Heart failure and atrial fibrillation - Its a two way relation

Raja Selvaraj

Introduction

Emerging epidemics

Emerging epidemics

Shared risk factors

  • Age
  • Hypertension
  • Diabetes
  • Coronary artery disease
  • Valvular heart disease

Temporal relationship

Thomas J. Wang et al .Temporal Relations of Atrial Fibrillation and Congestive Heart Failure and Their Joint Influence on Mortality Circulation. 2003;107:2920-2925

Heart failure and AF cycle

Anter E, Jessup M, Callans DJ. Atrial fibrillation and heart failure: treatment considerations for a dual epidemic. Circulation. 2009 May 12;119(18):2516-25

Prognosis of shared comorbidity

  • Increased risk of death
  • Increased risk of stroke

Management

Management principles

  • Thromboembolism prophylaxis - One additional risk factor
  • Rate or rhythm control ?
  • Possibility of reversal of LV dysfunction? (Tachycardia induced cardiomyopathy)

Tachycardia induced cardiomyopathy

  • Arrhythmia in first reported case in 1913
  • Less often recognised in AF compared to other arrhythmias
  • Irregularity of response may contribute ?

Tachycardia induced cardiomyopathy

  • No previous structural heart disease
    • AF -> Severe LV dysfunction - Uncommon, but not rare
    • AF -> Mild to moderate LV dysfunction - Probably common
  • Preexisting structural heart disease
    • AF -> Further reduction of LV function - Clinically under recognised

Cha YM, Redfield MM, Shen WK, Gersh BJ. Atrial fibrillation and ventricular dysfunction: a vicious electromechanical cycle. Circulation. 2004 Jun 15;109(23):2839-43

DCM with AF or AF with TIC

  • LV dimension may help differentiate
  • BNP / LVEF not different, but LV size smaller (1)
  • LVEDD < 66 predicts TIC (2)
  1. Fujino et al. Characteristics of congestive heart failure accompanied by atrial fibrillation with special reference to tachycardia-induced cardiomyopathy. Circ J. 2007 Jun;71(6):936-40.
  2. Jeong YH et al. Diagnostic approach and treatment strategy in tachycardia-induced cardiomyopathy. Clin Cardiol. 2008;31:172–178

Rate vs rhythm control

AF-CHF study

  • Rate control
    • Beta blockers + Digoxin
    • 80 bpm at rest and 110 bpm with exercise
  • Rhythm control
    • Amiodarone
    • Sotalol / Dofetilide
    • Cardioversion at 6 weeks / 3 months

AF-CHF study - Result

Rate and rhythm control

  • Rate control
    • Beta blockers / Calcium channel blockers
    • Digoxin as add on
    • AV node modification / ablation
  • Rhythm control
    • DC Cardioversion
    • AAD - Amiodarone
    • AF ablation

Ablate and Pace

Wood et al. Clinical outcomes after ablation and pacing therapy for atrial fibrillation : a meta-analysis. Circulation. 2000 Mar 14;101(10):1138-44.

PABA-CHF study

Khan MN et al. Pulmonary-Vein Isolation for Atrial Fibrillation in Patients with Heart Failure. N Engl J Med 2008; 359:1778-1785

Recommendations

  • Aggressive heart failure management
  • Anticoagulation
  • Rate or rhythm control
    • Age
    • Duration of AF
    • LA size
    • Previous attempts at rhythm control

PVI or Ablate and PACE for refractory AF

  • Atypical flutter / AF - Often refractory to pharmacologic therapy
  • AVN ablation with pacing can be an excellent alternative
  • In an experienced center, PVI may be superior ?
  • Recurrences can result in rapid deterioration