventricular dysfunction
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CRT and AF• AF patients were excluded from
the first studies
• new data available…
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CRT and AF• Assess % BV pacing
• Ablation of the AV node…
• new data available…
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Effect of AV nodal ablation in patients with IHD versus DCM and a BV ICD
Sohinki et al, Eurpace 2013, in press
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• 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
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Conclusions
treat both conditions, and as early as possible