1. Atrial Arrhythmia Management in Advanced Heart Failure Patients
Eric E. Johnson, MD, FACC, FHRS
The Stern Cardiovascular Foundation
Baptist Memorial Hospital-Memphis

2. Disclosures
Medtronic advisory board, speaking engagements, clinical research support.
Speaker for BMS, Pfizer.

3. Cheney Recovering at Home After Being Treated for Irregular Heartbeat
MONDAY, NOVEMBER 26, 2007
Question 1: How would you manage AF in this patient?
1.) Rate control and anticoagulate
2.) Anticoagulate and begin amiodarone
3.) Cardiovert
4.) No change in therapy
5.) Go on hunting trip and not worry

4. Dick Cheney Cheney has a long history of cardiovascular disease
He had his first of five heart attacks in 1978, at age 37. Subsequent attacks resulted in moderate left ventricular dysfunction.
He underwent four-vessel coronary artery bypass grafting in 1988, coronary artery stenting in November 2000, urgent coronary balloon angioplasty in March 2001
He underwent implantation of an implantable cardioverter-defibrillator in June, 2001.
CBS News reported that during the morning of November 26, 2007, Cheney was diagnosed with atrial fibrillation and underwent treatment that afternoon.
In July 2010, Cheney was outfitted with a left-ventricular assist device (LVAD) at Inova Fairfax Heart and Vascular Institute to compensate for worsening congestive heart failure.
On March 24, 2012, Cheney underwent a seven-hour heart transplant procedure at Inova Fairfax Hospital in Falls Church, Virginia, at the age of 71.
From Wikipedia

5. Introduction
Atrial fibrillation begets atrial fibrillation. AF begets heart failure. HF begets AF.
RATE CONTROL & ANTICOAGULATION (AFFIRM) What about CHF? (AF-CHF)
Underlying substrate - optimize meds for HTN, HF
Device therapy: pacing - selective site, multiple site, minimize ventricular pacing, atrial therapies, CRT
Catheter Ablation - AVN RF & AF ablation (PVI)
AF in LVAD AND HT patients
Review of guidelines

6. AF is associated with increased risk of stroke, HF, and all-cause mortality
Mortality rate with AF is double that of patients in SR and linked to severity of underlying disease
SOLVD mortality 34% AF vs 23% SR
Difference in deaths due to HF rather than thromboembolism
COMET
No difference in all-cause mortality with AF at entry
Mortality increased if AF developed during follow-up
HF promotes AF, AF aggravates HF, and individuals who develop alternate condition share poor prognosis.

9. Copyright © The American College of Cardiology.
From: Rhythm Control in Heart Failure Patients With Atrial Fibrillation: Contemporary Challenges Including the Role of Ablation
J Am Coll Cardiol. 2014;64(7): doi: /j.jacc
Figure Legend:
∗Action potential duration heterogeneity includes spatial and temporal nonuniformities (36). ∗∗This mechanistic hypothesis has fallen out of favor with recent evidence (33).
Date of download:
2/1/2015
Copyright © The American College of Cardiology.
All rights reserved.

12. AFFIRM Primary Endpoint – Total Mortality30 25
Rhythm 20
Rate
Mortality (%) 15
p = unadjusted
p = adjusted 10 5
Note scale
P-value adjusted for interim monitoring
Total of 662 deaths:
Rate 306
Rhythm 356
Power to see a difference of > 30% was
> 90% 1 2 3 4 5
Time (Years)
No difference between strategies, but a late mortality advantage for rate control starting at about 2 years after randomization.

13. Implications of AFFIRM
Rate control is appropriate primary therapy
Anticoagulation for all with one or more risk factors for stroke
What therapies are under-represented?
Non-pharmacologic therapies
Who is under-represented in AFFIRM?
Young patients
Paroxysmal atrial fibrillation
Disabling symptoms of AF
CHF

14. Rhythm Control Drugs in HF
What drug(s) are indicated for HF patients?
Propafenone
Amiodarone
Sotalol
Dofetilide
1&3
2&4

15. AF-CHF Trial

16. AF-CHF Study Design

17. Strategy Algorithm

18. Baseline Characteristics

19. Medical Therapy at 12 Months

20. Primary Endpoint: Cardiovascular Death

21. Secondary Endpoints

22. AF-CHF Conclusions

23. AF Ablation: Pulmonary Vein Isolation (PVI)

24. Copyright © The American College of Cardiology.
From: Rhythm Control in Heart Failure Patients With Atrial Fibrillation: Contemporary Challenges Including the Role of Ablation
J Am Coll Cardiol. 2014;64(7): doi: /j.jacc
Figure Legend:
CFAE = complex fractionated atrial electrogram; PV = pulmonary vein; PVI = pulmonary vein isolation; other abbreviations as in Figure 1.
Date of download:
2/1/2015
Copyright © The American College of Cardiology.
All rights reserved.

