Ablation for Atrial Fibrillation in Heart Failure with Reduced Ejection Fraction.
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ABSTRACT:
SUBMITTER: Liang JJ
PROVIDER: S-EPMC5971677 | biostudies-other | 2018 May
REPOSITORIES: biostudies-other
Publications
Ablation for Atrial Fibrillation in Heart Failure with Reduced Ejection Fraction.
Liang Jackson J JJ Callans David J DJ
Cardiac failure review 20180501 1
AF and heart failure with reduced ejection fraction (HFrEF) frequently coexist. Catheter ablation is an increasingly utilised treatment strategy for patients with AF and can be safely performed and is effective in achieving sinus rhythm for patients with HFrEF. Successful ablation may result in improved LV function, clinical heart failure status, quality of life and possibly even mortality. This review summarises the literature analysing efficacy, safety and outcomes of AF ablation for patients ...[more]
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Project description:BackgroundRandomized clinical trials have demonstrated that catheter ablation for atrial fibrillation in patients with heart failure with reduced ejection fraction may improve survival and other cardiovascular outcomes.MethodsWe constructed a decision-analytic Markov model to estimate the costs and benefits of catheter ablation and medical management in patients with symptomatic heart failure with reduced ejection fraction (left ventricular ejection fraction ≤35%) and atrial fibrillation over a lifetime horizon. Evidence from the published literature informed the model inputs, including clinical effectiveness data from meta-analyses. Probabilistic and deterministic sensitivity analyses were performed. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective.ResultsCatheter ablation was associated with 6.47 (95% CI, 5.89-6.93) quality-adjusted life years (QALYs) and a total cost of $105 657 (95% CI, $55 311-$191 934; 2018 US dollars), compared with 5.30 (95% CI, 5.20-5.39) QALYs and $63 040 (95% CI, $37 624-$102 260) for medical management. The incremental cost-effectiveness ratio for catheter ablation compared with medical management was $38 496 (95% CI, $5583-$117 510) per QALY gained. Model inputs with the greatest variation on incremental cost-effectiveness ratio estimates were the cost of ablation and the effect of catheter ablation on mortality reduction. When assuming a more conservative estimate of the treatment effect of catheter ablation on mortality (hazard ratio of 0.86), the estimated incremental cost-effectiveness ratio was $74 403 per QALY gained. At a willingness-to-pay threshold of $100 000 per QALY gained, atrial fibrillation ablation was found to be economically favorable compared with medical management in 95% of simulations.ConclusionsCatheter ablation in patients with heart failure with reduced ejection fraction patients and atrial fibrillation may be considered economically attractive at current benchmarks for societal willingness-to-pay in the United States.
| S-EPMC7738404 | biostudies-literature
Project description:AimsPatients with heart failure with reduced ejection fraction (HFrEF) are at significant risk of stroke. Anticoagulation reduces this risk in patients with and without atrial fibrillation (AF), but the risk-to-benefit balance in the latter group, overall, is not favourable. Identification of patients with HFrEF, without AF, at the highest risk of stroke may allow targeted and safer use of prophylactic anticoagulant therapy.Methods and resultsIn a pooled patient-level cohort of the PARADIGM-HF, ATMOSPHERE, and DAPA-HF trials, a previously derived simple risk model for stroke, consisting of three variables (history of prior stroke, insulin-treated diabetes, and plasma N-terminal pro-B-type natriuretic peptide level), was validated. Of the 20 159 patients included, 12 751 patients did not have AF at baseline. Among patients without AF, 346 (2.7%) experienced a stroke over a median follow up of 2.0 years (rate 11.7 per 1000 patient-years). The risk for stroke increased with increasing risk score: fourth quintile hazard ratio (HR) 2.35 [95% confidence interval (CI) 1.60-3.45]; fifth quintile HR 3.73 (95% CI 2.58-5.38), with the first quintile as reference. For patients in the top quintile, the rate of stroke was 21.2 per 1000 patient-years, similar to participants with AF not receiving anticoagulation (20.1 per 1000 patient-years). Model discrimination was good with a C-index of 0.84 (0.75-0.91).ConclusionIt is possible to identify a subset of HFrEF patients without AF with a stroke-risk equivalent to that of patients with AF who are not anticoagulated. In these patients, the risk-to-benefit balance might justify the use of prophylactic anticoagulation, but this hypothesis needs to be tested prospectively.
