A Compelling Case for Less Aggressive Arrhythmia Management in Patients With Chronic Heart Failure and Long-Standing Atrial Fibrillation.
Anti-Arrhythmia Agents
/ administration & dosage
Anticoagulants
/ administration & dosage
Atrial Fibrillation
/ epidemiology
Cardiac Catheterization
/ methods
Chronic Disease
Disease Management
Female
Heart Failure
/ epidemiology
Heart Rate
/ drug effects
Humans
Male
Randomized Controlled Trials as Topic
/ methods
Atrial fibrillation
heart failure
rate control
rhythm control
Journal
Journal of cardiac failure
ISSN: 1532-8414
Titre abrégé: J Card Fail
Pays: United States
ID NLM: 9442138
Informations de publication
Date de publication:
Jan 2020
Jan 2020
Historique:
received:
18
06
2019
revised:
06
08
2019
accepted:
20
08
2019
pubmed:
30
8
2019
medline:
16
4
2021
entrez:
30
8
2019
Statut:
ppublish
Résumé
Atrial fibrillation (AF) is common in chronic heart failure, and some have advocated intensive rate and/or rhythm control strategies for these patients. However, the loss of atrial systole and irregularity of the ventricular response has not been shown to contribute to the progression of heart failure, and the presence or rate of long-standing AF in patients with chronic heart failure does not have prognostic significance. In randomized clinical trials, pharmacological rhythm control has not been shown to be superior to rate-control in influencing long-term outcomes, but the use of membrane-active antiarrhythmic drugs can increase the risk of both pump failure and arrhythmic deaths in patients with heart failure. Additionally, intensive efforts to slow the ventricular rate in AF can potentially cause clinically inapparent bradyarrhythmias, which can trigger rate-dependent lethal rhythm disturbances or hemodynamic abnormalities. In patients with AF, a more stringent approach to rate control (target rate <80/min) is not superior to a more lenient strategy (target rate <110/min) on the risk of major events. Little is known about the effects of catheter ablation of long-standing AF in established heart failure, particularly in patients with a preserved or a meaningfully reduced ejection fraction, but ablation can add to the fibrotic burden of the left atrium and impair its capacitance functions. For all of these reasons, the management of heart failure and long-standing AF should be primarily directed to slowing of the progression of their underlying cardiomyopathic process rather than the treatment of the arrhythmia. In addition, patients should receive long-term oral anticoagulation with non-vitamin K-antagonist oral anticoagulants to reduce the risk of thromboembolic events. The utility of intensive rate and rhythm control interventions for long-standing AF in patients with established heart failure requires further study.
Sections du résumé
BACKGROUND AND METHODS
METHODS
Atrial fibrillation (AF) is common in chronic heart failure, and some have advocated intensive rate and/or rhythm control strategies for these patients. However, the loss of atrial systole and irregularity of the ventricular response has not been shown to contribute to the progression of heart failure, and the presence or rate of long-standing AF in patients with chronic heart failure does not have prognostic significance.
RESULTS
RESULTS
In randomized clinical trials, pharmacological rhythm control has not been shown to be superior to rate-control in influencing long-term outcomes, but the use of membrane-active antiarrhythmic drugs can increase the risk of both pump failure and arrhythmic deaths in patients with heart failure. Additionally, intensive efforts to slow the ventricular rate in AF can potentially cause clinically inapparent bradyarrhythmias, which can trigger rate-dependent lethal rhythm disturbances or hemodynamic abnormalities. In patients with AF, a more stringent approach to rate control (target rate <80/min) is not superior to a more lenient strategy (target rate <110/min) on the risk of major events. Little is known about the effects of catheter ablation of long-standing AF in established heart failure, particularly in patients with a preserved or a meaningfully reduced ejection fraction, but ablation can add to the fibrotic burden of the left atrium and impair its capacitance functions.
CONCLUSIONS
CONCLUSIONS
For all of these reasons, the management of heart failure and long-standing AF should be primarily directed to slowing of the progression of their underlying cardiomyopathic process rather than the treatment of the arrhythmia. In addition, patients should receive long-term oral anticoagulation with non-vitamin K-antagonist oral anticoagulants to reduce the risk of thromboembolic events. The utility of intensive rate and rhythm control interventions for long-standing AF in patients with established heart failure requires further study.
Identifiants
pubmed: 31465842
pii: S1071-9164(19)30648-7
doi: 10.1016/j.cardfail.2019.08.011
pii:
doi:
Substances chimiques
Anti-Arrhythmia Agents
0
Anticoagulants
0
Types de publication
Journal Article
Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
85-92Informations de copyright
Copyright © 2019 Elsevier Inc. All rights reserved.