Rhythm Control in Heart Failure Patients With Atrial Fibrillation

Background: Even on optimal therapy, many patients with heart failure and atrial fibrillation experience cardiovascular complications. Additional treatments are needed to reduce these events, especially in patients with heart failure and preserved left ventricular ejection fraction (HFpEF). Methods: This prespecified subanalysis of the randomized EAST - AFNET 4 trial assessed the effect of systematic, early rhythm control therapy (ERC; using antiarrhythmic drugs or catheter ablation) compared to usual care (UC, allowing rhythm control therapy to improve symptoms) on the two primary outcomes of the trial and on selected secondary outcomes in patients with heart failure, defined as heart failure symptoms NYHA II-III or left ventricular ejection fraction [LVEF] <50%. Results: This analysis included 798 patients (300 (37.6%) female, median age 71.0 [64.0, 76.0] years, 785 with known LVEF). The majority of patients (n=442) had HFpEF (LVEF≥50%; mean LVEF 61% ± 6.3%), the others had heart failure with mid-range ejection fraction (n=211; LVEF40-49%; mean LVEF 44% ± 2.9%) or heart failure with reduced ejection fraction (n=132; LVEF<40%; mean LVEF 31% ± 5.5%). Over the 5.1-year median follow-up, the composite primary outcome of cardiovascular death, stroke or hospitalization for worsening of heart failure or for acute coronary syndrome occurred less often in patients randomized to ERC (94/396; 5.7 per 100 patient-years) compared with patients randomized to UC (130/402; 7.9 per 100 patient-years; hazard ratio 0.74 [0.56-0.97], p=0.03), not altered by heart failure status (interaction p-value=0.63). The primary safety outcome (death, stroke, or serious adverse events related to rhythm control therapy) occurred in 71/396 (17.9%) heart failure patients randomized to ERC and in 87/402 (21.6%) heart failure patients randomized to UC (hazard ratio 0.85 [0.62-1.17], p=0.33). LV ejection fraction improved in both groups (LVEF change at two years: ERC 5.3%±11.6%, UC 4.9%±11.6%, p=0.43). ERC also improved the composite outcome of death or hospitalization for worsening of heart failure. Conclusions: Rhythm control therapy conveys clinical benefit when initiated within one year of diagnosing atrial fibrillation in patients with signs or symptoms of heart failure. Clinical Trial Registration: Unique Identifiers: ISRCTN04708680, NCT01288352, EudraCT2010-021258-20, Study web site www.easttrial.org; URLs: www.controlled-trials.com; https://clinicaltrials.gov; https://www.clinicaltrialsregister.eu

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The Role of Atrial Fibrillation among Patients with Chronic Heart Failure

In a good rythm ◽

10.5604/01.3001.0014.0498 ◽

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.

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Atrial Fibrillation Ablation in Heart Failure Patients

Journal of Clinical Medicine ◽

10.3390/jcm10163512 ◽

2021 ◽

Vol 10 (16) ◽

pp. 3512

Author(s):

Michael Derndorfer ◽

Shaojie Chen ◽

Helmut Pürerfellner

Keyword(s):

Quality Of Life ◽

Heart Failure ◽

Atrial Fibrillation ◽

Side Effects ◽

Meta Analysis ◽

Treatment Options ◽

Rhythm Control ◽

The Other ◽

Heart Failure Patients

Atrial Fibrillation (AF) and Heart Failure (HF) are closely linked to each other, as each can be either the cause of or the result of the other. Successfully treating one of the two entities means laying the basis for treating the other one as well. Management of patients with AF and HF can be challenging and should primarily adhere to available guidelines. Concerning AF, medication is limited and causes many side effects, leading to low medical adherence. Several smaller studies, summarized in a big meta-analysis, provide evidence that ablation of AF in HF patients is crucial for improving quality of life, reducing HF hospitalizations, and reducing death, provided the LVEF is at least 25% or higher. In advanced HF, alternative treatment options (including assist devices, heart transplant) might still be the better option. Early rhythm control should be taken into consideration, as there is evidence that it is associated with better cardiovascular outcome.

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