| S-EPMC9637422 | biostudies-literature
Project description:BackgroundThe role of catheter ablation (CA) is increasingly recognized as a reasonable therapeutic option in patients with atrial fibrillation (AF) and heart failure (HF).HypothesisWe aimed to compare CA to medical therapy in AF patients with HF with reduced ejection fraction (HFrEF).MethodsWe searched the literature for randomized clinical trials comparing CA to medical therapy in this population.ResultsSix trials with a total of 775 patients were included. AF was persistent in 95% of patients with a mean duration of 18.5 ± 23 months prior enrollment. The mean age was 62.2 ± 7.8 years, mostly males (83%) with mean left ventricular ejection fraction (LVEF) of 31.2 ± 6.7%. Compared to medical therapy, CA has significantly improved LVEF by 5.9% (Mean difference [MD] 5.93, confidence interval [CI] 3.59-8.27, P < 0.00001, I2 = 87%), quality of life, (MD -9.01, CI -15.56, -2.45, P = 0.007, I2 = 47%), and functional capacity (MD 25.82, CI 5.46-46.18, P = 0.01, I2 = 90%). CA has less HF hospital readmissions (odds ratio [OR] 0.5, CI 0.32-0.78, P = 0.002, I2 = 0%) and death from any cause (OR 0.46, CI 0.29-0.73, P = 0.0009, I2 = 0%). Freedom from AF during follow-up was higher in patients who had CA (OR 24.2, CI 6.94-84.41, P < 0.00001, I2 = 81%.ConclusionCA was superior to medical therapy in patients with AF and HFrEF in terms of symptoms, hemodynamic response, and clinical outcomes by reducing AF burden. However, these findings are applicable to the very specific patients enrolled in these trials.
| S-EPMC6489934 | biostudies-literature
Project description:BackgroundThis study evaluated the relationship between guideline adherence for heart failure (HF) with reduced ejection fraction (HFrEF) at discharge and relevant clinical outcomes in patients with acute HF with preserved ejection fraction (HFpEF) with or without atrial fibrillation (AF).MethodsWe analyzed Korean Acute Heart Failure Registry data for 707 patients with HFpEF with documented AF and 687 without AF. Guideline adherence was defined as good or poor according to the prescription of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and mineralocorticoid receptor antagonists. Anticoagulation adherence was also incorporated for the AF group.ResultsAmong patients with normal sinus rhythm, those with poor guideline adherence had a reduced prevalence of comorbidities and favorable clinical characteristics when compared with those with good guideline adherence. Using inverse probability of treatment weighting (IPTW) to address the bias of nonrandom treatment assignment, good adherence was associated with a poor 60-day composite endpoint in the multivariable Cox model (weighted hazard ratio [wHR], 1.74; 95% confidence interval [CI], 1.01-3.00; P = 0.045). For patients with AF, baseline clinical characteristics were similar according to the degree of adherence. The IPTW-adjusted analysis indicated that good adherence was significantly associated with the 60-day composite endpoint (wHR, 0.47; 95% CI, 0.27-0.79; P = 0.005). In the analysis excluding warfarin, good adherence was associated with 60-day re-hospitalization (wHR, 0.60; 95% CI, 0.37-0.98; P = 0.040), 1-year re-hospitalization (wHR, 0.67; 95% CI, 0.48-0.93; P = 0.018), and the composite endpoint (wHR, 0.77; 95% CI, 0.59-0.99; P = 0.041).ConclusionOur findings indicate that good adherence to guidelines for HFrEF is associated with a better 60-day composite endpoint in patients with HFpEF with AF.
