1. Atrial Fibrillation and Congestive Heart Failure:
the chicken or egg story
Luc DE ROY

2. The 30 most important diagnoses
pathology
ICD
-9-CM
Number of
admissions
%
admissions
mean
duration
(days)
4 Chronic IHD 414 21996 1,35 9,2
12 Arrhythmias 427 17129 1,05 10,5
14
Angina
pectoris
413 16798 1,03 8,2
16 AMI 40 15881 0,98 13
17 CHF 428 15869 0,98 18,8

3.  Affects after the 40th year of life 26% of
men and 23% of all women
 Increases the risk for TIA/ CVA – HR: 3,9
 Causes myocardial dysfunction
 Worsens heart failure
Atrial fibrillation

4. AF begets HF and HF begets AFAF begets HF and HF begets AF

8. Fibrose met reentry ?

9. AF ontstaat bij een
belangrijke patiëntengroep
in de longvenen
Getriggerd ?

10. (bayes de luna ? – no - from Maurits Alessie)

11. (Wijffels, Alessie, Circulation 1995)

12. Atrial Fibrillation and congestive heart failure :
survival (cardiac death) according to treatment
adapted from Flaker, SPAF study 1992
0 90 180 270 360 450 540 630 720
Time in SPAF (days)
0
20
40
60
80
100
%
Def CHF, on AAD
Def CHF, off AAD

13. Klasse Ic Antiarrhythmic agents
AF + RBBB + LBBB
VT ?
Sinus

14. • What is known on the relationship of AF
and HF ?
• Is AF a marker of mortality ?
• What about the timing of onset of AF ?

15. 1. Is upstream therapy useful ?
2.Should we aim for sinus rhythm
(i.e. drugs, cardioversion, ablation) ?
3. Should we use CRT ?

18. Prognostic significance of AFPrognostic significance of AF
COMET: N= 3029 pts (20% with AF)
New Onset AF:New Onset AF: (multivariate) RR=1.90(multivariate) RR=1.90 Eur Heart J 2005;26:1303
c
Stopped prior to study start.
Figure 1 All-cause mortality by baseline atrial fibrillat ion.

19. EHS-HFEHS-HF
In-hospital mortality
7%7% 7%7% 12 %12 % 13 %13 %
P < 0.001P < 0.001 P < 0.001P < 0.001
No AF Previous AF New onset
AF
13 %13 % 19 %19 %
Rivero-Ayerza et al. Eur Heart J, 2008
EuroHeart Failure - MortalityEuroHeart Failure - Mortality
In-hospital mortality 12 week mortality

20. EHS-HF
No AF
(n=419)
Previous AF
(n=249)
New-onset AF
(n=123)
P-value
Worsening HF
Pulmonary oedema
Stroke
Other cardiovasc.
Non-cardiovascular
141 (34%)
99 (24%)
17 (4%)
79 (19%)
71 (17%)
71 (29%)
58 (23%)
27 (11%)
35 (14%)
40 (16%)
42 (34%)
34 (28%)
8 (7%)
27 (22%)
25 (20%)
0.551
0.794
0.014
0.298
0.768
Mode of Death ?Mode of Death ?
Rivero-Ayerza et al. Eur Heart J, 2008

23. Smit et al, Eur J HF 2012

24. Timing of AF in relation to HF
•AF patients developing HF seem to
have a better prognosis than HF
patients developing AF
•Development of AF in patients with HF
may be a sign of worsening HF

25. Upstream Therapy
• Renin-angiotensin-aldosterone
modulators
• Omega-3 fatty acids
• Statins
• Retrospective data better than
prospective …

26. Li D, Nattel et al. Circulation 2001
Control
5 Weeks
5 Weeks
+Enalapril
ACE inhibition reducesACE inhibition reduces
atrial fibrosis in a heart failure modelatrial fibrosis in a heart failure model

27. Amiodarone plus angiotensine I receptor blockers
maintain sinus rhythm
Madrid et al, 2002
dr
an
thy
hy
On
pr
ga
de
M
Th
tha
lon
hig
aro
pa
Figure2. Kaplan-Meier estimates of the percentage of patients
remaining free from recurrence of atrial fibrillation. Time to first
ECG-documented recurrence of atrial fibrillation since random-
ization. Days of follow-up (days), timed after cardioversion.
Madrid et al

28. 16-10-2001
ACE inhibitors and ARB`s
Savelieva I et al. Europace 2011;13:308-328

29. 16-10-2001
Efficacy of statins in prevention of atrial fibrillation
Savelieva I et al. Europace 2011;13:308-328