25. AV Node Ablation Does not eliminate AF
Effective in controlling ventricular rate
Improves:
QOL
Exercise tolerance
Left ventricular function
No deleterious effect on survival

27. Copyright © The American College of Cardiology.
From: Rhythm Control in Heart Failure Patients With Atrial Fibrillation: Contemporary Challenges Including the Role of Ablation
J Am Coll Cardiol. 2014;64(7): doi: /j.jacc
Table Title:
Key Questions Specific to Catheter Ablation of AF in Patients With HF
Date of download:
2/1/2015
Copyright © The American College of Cardiology.
All rights reserved.

28. Clinical Impact of AF in Patients with LVAD
AF develops in up to 50% of patients with LVADs
PAF is not associated with worse outcomes in patients with HMII LVAD
Persistent AF may be associated with increased mortality and HF hospitalization
Patients with AF may have thromboembolic events at higher INR levels
JACC. 2014;64(18):

29. AF post-heart transplantation
J Am Heart Assoc Apr; 1(2): e
Published online 2012 Apr 24.

30. 2014 AHA/ACC/HRS Guideline for the Management of Patients with AF and CHF
Class I
In the absence of pre-excitation, intravenous beta-blocker administration is recommended to slow the ventricular response to AF in the acute setting, with caution needed in patients with overt congestion, hypotension, or HF with reduced EF
In the absence of pre-excitation, intravenous digoxin or amiodarone is recommended to control heart rate acutely in patients with HF
Digoxin is effective to control resting heart rate in patients with HF with reduced EF
JACC. 2014;64(21):

31. Guideline: AF and CHF Class IIa
A combination of digoxin and a beta blocker is reasonable to control resting and exercise heart rate in patients with AF
It is reasonable to perform AV node ablation with ventricular pacing to control heart rate when pharmacological therapy is insufficient or not tolerated
Intravenous amiodarone can be useful to control heart rate in patients with AF when other measures are unsuccessful or contraindicated
JACC. 2014;64(21):

32. Guideline: AF and CHF Class IIa
For patients with AF and rapid ventricular response causing tachycardia-induced cardiomyopathy, it is reasonable to achieve rate control by either AV nodal blockade or a rhythm-control strategy
For patients with chronic HF who remain symptomatic from AF despite a rate-control strategy, it is reasonable to use a rhythm-control srategy
JACC. 2014;64(21):

33. Guideline: AF and CHF Class IIb
Oral amiodarone may be considered when resting and exercise heart rate cannot be adequately controlled using a beta blocker or digoxin, alone or in combination
AV node ablation may be considered when the rate cannot be controlled and tachycardia-mediated cardiomyopathy is suspected
JACC. 2014;64(21):

34. Guideline: AF and CHF Class III:Harm
AV node ablation should not be performed without a pharmacological trial to achieve ventricular rate control
For rate control, intravenous nondihydropyridine calcium channel antagonists, intravenous beta blockers, and dronedarone should not be administered to patients with decompensated HF
JACC. 2014;64(21):

35. Increased Mortality Associated with Digoxin in Patients with AF: The TREAT-AF Study
Digoxin is widely used to control the ventricular rate in patients with AF, but evidence supporting safety and efficacy are limited
In patients with recently identified AF, treatment with digoxin was associated with an increased risk of death, independent of kidney function or cardiovascular comorbidities
Consider alternatives to digoxin in managing AF
Prospective studies are needed to confirm findings and explore mechanisms for increased mortality
TREAT-AF (The Retrospective Evaluation and
Assessment of Therapies in AF)
JACC 2014;64(7):

36. Conclusions 1.) Increasing evidence of interaction AF and HF
2.) Rhythm control and anticoagulation appropriate primary therapy for most patients
3.) Management of underlying substrate and device therapy when appropriate
4.) Evolving role of atrial fibrillation ablation