| S-EPMC8524233 | biostudies-literature
Project description:AimsIvabradine is indicated for heart failure (HF) patients with reduced ejection fraction (HFrEF), but limited data are available with regards to the use of ivabradine in those with a history of paroxysmal atrial fibrillation (AF). To assess the effect of ivabradine in HFrEF patients with paroxysmal AF, we analysed heart failure (HF) hospitalization and mortality from multiple-centre registry database.Methods and resultsWe conducted a multicentre observational matched cohort study, and this study enrolled patient with symptomatic HFrEF from 1 January 2015 to 31 December 2018 who had a history of paroxysmal AF in Chang Gung Memorial Hospital medical database in Taiwan. A total of 2042 patients were eligible for the study, of whom 887 were prescribed with ivabradine and 1115 were not. The primary outcome, including HF hospitalization and cardiovascular death, and individual outcome during the 12 month observation period were analysed after inverse probability of treatment weighting. The ivabradine group had significantly lower mean heart rate after 12 months follow-up than the non-ivabradine group (P < 0.05). The primary outcome was significantly higher in the ivabradine group than the non-ivabradine group after 12 months follow-up (hazard ratio [HR] = 1.58; 95% confidence interval [CI], 1.26-2.00, P < 0.001). Moreover, the ivabradine group had a significantly higher event rate of HF hospitalization (HR = 1.56; 95% CI, 1.40-1.75, P < 0.001) and HF death (HR = 1.67; 95% CI, 1.14-2.44, P = 0.009) than the non-ivabradine group.ConclusionsIvabradine treatment was associated with an increased risk of HF hospitalization in symptomatic HFrEF patients with a history of paroxysmal AF. Further prospective randomized studies are warranted.
| S-EPMC9288788 | biostudies-literature
Project description:BackgroundHeart failure (HF) and atrial fibrillation (AF) are often concomitant and act in a vicious cycle. Atrial fibrillation is associated with greater functional limitations and increased morbidity and mortality in patients with HF. Moreover, AF associated with HF increases patients' physical inactivity, worsening their clinical condition, and prognosis. Exercise training is safe and has clear benefits in HF. However, these benefits have not been demonstrated when AF is associated with HF.Case summaryWe present the case of a 57-year-old man with permanent AF and HF with reduced ejection fraction, who underwent 12 weeks of exercise training that included cardiopulmonary exercise testing, neuromuscular sympathetic activity (NMSA), and muscle blood flow (MBF) before and after training.DiscussionExercise training was shown to have a potential benefit in reducing the activity of the sympathetic nerve and increasing muscle blood flow, as well as increasing VO2peak and decreasing the VE/VCO2 slope in a patient with AF associated with HF with reduced ejection fraction. These results may indicate favourable clinical implications in this group of patients.
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Project description:BackgroundThere is a lack of research comparing procedural outcomes of surgical ablation (SA) and catheter ablation (CA) among patients with heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation (AF). The main objective was to compare the short-term procedural outcomes of SA and CA in patients with HFrEF.MethodsWe used the national inpatient sample to identify hospitalizations over 18 years with HFrEF hospitalization and AF, and undergoing SA and CA from 2016 to 2017. Furthermore, the clinical outcomes of SA vs CA in AF stratified as nonparoxysmal and paroxysmal were analyzed.ResultsA total of 1,770 HFrEF hospitalizations with AF who underwent SA and 1,620 HFrEF hospitalizations with AF who underwent CA were included in the analysis. Hospitalizations with CA had higher baseline comorbidities. The in-hospital mortality among HFrEF with AF undergoing SA as compared with CA was similar (2.8% vs 1.9%, respectively, adjusted P-value 0.09). Hospitalizations with SA had a significantly longer length of hospital stay, a higher percentage of postprocedural, and cardiac complications. In HFrEF hospitalizations with nonparoxysmal AF, SA as compared with CA was associated with a higher percentage of in-hospital mortality (2.4% vs 1%, adjusted P-value <.05), a longer length of stay, a higher cost of treatment, and a higher percentage of cardiac complications.ConclusionCA is associated with lower in-hospital adverse procedural outcomes as compared with SA among HFrEF hospitalizations with AF. Further research with freedom from AF as one of the outcome is needed between two groups for HFrEF.
