1. Management of Atrial Fibrillation in Heart Failure
Maximo Rivero-Ayerza M.D.
Clinical Electrophysiology
Ziekenhuis Oost Limburg, Genk

2. Objectives
Assess the relation between AF and HF
Try to establish the optimal treatment strategy

3. 20% of patients with HF develop AF within 4 years
Prevalence
Unadjusted cumulative incidence of first AF after Heart Failure Framingham Study
↑ Mortality in AF:
- Men HR 1.6
- Women HR 2.7
20% of patients with HF develop AF within 4 years
Wang, T. J. et al. Circulation 2003;107:

4. Prevalence Concomitant HF: 13 % age 35 – 64 yrs 21% age > 65 yrs
Wattigneyet al. Circulation 2003;108:

5. Class I – II Class III - IV
Prevalence
% Patients with Atrial Fibrillation
prevalence increases with severity of heart failure
Class I – II Class III - IV

6. Relation between AF and HF

7. Atrial Fibrillation
Substrate
Triggers

8. AF – Atrial remodeling CHF induced followed by 5 weeks of recovery
Irreversible induction of fibrosis and conduction abnormalities.
Duration of AF was reduced in parallel to LA function.
Shinagawa, K. et al. Circulation 2002;105:

9. Effect of intra-atrial pressure on AF
5 cm H2O
18 cm H2O
Increases in intra-atrial pressure increases the rate of the dominant frequency at the level of the PV junction compared to LA free wall
Kalifa et al. Circulation. 2003;108:668.

10. Effect of intra-atrial pressure on AF
Increases in intra-atrial pressure increases the number of waves (rotors) emanating from the PVs
Kalifa et al. Circulation. 2003;108:668.

11. Types of AF Triggers Paroxysmal AF Electrophysiologic Persistent AF
ectopic foci
Paroxysmal AF
Electrophysiologic
Remodeling
Chronic Substrate
fibrosis
Persistent AF
Permanent AF
Stambler et al JCE 2003;14:499 Li, Nattel et al. Circulation. 1999;100:87-95

12. AF – Hemodynamic Effects Cardiac Output (L/Min) Cardiac Output (L/Min)
NSR AF VVI VVI VVT AVG
VVI -AVG VVT
Clark DM. JACC 1997; 30:

13. Effects of AF in HF
Rapid heart rates depress contractility: abnormal force - frequency relationship in heart failure
100
200 20 60
120
180
Nonfailing
Failing
Heart Rate (beats / min)
% change in Force
Mulieri Circulation 1992;

14. Effects of AF in HF Development of AF (28 pts): 344 HF pts
FU= 19± 12 months
Development of AF (28 pts):
NYHA worsened (2.4 to 2.9)
Peak O2 consumption declined
(16 to 11 ml/kg/min)
CI decreased (2.2 to 1.8)
Mitral regurgitation increased
(1.8 to 2.4)
Pozolli et al. JACC 1998;31(1):

15. Prognostic significanse of AF
CHARM
N= pts (15% with AF)
Age= 65 y
Baseline AF HR 1.38 (low EF)
HR 1.80 (PEF)
New onset AF HR 2.57 (PEF)
HR 1.85 (low EF)
J Am Coll Cardiol 2006;47:1997

16. Prognostic significanse of AF
COMMET
N= 3029 pts (20% with AF)
Age= 62 y
Baseline AF RR=1.29 (univariate)
Baseline AF predictive of HF hosp.
New Onset AF RR=1.90 (multivariate)
Eur Heart J 2005;26:1303

17. Prognostic significanse of AF
DIG
N= pts (11% SVT)
Age= 63 y
RR=
CHEST 2000;118:914

18. Prognostic significanse of AF Epidemiological
As many AF pts developed HF as HF pts developed AF.
New AF in CHF individuals was associated with increased mortality
Antecedent AF was not predictive of mortality in CHF pts.
Wang TJ. Et al Circulation. 2003;107:2920

19. EuroHeart Failure - Mortality
P < 0.001
P < 0.001 7% 7%
12 %
13 %
13 %
19 %
No AF
Previous AF
New onset AF
Rivero-Ayerza et al. submitted
EHS-HF
EHS-HF

20. Independent predictors of hospital mortality Multiple logistic regression analysis
Less likely to die
More likely to die
New Onset AF
1.5 ( )
Previous AF
Age
Male Gender
Rapid AF
LA Dilatation EF 
50%
ACS
VHD
Renal Failure
Stroke
Elevated BP
0.1 1 10
OR (95%CI)
Rivero-Ayerza et al. submitted
EHS-HF

21. AF and HF
Summary
AF and HF tend to coexist and share predisposing factors
One may directly predispose to the other
The combination of both is believed to carry a worse
prognosis then either alone.
In the setting of HF onset of AF seems to be a stronger
predictor of adverse outcome irrespective of LV function

22. Management of AF in HF Objectives Prevention of AF would be ideal
Avoiding hemodynamic deterioration
and improving symptoms
3. Preventing stroke

23. Role of ACEI and ARB’s in prevention of AF
177 pts parox AF
End point: recurrence of
AF Randomized
- Amiodarone (41 % recurrence)
- Amio + losartan (19% recurrence)
- Amio + perindopril (24 % rec.)
Yuehui et al. EHJ 2006;27:1841

