Management of AF in Heart Failure Patients

Do Van Buu Dan, MD, FHRS Tam Duc Heart Hospital

Case 1

•Male, 20y.o

• Persistent AF, EF 40%

•Normal CAG

• Cardioversion x 3 times

• Rhythm control with • Amiodarone

• Metoprolol

• EF back to 65%

Case 2

• Male, 51 y.o

• Persistent AF, hypertension

• EF 30%, normal CAG

• AF recurrences despites cardioversion, AADs (betablocker and amiodarone)

• PV isolation

• EF back to 54% after 6 months.

• Currently no recurrence under metoprolol 50mg/d

1. Mozaffarian D et al. Circulation. 2015;131(4):e29-e322. 2. Mosterd A et al. Heart. 2007;93(9):1137-1146. 3. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf 4. Cowie MR et al. Oxford PharmaGenesis; 2014. http://www.oxfordhealthpolicyforum.org/AHFreport. Accessed February 18, 2015. 5. Fauci AS et al. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008. 6. Cook C et al. Int J Cardiol. 2014;171(3):368-376.

NUMBER of PATIENTS

21 MILLION adults worldwide are

living with heart failure

This number is expected to rise.1,2

REHOSPITALISATION

Heart failure is the NUMBER 1

cause of hospitalisation for patients

aged >65 years.4

MORTALITY

of heart failure patients 50% die within 5 years from diagnosis.5

COMORBIDITIES: The vast

majority of HF patients has 3 or

more comorbidities 3

ECONOMIC BURDEN

In 2012, the overall worldwide cost

of heart failure was nearly

$108 BILLION.6

The burden of heart failure

HF & AF like fire & fury

• HF and AF complicate each other and

exert a significant detrimental effect on

cardiovascular health and well-being.

• Both HF&AF continue to increase in

prevalence as the risk factors underlying

each condition become more common

• 50% of patients with advanced HF also

have AF

JACC: HEARTFAILURE VOL.5 , NO.2 , 2017

AF increases hospitalization in HF

Sarkar S, et al. Am Heart j 2012;164:616-24

Kaplan-Meier curves for time to first HF hospitalization in patients with and without AF

in patients with HF with left ventricular systolic dysfunction.

AF increases the risk of CV events (CV Death, HHF, All cause death, fatal & non fatal stroke)

in HF patient regardless of EF

https://doi.org/10.1016/j.ahj.2012.06.020

Prevalence of atrial fibrillation (AF) in several major heart failure trials

Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy https://doi.org/10.1016/S0002-9149(02)03373-8

Elad Anter. Circulation. Atrial Fibrillation and Heart Failure, Volume:

119, Issue: 18, Pages: 2516-2525, DOI:

(10.1161/CIRCULATIONAHA.108.821306)

HF & AF: the vicious cycle

Jagmeet P. Singh, and Sunu S. Thomas JCHF 2017;5:53-55

American College of Cardiology Foundation

Treatment aim to cut the vicious cycle: HF & AF

Management of AF in CHF

DOI: 10.1161/CIRCULATIONAHA.111.019935

Anticoagulation

http://dx.doi.org/10.4070/kcj.2017.0040

Rate control The role of Beta-blocker

Beta-blocker mechanism in HF

Beta-blocker reduce the AF onset in HF patients

Meta-analysis of 7 RCTs with 11,952 pts, follow-up 6-24 months

AF onset was significantly reduced with beta-blocker

European Heart Journal (2007) 28, 457–462

Beta-blocker have better rate control vs CCB and digoxin alone

The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study: Approaches to control rate in atrial fibrillation https://doi.org/10.1016/j.jacc.2003.11.032

Bate blocker and outcome in HF patient with AF and HF with SR

Rienstra M, Damman K, Mulder BA, et al. Beta-blockers and outcome in heart failure and atrial fibrillation: a meta-analysis. JACC: Heart Failure 2013;1:21–8

The effect of Beta blocker on HFrEF with AF differs among studies

ESC 2016 – Acute heart rate control

2016 ESC Guidelines for the management of atrial fibrillation. European Journal of Cardio-Thoracic Surgery 50 (2016) e1–e88

ESC 2016 – Long term heart rate control

2016 ESC Guidelines for the management of atrial fibrillation. European Journal of Cardio-Thoracic Surgery 50 (2016) e1–e88

Beta blockers’ indications in Vietnam

Metoprolol succinate Bisoprolol Nebivolol

Hypertension x x x

CAD (Angina Pectoris) x x

Post MI x

HF : Mild - moderate x x x

HF: Servere x x

Arrhythmias

X

Treatment of some tachyarrhythmias disorders: supraventricular tachyarrhythmias (tachycardia, atrial fibrillation and atrial flutter, AV junctional tachycardia) or ventricular tachycardia (ventricular tachycardia, paroxysmal ventricular tachycardia).

Vui lòng tham khảo Thông tin kê toa đầy đủ các thuốc được phê duyệt tại Việt Nam khi sử dụng

The simple choice for patients

Please review the product information of each product before prescribe

Impaired hepatic

function

Impaired renal

function Elderly patient

Metoprolol

succinate

Nebivolol •Contraindications

•Impaired renal function mild to

moderate: 2,5 mg/day

•Impaired renal function severe:

not recommended

•>65 yrs: initial dose

2,5mg/day, increase dose

5mg/day as needed

Bisoprolol •Impaired hepatic function: maximal dose: 10mg/day

•Impaired renal function severe

(ClCr <20mL/phút): maximal

dose: 10mg/day

•Dose adjustment is not

needed

DOSE ADJUSTMENT IS NOT NEEDED

ACUTE AND CHRONIC MANAGEMENT OF ATRIAL FIBRILLATION

European Heart Journal (2016) 37, 2893–2962

Improve Survival

Improve QoL

Rhythm control

Pharmacological rhythm control

• 2 largest trials to evaluate the potential benefit of pharmacological rhythm control over rate control in patients with HF • AF-CHF trial (Atrial Fibrillation and Congestive Heart Failure)1

• DIAMOND-CHF trial (Danish Investigators of Arrhythmia and Mortality on Dofetilide in Congestive Heart Failure)2

• Both failed to show the benefit of rhythm control vs rate control in HF patients

1. N Engl J Med 2008; 358:2667-2677 2. N Engl J Med 1999; 341:857-865

Pharmacological rhythm control

AF-CHF DIAMOND-CHF

Catheter ablation

PV isolation Substrate ablation

Cardiac Failure Review 2018;4(1):33–7.

Cardiac Failure Review 2018;4(1):33–7.

CASTLE-AF

CASTLE-AF

CASTLE-AF

CASTLE-AF

Catheter ablation in HF

Recommendation for Catheter Ablation in HF COR LOE Recommendation

IIb B-R

AF catheter ablation may be reasonable in selected patients with symptomatic AF and HF with reduced left ventricular (LV) ejection fraction (HFrEF) to potentially lower mortality rate and reduce hospitalization for HF. NEW: New evidence, including data on improved mortality rate, has been published for AF catheter ablation compared with medical therapy in patients with HF.

ACC/AHA/HRS 2019

Take home message

• AF increases cardiovascular events in HF patients.

•Management of AF in HF patients requires an individualized strategy including anticoagulation, rate control and rhythm control.

• Beta-blocker is the mainstay for rate control of AF in HF patients.

• Catheter ablation is reasonable in selected AF patients with HF.

Thanks for your attention!