| S-EPMC7896461 | biostudies-literature
Project description:AimsPatients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) have worse clinical outcomes than those with sinus rhythm (SR). We aim to investigate whether maintaining SR in patients with HFpEF through a strategy such as AF ablation would improve outcomes.Methods and resultsThis is a cohort study that analysed 1034 patients (median age 69 [63-76] years, 46.2% [478/1034] female) with HFpEF and AF. Of these, 392 patients who underwent first-time AF ablation were assigned to the ablation group, and the remaining 642 patients, who received only medical therapy, were assigned to the no ablation group. The primary endpoint was a composite of all-cause death or rehospitalization for worsening heart failure. After a median follow-up of 39 months, the cumulative incidence of the primary endpoint was significantly lower in the ablation group compared to the no ablation group (adjusted hazard ratio [HR], 0.55 [95% CI, 0.37-0.82], P = 0.003) in the propensity score-matched model. Secondary endpoint analysis showed that the benefit of AF ablation was mainly driven by a reduction in rehospitalization for worsening heart failure (adjusted HR, 0.52 [95% CI, 0.34-0.80], P = 0.003). Patients in the ablation group showed a 33% relative decrease in atrial tachycardia/AF recurrence compared to the no ablation group (adjusted HR, 0.67 [95% CI, 0.54-0.84], P < 0.001).ConclusionAmong patients with HFpEF and AF, the strategy of AF ablation to maintain SR was associated with a lower risk of the composite outcome of all-cause death or rehospitalization for worsening heart failure.
| S-EPMC10754157 | biostudies-literature
Project description:BACKGROUND:Previous randomized controlled trials (RCT)s showed similar outcomes in patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) treated with anti-arrhythmic drugs (AAD) compared to rate control therapy. We sought to evaluate whether catheter ablation is superior to medical therapy in patients with AF and HFrEF. METHODS:We searched electronic databases for all RCTs that compared catheter ablation and medical therapy (with or without use of AAD). We used random-effects models to summarize the studies. The primary end-point was all-cause mortality. Secondary outcomes included heart failure-related hospitalizations and change in left ventricular ejection fraction (LVEF). RESULTS:We retrieved and summarized 7 randomized controlled trials, enrolling 856 patients (429 in the catheter ablation arm and 427 in the medical therapy arm). Compared with medical therapy (including use of AAD), AF catheter ablation was associated with a significant reduction in mortality (risk ratio 0.50; 95% confidence interval [CI]: 0.34 to 0.74; P?=?0.0005) and heart failure-related hospitalizations (risk ratio 0.56; 95% CI: 0.44 to 0.71; P?<?0.0001). Furthermore, catheter ablation led to significant improvements in LVEF (weighted mean difference, 7.48; 95% CI: 3.71 to 11.26; P?<?0.0001). CONCLUSIONS:Compared to medical therapy, including use of AAD, catheter ablation for AF was associated with a significant reduction in mortality and heart failure-related hospitalizations as well as an improvement in LVEF in patients with HFrEF. Larger trials are needed to confirm whether rhythm control with ablation is superior to rate control in patients with AF and heart failure.
| S-EPMC6332840 | biostudies-literature
Project description:BackgroundAtrial fibrillation (AF) among patients with heart failure with reduced ejection fraction (HFrEF) is associated with adverse clinical outcomes. Our primary aim was to evaluate patient-centered outcomes and surrogate outcomes following catheter ablation (CA) of AF among patients with HFrEF compared to standard medical therapy with or without device therapy (atrioventricular node ablation and cardiac resynchronization therapy).MethodsA systematic literature review was performed limiting our searches to randomized control trials reporting outcomes of CA compared to standard medical therapy with or without device therapy were included. Patient-centered outcomes were relative reduction in all-cause mortality, heart failure readmissions, and recurrence of AF. Surrogate outcomes of interest were change in ejection fraction, change in peak oxygen consumption, reduction in brain natriuretic peptide levels, change in 6-minute walk distance, and change in Minnesota living with heart failure score.ResultsSeven randomized control trials (Patient n = 721) met our inclusion criteria. All trials used radiofrequency energy for CA of AF. CA for AF was associated with significantly lower all-cause mortality (Risk ratio [RR] = 0.52, 95% confidence interval [CI] = 0.35-0.76, P = 0.001, I 2 = 0%), lower rate of heart failure readmission (RR = 0.58, 95% CI = 0.46-0.74, P < 0.001, I 2 = 0%) and lower rate of AF recurrence (RR = 0.33, 95% CI = 0.22-0.50, P < 0.001, I 2 = 68%) as compared to standard medical therapy. Surrogate outcomes showed a similar benefit favoring CA.Conclusion and relevanceCatheter ablation for AF in HFrEF is associated with improvement in patient-centered outcomes and surrogate outcomes when compared to standard medical therapy with or without device therapy.
| S-EPMC6457370 | biostudies-literature