Long term effects of an aggressive rhythm control strategy in patients with permanent atrial fibrillation and advanced heart failure

Heart Rhythm ◽  
2005 ◽  
Vol 2 (5) ◽  
pp. S116 ◽  
Author(s):  
Gaetano M. De Ferrari ◽  
Barbara Petracci ◽  
Folco Frattini ◽  
Roberto Rordorf ◽  
Francesco Cantù ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Control Strategy ◽  
Advanced Heart Failure ◽  
Rhythm Control ◽  
Long Term Effects ◽  
Permanent Atrial Fibrillation

scholarly journals Catheter Ablation for Atrial Fibrillation in Patients with Heart Failure with Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

2022 ◽  
Vol 11 (2) ◽  
pp. 288
Author(s):  
Emmanuel Androulakis ◽  
Catrin Sohrabi ◽  
Alexandros Briasoulis ◽  
Constantinos Bakogiannis ◽  
Bunny Saberwal ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Systematic Review ◽  
Ejection Fraction ◽  
Control Strategy ◽  
Meta Analysis ◽  
Rhythm Control ◽  
Preserved Ejection Fraction ◽  
Patients With Heart Failure

Background: Catheter ablation (CA) for atrial fibrillation (AF) has been proposed as a means of improving outcomes among patients with heart failure and reduced ejection fraction (HFrEF) who are otherwise receiving appropriate treatment. Unlike HFrEF, treatment options are more limited in patients with preserved ejection fraction (HFpEF) and the data pertaining to the management of AF in these patients are controversial. The aim of this systematic review and meta-analysis was to investigate the effects of CA on outcomes of patients with AF and HFpEF, such as functional status, post-procedural complications, hospitalization, morbidity and mortality, based on data from observational studies. Methods: We systematically searched the electronic databases MEDLINE, PUBMED, EMBASE and the Cochrane Library for Central Register of Clinical Trials until May 2020. Results: Overall, the pooling of our data showed that sinus rhythm was achieved long-term in 58.0% (95% CI 0.44–0.71). Long-term AF recurrence was noticed in 22.3% of patients. Admission for HF occurred in 6.2% (95% CI 0.04–0.09) whilst all-cause mortality was identified in 6.3% (95% CI 0.02–0.13). Conclusion: This meta-analysis is the first to focus on determining the benefits of a rhythm control strategy for patients with AF and HFpEF using CA, suggesting it may be worthwhile to investigate the effects of a CA rhythm control strategy as the default treatment of AF in HFpEF patients in randomized trials.

3153Rate versus rhythm control and mortality in atrial fibrillation patients: a Danish nationwide cohort study

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
F Dalgaard ◽  
S Al-Khatib ◽  
J Pallisgaard ◽  
C Torp-Pedersen ◽  
T B Lindhardt ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Heart Disease ◽  
Control Strategy ◽  
Rate Control ◽  
Channel Blocker ◽  
Rhythm Control ◽  
All Cause Mortality ◽  
Control Therapy

