Atrial Fibrillation in Heart Failure US Ambulatory Cardiology Practices and the Potential for Uptake of Catheter Ablation: An National Cardiovascular Data Registry (NCDR ^® ) Research to Practice (R2P) Project

Abstract

BackgroundAtrial fibrillation (AF) and heart failure with reduced ejection fraction frequently coexist. The AATAC (Ablation versus Amiodarone for Treatment of persistent Atrial fibrillation in patients with Congestive heart failure and an implantable device) trial suggests that catheter ablation may benefit these patients. However, applicability to contemporary ambulatory cardiology practice is unknown.Methods and ResultsUsing the outpatient National Cardiovascular Data Registry® Practice Innovation and Clinical Excellence Registry, we identified participants meeting AATAC enrollment criteria between 2013 and 2014. Treatment with medications and procedures was assessed at registry inclusion. From 164 166 patients with AF and heart failure, 8483 (7%) patients potentially met AATAC inclusion criteria. Eligible subjects, compared to AATAC trial participants, were older (mean age, 71.2±11.4 years) and had greater comorbidity (coronary artery disease 79.2%, hypertension 82.4%, and diabetes mellitus 31.8%). AF was predominantly paroxysmal (65.5%), rather than persistent/permanent (16.7%) or new onset (17.8%), whereas all patients in the AATAC trial had persistent AF. Commonly used atrioventricular‐nodal blocking agents were carvedilol (71.2%), digoxin (31.9%), and metoprolol (27.1%). Rhythm control with anti‐arrhythmic drugs was reported in 29.0% of AATAC eligible patients (predominantly amiodarone [24.6%]) and 9.3% had undergone catheter ablation. Patients who underwent ablation were more likely to be younger and have less comorbidities than those who did not.ConclusionsAmong the contemporary ambulatory AF/heart failure with reduced ejection fraction population, treatment is predominantly rate control with few catheter ablations. Application of AATAC findings has the potential to markedly increase the use of catheter ablation in this population, although significant differences in clinical profiles might influence ablation outcomes in practice.

European Heart Rhythm Association (EHRA)/Heart Rhythm Society (HRS)/Asia Pacific Heart Rhythm Society (APHRS)/Latin American Heart Rhythm Society (LAHRS) expert consensus on risk assessment in cardiac arrhythmias: use the right tool for the right outcome, in the right population

“…Management can vary widely according to presentation and should be individualized since treatments shown to be effective in one or other condition alone, may give rise to safety or efficacy issues in an individual patient. Several recent trials have suggested a preferential role for primary catheter ablation of AF in select AF patients with HF compared to medical therapy alone 296–298 . Treatment of AF by either rate or rhythm control may reverse the cardiomyopathy and improve clinical HF substantially in selected patients.…”

Catheter ablation of atrial fibrillation—A key role in heart failure therapy?

“…Upon the reestablishment of SR, HF patients potentially benefit from atrial contraction improving diastolic filling and the restoration of atrio‐ventricular sequential activation. Conclusively, a relief of HF related symptoms was observed upon cardiac rhythm control . However, until recently, randomized trials failed to prove that the hemodynamic benefits of rhythm control strategies translate into decreased mortality.…”

“…Another important trial suggesting benefits of ablation in HF patients suffering from AF was AATAC (Ablation vs Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients with Congestive Heart Failure and an Implanted Device), published in 2016 . It was an open‐label, randomized and multicenter trial.…”

“…Conclusively, a relief of HF related symptoms was observed upon cardiac rhythm control. 18,22 However, until recently, randomized trials failed to prove that the hemodynamic benefits of rhythm control strategies translate into decreased mortality.…”

“…Heart Failure and an Implanted Device), published in 2016. 2,22 It was an open-label, randomized and multicenter trial. The study enrolled patients with persistent AF, dual chamber implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D), NYHA II or III and LVEF <40%.…”