Atrial Fibrillation In Heart Failure Patients Research Articles

Managing Atrial Fibrillation in Patients with Heart Failure

Atrial fibrillation (AF) in patients with heart failure (HF) is a growing problem because of the increasing incidence of HF related to long-standing hypertension, atrial remodeling due to elevated left ventricular diastolic pressure in HF patients, and the increasing age of the population. This article discusses the treatment of AF in HF patients.

A review of the epidemiological profile of patients with atrial fibrillation and heart failure

Heart failure (HF) and atrial fibrillation (AF) are cardiovascular diseases that have a continuously increasing prevelance and both often coexist. The presence of AF in HF patients has been reported as being between 10 and 50% depending on the different study settings. AF patients have a different clinical profile: they are older, with more severe HF and comorbidities than those without AF. Despite this poor clinical profile, observational studies report a lower use of the recommended treatments such as angiotensin-converting enzyme inhibitors and β-blockers. Clinical trials using antiarrhythmic drugs for rhythm control have failed to demonstrate the clinical advantage of a rhythm control approach over one for rate control. The prognostic role of AF in HF remains controversial, while the impact of new AF has been shown to be associated with an adverse outcome.

Atrial fibrillation and cardiac resynchronization therapy: how should rate be controlled?

Atrial fibrillation and cardiac resynchronization therapy: how should rate be controlled?

Managing atrial fibrillation in the CRT patient: Controversy or consensus?

The cumulative incidence of new onset atrial fibrillation (AF) in patients undergoing cardiac resynchronization therapy (CRT) is substantial, exceeding 25% in multiple recent studies. Although AF patients undergoing CRT show improved echocardiographic parameters, functional status, and quality of life in, they benefit to a lesser degree than do patients in normal sinus rhythm. They also exhibit a trend toward increased mortality. Understanding the barriers to response from CRT among AF patients is critical to addressing the needs of growing populations of patients with AF and HF. Foremost among these are suboptimal biventricular pacing, often characterized by fusion or pseudo-fusion complexes, leading to inefficient CRT delivery. Furthermore, AF increases the risk of inappropriate shocks, which lead to substantial psychiatric morbidity, increased risk of heart failure hospitalization, and may also increase mortality. Assiduous rate control is reasonable for all AF patients receiving CRT, but there is a paucity of data regarding specific antiarrhythmic drug therapy recommendations. For patients with permanent AF and severe symptoms, atrioventricular junction ablation appears effective in improving response by ensuring biventricular capture and reducing implantable cardioverter-defibrillator shock burden in selected patients. Catheter-based techniques such as pulmonary vein isolation appear more attractive and in the future may offer further advantages and lower risks, particularly for patients with paroxysmal AF.

The relationship between D-dimer level and the development of atrial fibrillation in patients with systolic heart failure

Heart failure (HF) is one of the most common and leading cause of death worldwide. Clinical trials provide evidence that the development of atrial fibrillation (AF) is a marker of poor prognosis in patients with HF. Furthermore, elevated D-dimer level is associated with increased cardiovascular mortality independent of AF in HF patients. We investigated whether plasma D-dimer levels in patients with hospitalized systolic HF could predict development of AF. A total of 150 consecutive patients with sinus rhythm who admitted to the emergency department with hospitalized systolic HF were evaluated. All hospitalized patients were obtained D-dimer levels within the first 24h following admission. Atrial fibrillation developed in 31 (20.7%) patients during follow-up period of 6.3±5months. Patients who developed atrial fibrillation had significantly increased levels of D-dimer [608 (339-1,022) ng/ml versus 1,100 (608-2,599) ng/ml, P=0.001]. Optimal cut-off level of D-dimer to predict development of AF was found to be>792ng/ml. D-dimer>792ng/ml, right ventricular dilatation, age, systolic pulmonary pressure, left atrium size, moderate to severe tricuspid regurgitation, and beta blocker usage were found to have prognostic significance in univariate analysis. In multivariate Cox proportional-hazards model, D-dimer levels>792ng/ml (HR=3.019, P=0.006), and right ventricular dilatation (HR=8.676, P=0.003) were associated with an increased risk of new-onset AF. In conclusion, D-dimer could predict development of AF in patients with hospitalized systolic HF.

