Arrhythmias and conduction disturbances - 2021 ESC Guidelines for the Diagnosis and Treatment o

12.1.1 Atrial fibrillation

AF and HF frequently coexist.

^519,520

They can cause or exacerbate each other through mechanisms such as structural cardiac remodel- ling, activation of neurohormonal systems, and rate-related LV

impairment.

⁵¹⁹⁵²³

The proportion of patients with HF who develop AF increases with age and HF severity. When AF causes HF the clini- cal course seems more favourable than with other causes of HF (so called tachycardiomyopathy).

⁵²⁴

In contrast, development of AF in patients with chronic HF is associated with worse prognosis, includ- ing stroke and increased mortality.

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The management of patients with concomitant HF and AF is sum- marized in Figure 14.

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It includes:

(1) Identification and treatment of possible causes or triggers of AF (2) Management of HF

(3) Prevention of embolic events (4) Rate control

(5) Rhythm control

Identification of triggers and management of heart failure Potential causes or precipitating factors such as hyperthyroidism, electrolyte disorders, uncontrolled hypertension, mitral valve dis- ease, and infection should be identified and corrected.

Worsening congestion due to AF should be managed with diu- retics. Congestion relief may reduce sympathetic drive and ventricu- lar rate and increase the chance of spontaneous return to SR. The presence of AF may reduce or abolish the prognostic benefits of beta-blockers and renders ivabradine ineffective.

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Some treat- ments for HF decrease the risk of developing AF, including ACE-I, slightly, and CRT, probably.

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Prevention of embolic events

Unless contraindicated, an oral, long-term anticoagulant is recom- mended in all patients with HF and paroxysmal, persistent, or perma- nent AF. Direct-acting oral anticoagulants (DOACs) are preferred Recommendations for pre-discharge and early post-dis- charge follow-up of patients hospitalized for acute heart failure

Recommendations Class^a Level^b

It is recommended that patients hospitalized for HF be carefully evaluated to exclude persistent signs of congestion before discharge and to opti- mize oral treatment.^427,472

I C

It is recommended that evidence-based oral medical treatment be administered before discharge.^103,513

I C

An early follow-up visit is recommended at 12 weeks after discharge to assess signs of congestion, drug tolerance and start and/or uptitrate evidence-based therapy.^517,518

I C

Ferric carboxymaltose should be considered for iron deficiency, defined as serum ferritin <100 ng/mL or serum ferritin 100299 ng/mL with TSAT <20%, to improve symptoms and reduce rehospitalizations.⁵¹²

IIa B

HR = heart failure; TSAT = transferrin saturation.

aClass of recommendation.

bLevel of evidence.

ESC 2021

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Management of atrial fibrillation in patients with HFrEF

Haemodynamic instability

Anticoagulation for preventing embolic events (Class I) Treatment of trigger(s) (Class I)

Optimization of heart failure therapies (Class I)

OR Beta-blockers

(Class IIa)

Digoxin/digitoxin (Class IIa)

Amiodarone i.v.

(Class IIa) OR Rate control

Symptom improvement Sinus rhythm

Amiodarone (Class IIb)

ECV (Class IIb) Rhythm control

PV ablation (Class IIa) ECV

(Class I) Rhythm control

OR Amiodarone

(Class IIb) Rhythm control

PV ablation (Class IIa)

AVN ablation (Class IIb) Rate control

Sinus rhythm

Follow-up N

N Y

Y N

Figure 14 Management of atrial fibrillation in patients with heart failure with reduced ejection fraction. AF = atrial fibrillation; AVN = atrioventricular node; ECV = electrical cardioversion; HF = heart failure; i.v. = intravenous; PV = pulmonary vein. Colour code for classes of recommendation: Green for Class of recommendation I; Yellow for Class of recommendation IIa; Orange for Class of recommendation IIb; Red for Class of recommendation III (see

Table1

for further details on classes of recommendation).

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for the prevention of thromboembolic events in patients with AF and .

without severe mitral stenosis and/or mechanical valve prosthesis, as they have similar efficacy to vitamin K antagonists (VKAs) but a lower risk of intracranial haemorrhage.

⁵²⁸

LA appendage closure can be considered in patients with HF and AF who have a contraindication to oral anticoagulation though data from randomized trials have not included patients with contraindica- tions to oral anticoagulants.

