Atrial Fibrillation and Heart failure: Good Old Friends

Adrian Baranchuk MD FACC FRCPC Associate Professor of Medicine Director, EP Training Program

Queen’s University

International Session: Asia Pacific Society of Cardiology, Inter-American Society of Cardiology and

American College of Cardiology San Diego, ACC.15

Conflict of Interest

•  Unrestricted Grant from Bayer •  Unrestricted Grant from

Medtronic •  Honorarium to deliver

conferences for Bayer, Boehringer Ingelheim, Medtronic, St Jude

•  No conflict of interest for this specific talk

Good Old Friends: What does it mean?

Old Friends Can Be Good Friends…but not necessarily…

•  Are AF and CHF Good friends?

•  Are they always together?

•  How do they treat each other?

•  Do they make favors to each other?

•  Are they the ONLY good friends in this story?

The Three Stooges: AF-CHF-OSA

AF

CHF

OSA

Overview

•  Epidemiology

•  Physiopathology

•  Interactions

•  Associations

•  Outcomes

Epidemiology: Facts about CHF

•  CHF affects 5,000,000 people in US

•  >550,000 new cases every year

•  12-15 million visits per year

•  6,5 million hospital/days per year

•  In 2007: 33 billion dollars

•  AF is the most common arrhythmia in daily practice

•  2.3 million people in NA

•  In the last 20 years, admission due to AF increased by 66%

•  By 2050, 5,6 million may have AF in NA

Epidemiology: Facts about AF

Physiopathology

CHF AF

Physiopathology

CHF AF

AF CHF Increased HR, shorter diastolic filling pressure, ↓ CO, irregularity of ventricular response, loss of atrial kick, Tachy-induced CM, impact of AAD

↑ cardiac filling pressures, Ca++ dysregulation, ANS dysfunction, neuroendocirne imbalance, dispersion of refractoriness, interstitial fibrosis

Interactions: Prognostic factor

OSA

A role for a trio rather than a duo?

CHF AF

•  OSA aggravates the course of CHF •  OSA and AF are associated •  AF and CHF are associated •  The presence of OSA turns difficult the treatment of AF &CHF

Sleep Apnea

Tachyarrhythmias Bradyarrhythmias

Atrial overdrivepacing

Heart failure

•  Supra/ventricular arrhythmia•  ? CRT

Autonomic dysfunction

•  Atrial Fibrillation•  Ventricular arrhythmia

•  Systemic hypertension•  Pulmonary hypertension

Stroke

Baranchuk et al. Europace 2008; 10(6):666-667

Challenges for treatment

•  OSA: no treatment implies more AF and CHF, but treatment may be deleterious in CHF (Canpap Study)

•  CHF: Treatment is mandatory to decrease both OSA & AF (Role of CRT)

•  AF: Treatment is beneficial to control physiopathological aspects, but maybe deleterious for CHF (AAD) + Poor impact on mortality. Role for Pace/ablate and for CRT/ablate

Rhythm control or Rate control for AF in patients with

CHF?

NEJM 2008

Invasive rate-control

•  PACE-Ablate: in patients with low LVEF it may aggravate CHF due to dyssynchrony

•  CRT-Ablate: as patients becomes dependent, CRT maybe beneficial to control for CHF (CERTIFY Study)

DOWNFALL: AF attenuates the benefit of CRT!!! PRO: Collateral benefit of CRT on OSA!!!!

“CRT reduces AHI in patients with Central SA but not in OSA”

Lamba, Baranchuk et al. Europace 2011

Invasive rhythm-control

•  PVI: Initial LVEF improvement, but the benefit depends on ability to stay in NSR without AAD

•  RAFT-AF Study: Ongoing

Bunch TJ. JCE 2014

(3 groups: AF ablation-267-, No AF ablation-1068-, No AF-1068)

Conclusions

•  More questions than answers despite >100 metaanalysis

•  AF-CHF-OSA are frequently associated

•  Selecting appropriate therapy is key

•  Controlling for impacting the other factor is also key

•  ADD can be deleterious for CHF

•  Pace-ablate in systolic dysfunction should be abandoned

•  Consider CRT-Ablate

•  Consider PVI as rhythm-control

Conclusions (cont)