Abstract Background Treatment of AF patients with rate or rhythm drug therapy have shown no difference in mortality in clinical trials. However, the generalizability of these trials to real-world populations can be questioned. Purpose We aimed to investigate the all-cause and cardiovascular (CV) mortality risk in a nationwide AF cohort by treatment strategy (rate vs. rhythm) and by individual drug classes. Methods We queried the Danish nationwide registries from 2000 to 2015 to identify patients with AF. A rate control strategy included the use of one or more of the following medications: beta-blocker, digoxin, and a class-4 calcium channel blocker (CCB). A rhythm control strategy included the use of an anti-arrhythmic drug (amiodarone and class-1C). Primary outcome was all-cause mortality. Secondary outcome was CV mortality. Adjusted incidence rate ratios (IRR) were computed using Poisson regression with time-dependent covariates allowing patients to switch treatment during follow-up. Results Of 140,697 AF patients, 131,793 were on rate control therapy and n=8,904 were on rhythm control therapy. At baseline, patients on rhythm control therapy were younger (71 yrs [IQR: 62–78] vs 74 [65–82], p<0.001) more likely male (63.5% vs 51.7% p<0.001), had more prevalent heart failure (31.1% vs 19.4%, p<0.001) and ischemic heart disease (40.1% vs. 23.3%, p<0.001), and had more prior CV-related procedures; PCI (7.4% vs. 4.0% p<0.001) and CABG (15.0% vs. 2.3%, p<0.001). During a median follow up of 4.0 (IQR: 1.7–7.3) years, there were 64,653 (46.0%) deaths from any-cause, of which 27,025 (19.2%) were CVD deaths. After appropriate adjustments and compared to rate control therapy, we found a lower IRR of mortality and CV mortality in those treated with rhythm control therapy (IRR: 0.93 [95% CI: 0.90–0.97] and IRR 0.84 [95% CI: 0.79–0.90]). Compared with beta-blockers, digoxin was associated with increased risk of all-cause and CV mortality (IRR: 1.26 [95% CI: 1.24–1.29] and IRR: 1.32 [95% CI: 1.28–1.36]), so was amiodarone: IRR for all-cause mortality: 1.16 [95% CI: 1.11–1.21] and IRR for CV mortality: 1.12 [95% CI: 1.05–1.19]. Class-1C was associated with lower all-cause (0.43 [95% CI: 0.37–0.49]) and CV mortality (0.35 [95% CI: 0.28–0.44]). Figure 1. Models were adjusted for age, sex, ischemic heart disease, stroke, chronic obstructive pulmonary disease, chronic kidney disease, valvular atrial fibrillation, bleeding, diabetes, ablation, pacemaker, implantable cardioverter defibrillator, hypertension, heart failure, use of loop diuretics, calendar year, and time on treatment. Abbreviations; CCB; calcium channel blocker, PY; person years. Conclusions In a real-world AF cohort, we found that compared with rate control therapy, rhythm control therapy was associated with a lower risk of all-cause and CV mortality. The reduced mortality risk with rhythm therapy could reflect an appropriate patient selection. Acknowledgement/Funding The Danish Heart Foundation

scholarly journals Rhythm control in patients with atrial fibrillation and heart failure: a meta-analysis of randomized controlled trials

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
S.Z Ramos ◽  
A.L.D Te-Rosano
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Risk Ratio ◽  
Control Strategy ◽  
Rate Control ◽  
Meta Analysis ◽  
Rhythm Control ◽  
Forest Plot ◽  
Randomized Controlled ◽  
All Cause Mortality

Abstract Background Atrial fibrillation (AF) is a common arrhythmia that can promote or worsen heart failure (HF). Limited data exist to guide treatment for patients with AF with HF regarding rate versus rhythm control. Purpose To perform a meta-analysis of randomized controlled trials (RCT) in the determination of the efficacy of rhythm control as compared to rate control among patients with AF and HF. Methods Extensive search of PubMed, Cochrane Library, Ovid, EMBASE, Google scholar, and Medline was done up to October 2020. Studies were limited to RCTs comparing rhythm control in patients with atrial fibrillation and heart failure with rate control. Outcome measures include all-cause mortality and cardiovascular mortality. Statistical analysis was done using Review manager V5.3. Results A total of 9800 patients were included in the pooled analysis of the comparison of rhythm control versus rate control strategy in patients with AF and HF. All pooled analyses were done using random effects model. The pooled risk ratio for all-cause mortality of rate control vs rhythm control did not achieve significance at 1.15, with 95% CI 0.91 to 1.45, and p=0.24. There was statistically significant heterogeneity across the two studies with I2 of 54% and p=0.02 (Figure 1A). The pooled risk ratio for cardiovascular mortality in rate control strategy vs rhythm control is 1.19, with 95% CI 0.94 to 1.50, and p=0.15 (Figure 1B). Eight trials with 9987 participants reported stroke. The pooled risk ratio of stroke in rate control vs rhythm control is 1.11, with 95% CI 0.84 to 1.46, and p=0.47 (Figure 1C). The 95% CI for the pooled risk ratio cross 1.00, indicating an equivocal result. Our results do not indicate statistical heterogeneity across the studies with I2 of 28% and p=0.27. Seven trials with 8311 participants reported bleeding. The pooled risk ratio of hospitalization for bleeding in rate control vs rhythm control is 1.18, with 95% CI 0.81 to 1.73, and p=0.39 (Figure 1D). Thus, we have insufficient evidence to demonstrate whether rate or rhythm control have significantly higher or lower risk for bleeding. Four trials with 8468 participants reported hospitalization rate. The pooled risk ratio of hospitalization in rate control compared to rhythm control is 0.96, with 95% CI 0.86 to 1.07, and p=0.42 (Figure 1E). None of the studies individually showed statistically significant differences but AF–CHF showed benefit of rate control in the first year after enrolment (p=0.001) and a tendency favouring rate control (p=0.06) when the study was analysed in full length except for AF-CHF. Conclusion Among patients with AF and concomitant HF, there is no sufficient evidence between rate and rhythm control strategies in their effects to rates of mortality and major clinical outcomes; therefore, choosing an appropriate therapeutic strategy should consider individual variations such as patient preferences, comorbidities, and treatment cost. FUNDunding Acknowledgement Type of funding sources: None. Forest Plot A–C Forest Plot D–E