Treatment of atrial fibrillation with a dual defibrillator in heart failure patients (TRADE HF): protocol for a randomized clinical trial

BackgroundHeart failure(HF) and atrial fibrillation(AF) frequently coexist in the same patient and are associated with increased mortality and frequent hospitalizations. As the concomitance of AF and HF is often associated with a poor prognosis, the prompt treatment of AF in HF patients may significantly improve outcome.Methods/designRecent implantable cardiac resynchronization (CRT) devices allow electrical therapies to treat AF automatically. TRADE-HF (trial registration: NCT00345592; http://www.clinicaltrials.gov) is a prospective, randomized, double arm study aimed at demonstrating the efficacy of an automatic, device-based therapy for treatment of atrial tachycardia and fibrillation(AT/AF) in patients indicated for CRT. The study compares automatic electrical therapy to a traditional more usual treatment of AT/AF: the goal is to demonstrate a reduction in a combined endpoint of unplanned hospitalizations for cardiac reasons, death from cardiovascular causes or permanent AF when using automatic atrial therapy as compared to the traditional approach involving hospitalization for symptoms and in-hospital treatment of AT/AF.DiscussionCRT pacemaker with the additional ability to convert AF as well as ventricular arrhythmias may play a simultaneous role in rhythm control and HF treatment. The value of the systematic implantation of CRT ICDs with the capacity to deliver atrial therapy in HF patients at risk of AF has not yet been explored. The TRADE-HF study will assess in CRT patients whether a strategy based on automatic management of atrial arrhythmias might be a valuable option to reduce the number of hospital admission and to reduce the progression the arrhythmia to a permanent form.Trial registrationNCT00345592

The incidence and prognostic significance of new-onset atrial fibrillation in patients with acute myocardial infarction and left ventricular systolic dysfunction: A CARISMA substudy

The incidence and risk associated with new-onset atrial fibrillation (AF) occurring after discharge in patients with acute myocardial infarction (MI) remains unknown. This study sought to describe the incidence and clinical risk associated with postdischarge new-onset AF in post-MI patients with left ventricular systolic dysfunction. The population included 271 post-MI patients with left ventricular ejection fraction ≤ 40% and no history of previous AF from the Cardiac Arrhythmias and Risk Stratification after Acute Myocardial Infarction (CARISMA) study. All patients were implanted with an implantable cardiac monitor and followed up every 3 months for 2 years. Major cardiovascular events were defined as reinfarction, stroke, hospitalization for heart failure, or death. The risk of new-onset AF is highest during the first 2 months after the acute MI (16% event rate) and decreases until month 12 post-MI, after which the risk for new-onset AF is stable. The risk of major cardiovascular events was increased in patients with AF events ≥ 30 seconds (hazard ratio [95% CI] = 2.73 [1.35 to 5.50], P = .005), but not in patients with AF events lasting <30 seconds (hazard ratio [95% CI] = 1.17 [0.35 to 3.92], P = .80). More than 90% of all recorded AF events were asymptomatic. Using an implantable cardiac monitor, the incidence of new-onset AF was found to be 4-fold higher than earlier reported. In the study population, in which treatment with beta-blockers was optimized, the vast majority of AF events were asymptomatic, emphasizing the importance of using continuous monitoring for studies concerning AF in heart failure patients. A duration of 30 seconds or more identified clinically important AF episodes documented by an implantable cardiac monitor.

Burden of asymptomatic episodes of atrial fibrillation in a heart failure cohort

Heart failure is associated with an increased risk of developing atrialfibrillation (AF). The prevalence of AF in heart failure patients is 20-50%compared to a prevalence of ???1% in the general population. Prevalencestudies rely on detecting AF by standard ECG which fails to detectasymptomatic episodes of AF that often occur during AF development.In patients with heart failure AF is associated with increased risk ofstroke, all cause mortality and hospitalisation, hence the importance ofidentifying these at risk patients.We examined the occurrence of AF in 162 heart failure patients with cardiacresynchronization therapy (CRT) devices. AF episodes were definedas a period of mode-switching on the CRT devices with atrial rate >200for over 30s. Patient records were reviewed to establish which patientswere known to have chronic or paroxysmal AF.Of the 162 patients, 43 had chronic AF (26.5%), 18 paroxysmal AF(11.1%), and 101 (62.3%) had no previous history of AF and were insinus rhythm at their last clinic appointment. Of the 101 patients notknown to have AF, 27 had significant episodes of AF (26.7%, Fig. 1A)with mean AF burden of 1.6??0.9% and longest duration of 5.6??2.3hours (Fig 1B). The mean AF burden (30.6??8.8%, p<0.01) and longestduration (635??355 hours, p<0.05) were significantly larger in patientswith known paroxysmal AF as were the rates of anticoagulation rates(83.3% vs. 13.5% respectively, p<0.01).A significant number of patients with heart failure suffer from asymptomaticundiagnosed episodes AF and are often not anticoagulated. Comparedto patients with known AF patients with undiagnosed AF have lessAF burden. Further studies are warranted to assess the true burden ofatrial fibrillation and the need for formal anticoagulation in these ???atrisk??? heart failure patients.