30. 16-10-2001
Upstream therapy after PVI in retrospective studies.
Savelieva I et al. Europace 2011;13:308-328

31. Maintaining sinus rhythm in CHF
• Why ?
• Drugs
• Cardioversion
• Ablation

32. DIAMONDDIAMOND
Pedersen et al. Circulation 2001;104:292
• 506 pts with LV dysfunction
• Randomized to Dofetilide or Placebo
• No effect on mortality
• Effect of SR on mortality RR 0.44 (0.30-0.64)
Survival according to Rx
Survival according to rhythm

33. AFFIRMAFFIRM
JACC 2005;46:1891 / NEJM 2002;347:1825
- SR improves survival
- AAD increase (non-cardiac)
mortality
- SR improved functional class

34. Cardioversion and CHF
• Traditionally delayed, unless
• Tachycardiomyopathy or emergent
restoration of sinus rhythm necessary
• few data available…

35. Recent
onset
ESC guidelines 2012

36. CLINICAL RESEARCH
Cardioversion for Atrial Fibrillation
Clinical correlates of immediate success
and outcome at 1-year follow-up of real-world
cardioversion of atrial fibrillation: the Euro
Heart Survey
Ron Pisters1,2*, Robby Nieuwlaat 3, Martin H. Prins4, Jean-Yves Le Heuzey5,
Aldo P. Maggioni6, A. John Camm 7, and Harry J.G.M. Crijns1,2 for the Euro Heart
Survey Investigators
1
Department of Cardiology, Maastricht University Medical Centre, The Netherlands; 2
Cardiovacular Research Institute Maastricht, Maastricht, The Netherlands; 3
Department of
Cardiology, Population Health Research Institute, Hamilton, Canada; 4
Department of Clinical Epidemiology, Maastricht University Medical Centre, The Netherlands; 5
Department of
Cardiology, Georges Pompidou Hospital, Rene´ Descartes University, Paris, France; 6
ANMCO Research Centre, Florence, Italy; and 7
Division of Clinical Sciences, St George’s
University, London, UK
Received 17 October 2011; accepted after revision 1 December 2011; online publish-ahead-of-print 5 January 2012
A im s In atrial fibrillation (AF) cardioversion is the cornerstone of the rhythm management strategy despite the lack of
contemporary dataon acute and long-term success. We aim to describe present-day cardioversion of AFand identify
Europace (2012) 14, 666–674
doi:10.1093/europace/eur406
http://europace.oxfordDownloadedfrom

37. CCV ECV
Transient ischaemic attack 13 (1.3) 2 (0.3)
Non-haemorrhagic stroke 1 (0.1) 2 (0.3)
Pisters et al, Europace 2012

38. CCV ECV
Success 71% (IV) 88%
Complications 64/643 38/712
Transient ischaemic attack 13(1.3%) 2(0.3%)
Non-haemorrhagic stroke 1(0.1%) 2(0.3%)
Pisters et al, Europace 2012

39. Markers of high risk: all related to CHF
• Thrombi in LA / LAA
• Spontaneous echo contrast
• Flow velocity profile in the LAA
• Low LA emptying velocity
• Dilatation above 6 sq cm

40. Indications for TEE
• Problematic anticoagulation
• Valvular disease
• LVD
• Prior stroke
• Enlarged LA (> 5cm)
• All new cases (duration < 1 month)

41. PVI ablation and CHF
• Normal anatomy ?
• Tachycardiomyopathy ?
• few data available…

42. Paroxysmal Persistent Permanent

43. ESC guidelines 2012

44. Endpoints: Ablation
success, LV function,
QOL, functional class
PV isolation & roof & PV-
MV lines. AADs
discontinued.
58 pts NYHA Class ≥
II, LVEF < 45%
referred for ablation
58 controls
matched for age,
sex, & AF class
Hsu et al; NEJM 2004;351:2373-2383

45. Management of AF in HFManagement of AF in HF
NEJM 2004:351
• 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

46. Anselmino M et al; JCE 2013
Ablation in left ventricular dysfunctionAblation in left ventricular dysfunction

47. CRT and AF
• AF patients were excluded from
the first studies
• new data available…

50. CRT and AF
• Assess % BV pacing
• Ablation of the AV node…
• new data available…

51. Figure 3
Effect of AV nodal ablation in patients with IHD versus DCM and a BV ICD
Sohinki et al, Eurpace 2013, in press

53. • Upstream therapy with ACE inhibitors
might be useful
• Cardioversion carries a higher risk for
emboli than is generally accepted
• PVI is useful in selected HF patients
• AV nodal ablation has a role in CRT,
especially in DCM
Conclusions

54. Conclusions
treat both conditions,
and as early as possible