24. ACE inhibition reduces atrial fibrosis in a heart failure model
Control
5 Weeks
5 Weeks +Enalapril
Li, Nattel, et al Circulation. 2001; 104: 2608

25. Role of ACEI and ARB’s in prevention of AF
56,308 patients (11 studies)
Overall RR reduction of 28%
Benefit is similar for ACEI or
ARBs
RR reduction 44% in HF
Healey J, Baranchuk A, et al JACC 2005;45:1832

26. Prevention of AF - Statins
Recurrence after cardioversion of lone persistent AF
Antiinflammatory effect ? / Antioxidant effect ? / Antiarrhythmic effect ?
Siu et al. Am J Cardiol 2003; 92:1343 // Shiroshita-Takeshita et al. Circulation. 2004;110:

27. Rate vs Rhythm control Rhythm Control Rate Control Improve symptoms
Improve functional capacity
Lower risk of stroke
Avoid anticoagulation
Improve survival
Improve symptoms
Avoid side effects of AAD
Avoid pro-arrhythmia

28. Rate vs Rhythm control
Vidaillet et al. Curr Opin Cardiol 20:15 // Testa et al. EHJ. 2005

29. AFFIRM 4060 patients No survival benefit (23.8% vs 21.3%)
23 % Prior HF
Mean EF 55%
Normal EF 74 %
NEJM 2002;347:1825

30. AFFIRM NYHA 6’ walk - SR improved survival
- AAD increased (non-cardiac) mortality
- Improved FC
JACC 2005;46:1891 / NEJM 2002;347:1825

31. RACE Sub-study HF Rate control is not inferior to rhythm
If SR is maintained prognosis may improve (more CV death, HF hospitalizations and Bleeding)
Hagens et al. Am Heart J 2005;149:1106

32. DIAMOND Survival according to rhythm Survival according to Rx
506 pts with LV dysfunction
Randomized to Dofetilide or Placebo
No effect on mortality
Effect of SR on mortality RR 0.44 ( )
Survival according to rhythm
Survival according to Rx
Pedersen et al. Circulation 2001;104:292

33. Amiodarone has proven to be safe in HF and CAD patients
Management of AF in HR
SAFE T (persistent AF)
CTAF
Amiodarone has proven to be safe in HF and CAD patients
NEJM 2000;342:913 / NEJM 2005;352:18

34. Management of AF in HR
Fuster, V. et al. Circulation 2006;114:e257-e354

35. Management of AF in HR
In HF patchy fibrosis tends to accumulate at or near PV ostia
Jaliffe et al. HRS 2007

36. AF ablation

37. AF ablation
RSPV

38. Management of AF in HF 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
NEJM 2004:351;23

39. Relation between AF and HF
Ablation
Neurohormonal/
Anti-inflammatory

40. Management of AF and HF NYHA II-IV and EF < 35%
NYHA I and HF hosp or EF <25%

41. Management of AF in HR Tachycardia Induced Cardiomyopathy
- Cardiomyopathy can be caused by any tachycardia (>110 bpm) that occurs as little as 10-15% of day
- Severity related to rate and duration of  HR
- Maximal improvement after rate control may require up to 8 months
- After improvement susceptibility to rapid deterioration remains if tachycardia recurs
Olshansky et al Circulation Fenelon et al PACE 1996; 19: Shinbane J et al. JACC 1997; 29:

42. AV junction ablation and Pacemaker Implantation
Management of AF in HR
AV junction ablation and Pacemaker Implantation
Advantages:
Rate control without drugs
Regularizes ventricular rate
Disadvantages
Requires permanent pacemaker
Fibrillation continues
Risk of torsade de pointes
Risk of hemodynamic deterioration (RV pacing)
Ozcan et al. NEJM 2001;344:1043

43. Management of AF in HF Favor rhythm control
First or infrequent episodes of persistent AF
Significant symptoms in AF
Difficult rate control
Contraindication to long term warfarin
Favor rate control
Asymptomatic in atrial fibrillation
Contraindication to amiodarone

44. Antithrombotic Therapy
Risk of stroke 6% / y (5 - 6 fold increase)
Warfarin (INR ):
62% reduction (CI 48% - 72%)
37 NNT to prevent 1 stroke
major hemorrhage: 0.6% / yr
20% discontinue anticoagulation
Aspirin (25 mg mg/day)
22% reduction (2% - 38%)
Hart et al. Ann Intern Med 1999;131:492

45. Antithrombotic Therapy
CHADS²
CHADS
Stroke rate
Score %/y
Score %/y
Score %/y
Score %/y
Score %/y
Score %/y
Congestive HF
Hypertension
Age >75
Diabetes
Previos stroke (2 points)
Gage et al. JAMA 2001;285:2864

46. Summary AF and HF are not only clinically associated but are
physiopatologically inter-related
AF seems to be a prognostic indicator (certainly recent onset AF)
irrespective of LV performance.
Consequently prevention of AF should carry a better prognosis
Although no benefit of rhythm vs rate control has been shown.
Data suggest that certain subgroup of patients will benefit from SR
Irrespective of management strategy, antithrombotic Rx is
warranted

47. “I have been poor and I have been rich. Rich is better.”
Conclusion
“I have been poor and I have been rich. Rich is better.”
Attributed to Sophie Tucker