Atrial fibrillation in heart failure patients: Prevalence in daily practice and effect on the severity of symptoms. Data from the ALPHA study registry

Estimates of the prevalence of atrial fibrillation (AF) in heart failure (HF) originate from patients enrolled in clinical trials. To assess the prevalence and clinical correlates of AF among HF patients in everyday clinical practice from HF patients screened for the T-wave ALternans in Patients with Heart fAilure (ALPHA) study; to investigate the correlation between AF and functional status. Consecutive patients (N=3513) seen at nine Heart Failure Clinics were studied; 21.4% were in AF. AF prevalence was greater with increasing age (OR 1.04/year, p<0.001) in non-ischaemic cardiomyopathy (OR 2.34, p<0.001) and with increasing NYHA class (p<0.0001). Multiple logistic regression predictors of AF were age >70 years (OR 2.35), NYHA class II III or IV vs class I (OR 1.8, 4.4 and 3.1) and non-ischaemic cardiomyopathy (OR 3.2). A logistic model indicated that AF was associated with a 2.5 OR of being in NYHA class III-IV vs I-II while accounting for age, gender, left ventricular ejection fraction (LVEF), and aetiology of HF. The prevalence of AF in HF patients exceeds 20%, and increases with age and functional class. The presence of AF leads to a more severe NYHA class, indicating that AF contributes to the severity of heart failure.

Association of New Parameters Derived from Relation between RR intervals and Left Ventricular Performances with Heart Failure in Patients with Atrial Fibrillation and Normal Systolic Function

Background and Objectives:Heart failure (HF) may occur in atrial fibrillation (AF) patients with a normal left ventricular (LV) systolic function if the diastolic function is impaired. The association of new parameters from the relationship between the preceding RR interval (RR-1) and LV outflow peak ejection velocity (Vpe) with systolic function has been reported. The aim of this study was to observe whether these parameters were associated with HF in AF patients with a normal systolic function. Subjects and Methods:AF patients with a normal systolic function were divided into two groups according to the presence (n=16) or absence (n=30) of a history of HF. From the logarithmic equation between RR-1 and Vpe, the slope, Vpe at RR-1 second (Vpe-1), and Slope/Vpe1 were calculated. Results:Patients with a history of HF were older (p=0.037) and tended to more frequently have hypertension (p=0.063) than those with no history of HF. The ejection fractions were similar between the two groups. In the coordinates with RR-1 from 0.6 to 1 second, the slope tended to be steeper (p=0.074) and slope/ Vpe-1 was higher in patients with a history of HF (p=0.011). The Vpe-1 was similar between the two groups (p= 0.66). A multiple forward logistic regression analysis showed that slope/Vpe-1 was the only independent variable associated with the occurrence of HF. Slope/Vpe-1 was related with aortic regurgitation, HF history, and the interventricular septal thickness in a multiple stepwise regression analysis. Conclusion:New parameters from the relationship between the RR intervals and LV performances were associated with the occurrence of HF in AF patients with a normal systolic function. This finding suggests that these parameters may be related with the LV diastolic function. (Korean Circulation J 2007;37:119-126)

Atrial fibrillation, ischaemic heart disease, and the risk of death in patients with heart failure

Atrial fibrillation (AF) is a risk factor for death in patients with a myocardial infarction, but highly variable results are reported in patients with heart failure. We studied the prognostic impact of AF in heart failure patients with and without ischaemic heart disease. During a period of 2 years, 3587 patients admitted to hospital because of heart failure were included in this study. All patients were examined by echocardiography and the presence of AF was recorded. Follow-up was available for 8 years. Twenty four percent of those discharged alive from hospital had AF. After 4 and 8 years of follow-up, mortality was higher in patients with AF than in patients without, 56 vs. 52% and 77 vs. 73%, respectively. Cox multivariable regression analysis showed a small but significant importance of AF for long-term mortality [hazard ratio (HR) 1.12, 95% confidence limits (CI), 1.02-1.23, P=0.018]. There was a significant interaction between the importance of AF and the presence of ischaemic heart disease (P=0.034). In patients with AF at the time of discharge and ischaemic heart disease, HR was 1.25 (95% CI: 1.09-1.42) and P<0.001; in patients with AF at discharge and without ischaemic heart disease, HR was 1.01 (95% CI: 0.88-1.16) and P=0.88. AF is associated with increased risk of death only in patients with ischaemic heart disease. This finding may explain the variable results of studies of the prognosis associated with AF in heart failure.