scholarly journals Atrial fibrillation ablation in heart failure

2020 ◽  
Vol 22 (Supplement_E) ◽  
pp. E50-E53
Author(s):  
Cristina Balla ◽  
Riccardo Cappato
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Control Strategy ◽  
Rate Control ◽  
Pharmacological Therapy ◽  
Rhythm Control ◽  
Invasive Approach ◽  
Normal Cardiac Function

Abstract Atrial fibrillation (AF) and heart failure (HF) commonly coexist in the same patient and either condition predisposes to the other. Several mechanisms promote the pathophysiological relationship between AF and HF, reducing quality of life, increasing the risk of stroke, and worsening HF progression. Although restoration and maintenance of sinus rhythm would be ideal for those patients, several trials comparing rhythm and rate control failed to show a benefit of rhythm control strategy, achieved with pharmacological therapy, in terms of hospitalization for HF or death. Catheter ablation is a well-established option for symptomatic AF patients, resistant to drug therapy, with normal cardiac function. Several recent studies have shown an improvement in clinical outcomes after AF ablation in HF patients highlighting the emerging role of the invasive approach in this subset of patients. However, several concerns regarding patients’ selection and standardization of the procedure still remain to be addressed.

The Role of Atrial Fibrillation among Patients with Chronic Heart Failure

2020 ◽  
Vol 4 (53) ◽  
pp. 13-18
Author(s):  
Katarzyna Przybylska-Siedlecka ◽  
Wiktoria Kowalska ◽  
Michał Mazurek ◽  
Oskar Kowalski
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Control Strategy ◽  
Rate Control ◽  
Rhythm Control ◽  
Atrial Fibrillation Ablation ◽  
Cardioverter Defibrillator ◽  
Heart Failure Patients ◽  
Patients With Heart Failure ◽  
Worse Prognosis

Both heart failure and atrial fibrillation are significant health problems affecting approximately 1-2% of the adult population. Atrial fibrillation (AF) increases the incidence of thromboembolic complications, increases the frequency of hospitalization, morbidity due to heart failure, and is an independent risk factor for death. AF is the most common arrhythmia occurring in patients with heart failure. Patients with heart failure and implantable devices Atrial fibrillation with rapid ventricular response remains one of the most common causes of inadequate interventions of implanted cardioverter-defibrillator (ICD) or resynchronization systems with cardioverter-defibrillator function (CRT-D). Both AF and inadequate interventions are strongly associated with worse prognosis and increased risk of all-cause death. Furthermore, in presence of multiple inapproriate shocks the patients’ prognosis worsens. Thus they require more frequent interventions most frequently reprogramming of the device, modification of pharmacotherapy and correction of accompanying irregularities such as electrolyte disturbances. AF is also a major cause of loss of biventricular pacing in patients with an implanted resynchronizing system, which leads into an exacerbation of heart failure symptoms, an increase in hospitalization and mortality. No clear advantage has been demonstrated for rate or rhythm control strategy for survival in patients with AF. In the European registry EORP-AF a higher mortality rate was observed in the group treated with rate control strategy. However, after considering the effects of associated diseases, the difference in mortality among patients undergoing rhythm control and rate control was not statistically significant. Recently, several studies comparing antiarrhythmic therapy with atrial fibrillation ablation have been published. The article briefly discusses some of them, such as the CASTLE-AF study, AATAC, CAMERA-MRI, the CABANA study. Despite the different results of these studies, reports on the effectiveness of atrial fibrillation ablation among patients with heart failure are promising. According to updated guidelines of American cardiology societies from 2019, ablation of atrial fibrillation can be considered in patients with symptomatic AF and heart failure with reduced left ventricular ejection fraction to reduce mortality and the frequency of hospitalization for heart failure. Patients with atrial fibrillation and heart failure have a worse prognosis than patients with heart failure and sinus rhythm. However, we can improve it by diagnosing atrial fibrillation and implementing adequate treatment, including invasive atrial fibrillation therapy.

