Rung nhĩ ở người bệnh suy tim điều trị năm 2014 có gì mới

Management of atrial fibrillation in patients with heart failure: what's new in 2014? Dr Reginald Liew MA, MBBS (Hons), PhD (Lond), FRCP (UK), FESC, FACC Senior Consultant Cardiologist, Gleneagles Hospital Asst Prof Duke-NUS Graduate Medical School, Singapore No conflict of interests to disclose Outline of talk • Incidence/ Pathophysiology of AF in patients with heart failure • Rate versus rhythm control • AVN ablation and PPM/ CRT insertion • Catheter ablation of AF in heart failure patients • HF with impaired LV function • HF with preserved EF Outline of talk • Incidence/ Pathophysiology of AF in patients with heart failure • Rate versus rhythm control • AVN ablation and PPM/ CRT insertion • Catheter ablation of AF in heart failure patients • HF with impaired LV function • HF with preserved EF Prevalence of AF in patients enrolled in HF studies • AF is very common in patients with heart failure • Incidence is around 20-50% from heart failure studies Hazard ratios of shared risk factors in patients with AF and heart failure Trulock et al JACC 2014; vol 64, no Pathophysiological relationship between AF and heart failure Trulock et al JACC 2014; vol 64, no Treatment options for AF in patients with heart failure Control ventricular rate • Beta-blockers, Ca- channel blockers, digoxin AVN ablation and insertion of PPM/ CRT device Restore SR (if persistent AF) with DC cardioversion + AAD Catheter ablation of AF • Stroke prevention with oral anticoagulation Outline of talk • Incidence/ Pathophysiology of AF in patients with heart failure • Rate versus rhythm control • AVN ablation and PPM/ CRT insertion • Catheter ablation of AF in heart failure patients • HF with impaired LV function • HF with preserved EF Rate v Rhythm control in heart failure patients with AF • No study has shown an overall survival benefit of either strategy – e.g RACE, AF-CHF, ANDROMEDA, AFFIRM, DIAMOND, CAFÉ II • However, the trials tested treatment strategies and not true rate v rhythm control – Substantial cross-over between treatment arms – Improved QoL in patients who remained in SR • Newer drugs are being studied (e.g ranolazine- Na Channel blocker) and possible future role for genetic test in best choice of drug (e.g genotypedirected bucindolol therapy in HF and AF) • Pts with AF and structural heart disease have limited choice of AAD due to toxicities and risk of TdP Lenient v strict rate control in AF Van Gelder et al NEJM 2010; 362(15):1363-73 • 614 pts with permanent AF randomly assigned to: • • • • Lenient rate control ([...]... catheter ablation in AF and heart failure Trulock et al JACC 2014; vol 64, no 7 AP n PA View of Ablation Spots on PV veins and Roof CFAE lesions in yellow RIPV isolation Major trials of AF ablation in patients with heart failure Trulock et al JACC 2014; vol 64, no 7 Major trials of AF ablation in patients with heart failure Trulock et al JACC 2014; vol 64, no 7 Jones et al JACC, vol 61, no 18, 2013 Primary... JACC, vol 61, no 18, 2013 Meta-analysis of AF ablation in pts with heart failure and LV systolic dysfunction Anselmino et al Circulation Arr and Electro 2014 (in press) Change in LVEF and NT-proBNP post ablation Anselmino et al Circulation Arr and Electro 2014 (in press) • Single centre, cohort study • AF ablation performed in 74 consecutive patients with compensated HFPEF (LVEF>50%) • LV strain and strain... 10 RCTs (18,254 pts) • Beta-blockers have no survival advantage or benefits on reduced hospital admissions in HF pts with AF, unlike their beneficial effects in HF patients in SR Kotecha et al Lancet 2014 (in press) Outline of talk • Incidence/ Pathophysiology of AF in patients with heart failure • Rate versus rhythm control • AVN ablation and PPM/ CRT insertion • Catheter ablation of AF in heart failure