Atrial Fibrillation and Heart Failure. Time to Change the Approach?

Editorial

Congestive heart failure is a prevalent disease in the Western society. Recent data determine the approximately 2% of the world population have heart failure with impressive 10% among people older than 70 years. Atrial Fibrillation (AF) is the most frequent sustain arrhythmia and his incidence increase with age and some comorbidities approximately 20% of Heart Failure (HF) patients have AF, and it worst this patients prognosis increasing in 1.2 times the risk for death and hospitalization [1-3].

The coexistence of atrial fibrillation and heart failure is associated with several clinical end points. AF not only increases the risk of death in HF patients but also increase the risk of thromboembolic complications if not properly anticoagulated patients [1-4].

Although the prognosis is better in heart failure patients in sinus rhythm, previously studies failed to show superiority in the rhythm control therapy with Antiarrythmics Drugs (AAD) against the rate control therapy in patients with atrial fibrillation and heart failure. Catheter ablation shown to be superior to AAD in maintenance of the sinus rhythm and also improve exercise capacity, quality of life and symptoms [1,4-6].

Recently was published the CASTLE AF, trying to answer a very ancient question in HF, is better to control the heart rate frequency or should we try to get to the physiological rhythm? It was 363 patients randomized in 2 strategies (catheter ablation and medical therapy), and one very interesting data is that all patients had a device that controlled the atrial fibrillation burden [7].

The results of AF burden wasn’t suprising at all, but the most impressive data was the reduction of primary end-point of death or hospitalization for worsening heart failure with a NNT of 6.2 in favor of ablation therapy. With early benefits, the Kaplan Meyer curve opens before one year. And another interesing data is the increase of mean ejection fraction of 8%, achieving from 2.2 to impressive 19.1% [7].

At the moment, ablation for AF in heart failure is class IIb of the ESC guidelines but after castle AF we probably are going to have some changes [1].

References

1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016; 20: 592.
2. Chioncel O, Lainscak M, Seferovic PM, Anker SD, Crespo-Leiro MG, Harjola VP, et al. Epidemiology and one-year outcomes in patients with chronic heart failure and preserved, mid-range and reduced ejection fraction: an analysis of the ESC Heart Failure Long-Term Registry. Eur J Heart Fail. 2017; 19:1574- 1585.
3. Swedberg K, Olsson LG, Charlesworth A, Cleland J, Hanrath P, Komajda M, et al. Prognostic relevance of atrial fibrillation in patients with chronic heart failure on long-term treatment with beta-blockers: results from COMET. Eur Heart J. 2005; 26: 1303-1308.
4. Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, Lee KL, et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008; 358: 2667–2677.
5. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014; 130: 2071-104.
6. Rose-Jones LJ, Bode WD, Gehi AK. Current approaches to antiarrhythmic therapy in heart failure. Heart Fail Clin. 2014; 10: 635-52.
7. Marrouche NF, Brachmann J, Andresen D, Siebels J, Boersma L, Jordaens L, et al. Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med. 2018; 378: 417-427.