scholarly journals Real-world applicability and impact of early rhythm control for European patients with atrial fibrillation: a report from the ESC-EHRA EORP-AF Long-Term General Registry

2021 ◽  
Author(s):  
Marco Proietti ◽  
Marco Vitolo ◽  
Stephanie L. Harrison ◽  
Deirdre A. Lane ◽  
Laurent Fauchier ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Atrial Fibrillation ◽  
Health Care ◽  
Real World ◽  
Control Strategy ◽  
Primary Outcome ◽  
Rhythm Control ◽  
Use Of Health Care

Abstract Background Use of rate/rhythm control is essential to control symptoms in patients with atrial fibrillation (AF). Recently, the EAST-AFNET 4 trial described how early rhythm control strategy was associated with a lower risk of adverse clinical outcomes. Objectives The aim was to evaluate the real-world applicability and impact of an early rhythm control strategy in patients with AF. Methods Use of an early rhythm control strategy was assessed in a European cohort of AF patients derived from the EHRA-ESC EORP-AF General Long-Term Registry. Early rhythm control was defined as use of antiarrhythmic drugs or cardioversion/catheter ablation. The primary outcome included cardiovascular death, stroke, acute coronary syndrome, and worsening of heart failure. Quality of life and health-care resource usage were also assessed as outcomes. Results Among the 10,707 patients evaluated for eligibility to EAST-AFNET 4, a total of 3774 (34.0%) were included. Early rhythm control was associated with better quality of life, but with greater use of health-care resources. During follow-up, the primary outcome occurred less often in early rhythm control patients than in those with no rhythm control (13.6% vs. 18.5%, p < 0.001). In the multivariate adjusted Cox regression model, no significant difference was found between no rhythm control and early rhythm control, for the primary outcome. No difference in the primary outcome between early rhythm control and ‘no rhythm control patients’ adherent to Atrial fibrillation Better Care (ABC) pathway’ was evident (p = 0.753) Conclusions Use of an early rhythm control strategy was associated with a lower rate of major adverse events, but this difference was non-significant on multivariate analysis, being mediated by differences in baseline characteristics and clinical risk profile. Early rhythm control was associated with a higher use of health-care resources and risk of hospital admission, despite showing better quality of life. Graphic abstract

scholarly journals Atrial fibrillation evolution and rhythm control strategy following left appendage closure: new insights from the prospective FLAAC registry

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Nicolas Lellouche ◽  
Raphaele Arrouasse ◽  
Julien Ternacle ◽  
Romain Gallet ◽  
Jean-Sylvain Hermida ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Control Strategy ◽  
Interventional Cardiology ◽  
Rhythm Control ◽  
History Of ◽  
Study Population ◽  
One Year ◽  
Laa Closure

Abstract Background Percutaneous left atrial appendage (LAA) closure is an alternative to oral anticoagulation (OAC) for atrial fibrillation (AF) patients with high thromboembolism risk, particularly with contraindications to OAC. The LAA itself could possess proarrhythmogenic properties. As patients undergoing LAA closure could be candidates for cardioversion or ablation, we aimed to evaluate AF disease progression following LAA closure and the outcome of patients undergoing a rhythm control strategy after the procedure. Methods The prospective multicenter French Nationwide Observational LAA Closure Registry (FLAAC) comprises 33 French interventional cardiology departments. Patients were included if they fulfilled the following criteria: history of non-valvular AF, successful LAA closure and long-term ECG follow-up. Results A total of 331 patients with successful LAA closure were enrolled in the study. Patients mean age was 75.4 ± 0.5 years. The study population was characterized by a high thromboembolic risk (CHA2DS2-VASc score: 4.5 ± 0.1) and frequent comorbidities. The median follow-up was 11.9 months. One hundred and nineteen (36.0%) patients were in sinus rhythm (SR) at baseline. Among SR patients, documented AF was observed in 16 (13.4%) patients whereas 15 (7.1%) patients in AF at baseline restored SR, at the end of follow up. Finally, only 13 patients (4%) underwent procedures to restore SR without complications during the follow-up. Conclusions The vast majority of patients undergoing LAA closure have the same AF status at baseline and one year after the index procedure. During the follow-up, a very small proportion (4%) of our population underwent procedures to restore SR without complications whatever the post-procedural antithrombotic strategy was.

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