Rhythm control for patients with atrial fibrillation complicated with heart failure in the contemporary era of catheter ablation: a stratified pooled analysis of randomized data

Abstract

Aims The optimal treatment for patients with atrial fibrillation (AF) and heart failure (HF) has been a subject of debate for years. We aimed to evaluate the efficacy and safety of rhythm control strategy in patients with AF complicated with HF regarding hard clinical endpoints. Methods and results Up-to-date randomized data comparing rhythm control using antiarrhythmic drugs (AADs) vs. rate control (Subset A) or rhythm control using catheter ablation vs. medical therapy (Subset B) in AF and HF patients were pooled. The primary outcomes were all-cause mortality, re-hospitalization, stroke, and thromboembolic events. A total of 11 studies involving 3598 patients were enrolled (Subset A: 2486; Subset B: 1112). As compared with medical rate control, the AADs rhythm control was associated with similar all-cause mortality [odds ratio (OR): 0.96, P = 0.65], significantly higher rate of re-hospitalization (OR: 1.25, P = 0.01), and similar rate of stroke and thromboembolic events (OR: 0.91, P = 0.76,); however, as compared with medical therapy, catheter ablation rhythm control was associated with significantly lower all-cause mortality (OR: 0.51, P = 0.0003), reduced re-hospitalization rate (OR: 0.44, P = 0.003), similar rate of stroke events (OR: 0.59, P = 0.27), greater improvement in left ventricular ejection fraction [weighted mean difference (WMD): 6.8%, P = 0.0004], lower arrhythmia recurrence (29.6% vs. 80.1%, OR: 0.04, P < 0.00001), and greater improvement in quality of life (Minnesota Living with Heart Failure Questionnaire score) (WMD: −9.1, P = 0.007). Conclusion Catheter ablation as rhythm control strategy substantially improves survival rate, reduces re-hospitalization, increases the maintenance rate of sinus rhythm, contributes to preserve cardiac function, and improves quality of life for AF patients complicated with HF.

Cabins, castles, and constant hearts: rhythm control therapy in patients with atrial fibrillation

“…Improved exercise capacity and to some extent improved left ventricular function, but not lower BNP, could be partially explained by bias in unblinded trials. These effects have been extrapolated with a certain enthusiasm 61 . The largest trial comparing AF ablation with ‘medical therapy’ (mostly rate control, but including antiarrhythmic drugs) in patients with AF+HF is CASTLE-AF ( Table 2 ) 10 .…”

Meta-analysis of medical management versus catheter ablation for atrial fibrillation

“…All the RCTs included in our analysis were of high methodological quality. Because recent metaanalyses have only assessed AF patients with HF (Asad et al, 2019;Chen et al, 2019;Ruzieh et al, 2019;Virk et al, 2019), we included studies that enrolled AF patients without HF and with AHF. In ad- Fig.…”

Herzinsuffizienz und Arrhythmien

“…Nachdem in einigen kleineren, randomisierten Studien ein positiver Effekt der Katheterablation im Vergleich zur frequenzkontrollierenden Therapie auf linksventrikuläre Ejektionsfraktion, Lebensqualität, kardiopulmonale Belastbarkeit und Hospitalisationsrate gezeigt werden konnte [34 -36], wurde durch die prospektiv-randomisierte CASTLE-AF-Studie erstmals auch ein Überlebensvorteil durch die Katheterablation demonstriert [37]. Obwohl diese Studie methodische Schwächen aufwies (langsamer Einschluss, vorzeitiger Studienabbruch, höhere Komorbidität in der Vergleichsgruppe, hohe "Drop-out"-Rate), konnten die Ergebnisse inzwischen in Metaanalysen bestätigt werden [38,39], und die Katheterablation hat in den aktuellen VHF-Leitlinien des American College of Cardiology (ACC), der American Heart Association (AHA) und der Heart Rhythm Society (HRS) eine Klasse-IIb-Indikation erhalten [40]. Bei der Indikationsstellung zur VHF-Ablation muss allerdings berücksichtigt werden, dass die Erfolgsraten niedriger sind als bei Patienten ohne Herzinsuffizienz [41] und bei den oft älteren Patienten die Komplikationsraten höher [42].…”