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Rate control

Data regarding rate control are not conclusive for the patients with AF and HF. A strategy of lenient rate control, defined by a resting heart rate <110 b.p.m., was compared to a strategy of strict rate con- trol, defined by a heart rate <80 b.p.m. at rest and <110 b.p.m. during moderate exercise, in RACE II and in a pooled analysis of RACE and AFFIRM.

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The studies showed no differences in outcome between the two strategies. However, only 10% of the patients in RACE II and 17% of those in the pooled analysis had a history of HF hospitalization or NYHA class IIIII, respectively.

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Higher heart rates are associated with worse outcomes in observational stud- ies.

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Thus, a lenient rate control is an acceptable initial approach with, however, treatment targeting a lower heart rate in case of per- sistent symptoms or cardiac dysfunction likely related to tachycardia (e.g. tachycardia-induced cardiomyopathy).

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Beta-blockers can be used for rate control in patients with HFrEF or HFmrEF because of their established safety in these patients (see section 5.3.2).

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Digoxin or digitoxin can be considered when the ventricular rate remains high, despite beta-blockers, or when beta-blockers are contraindicated or not tolerated.

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It may therefore be considered also an alternative to beta-blockers. For patients with NYHA class IV and/or haemodynamic instability, i.v.

amiodarone can be considered to reduce ventricular rate.

⁵³⁷

For HFpEF, there is a paucity of evidence to demonstrate efficacy of any agent. The RATE-AF trial compared digoxin with bisoprolol in patients with persistent AF and NYHA class IIIV symptoms.

Compared with bisoprolol, digoxin had the same effect on QOL at 6 months (primary endpoint) and a better effect on EHRA and NYHA functional class.

⁵³⁶

Only 19% of the patients had LVEF <50% so that most of the patients can be considered as having HFmrEF or HFpEF.

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AV node ablation can be considered in patients with poor ventric- ular rate control despite medical treatment not eligible for rhythm control by catheter ablation or in patients with biventricular pacing.

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Rhythm control

Urgent electrical cardioversion is recommended in the setting of acute worsening HF in patients presenting with rapid ventricular rates and haemodynamic instability, after consideration of the thromboem- bolic risk. Cardioversion should be considered also to improve symp- toms in patients who have persistent and symptomatic AF, despite optimal pharmacological management. In patients who do not receive chronic therapy with oral anticoagulant and with AF onset

>48 h, at least 3 weeks of therapeutic anticoagulation or a transoeso- phageal echocardiography is needed before cardioversion.

⁷

When pharmacological cardioversion is preferred, amiodarone is the drug of choice as other antiarrhythmic drugs (i.e. propafenone, flecainide,

dronedarone) are associated with worse outcomes in HFrEF.

186,534,541544

Amiodarone can help maintain HF patients in SR after cardioversion.

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Trials including patients with HF and comparing rate control and rhythm control strategies with the latter based on antiarrhythmic drugs failed to show any benefit of one strategy over the oth- er.

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More recently, EAST-AFNET 4, enrolling patients with early AF, 28.6% with HF, was stopped early after a median follow-up of 5.1 years for a lower occurrence of the primary outcome of death, stroke, or hospitalization for worsening HF or ACS in the patients assigned to early rhythm control vs. those assigned to usual care.

⁵⁵¹

However, the patients assigned to the rhythm control strategy had a closer follow-up, which may have influenced their better outcome.

Catheter ablation was performed in a minority of the patients in the rhythm control arm (19.4%).

⁵⁵¹

LA catheter ablation was compared with MT, rate or rhythm con- trol strategy, in 363 patients with persistent or paroxysmal AF, LVEF

<35% and an implanted device (ICD or CRT-D) enrolled in the CASTLE-AF trial.

⁵⁵²

The primary endpoint of all-cause death or HF hospitalizations occurred in fewer patients in the ablation group vs.

the MT group, 51 patients (28.5%) vs. 82 (44.6%) [hazard ratio (HR);

95% confidence interval (CI), 0.62; 0.430.87; P = 0.007]. Also, other endpoints, all-cause or CV death or worsening HF, were reduced by catheter ablation.

⁵⁵²

This trial suggests that catheter ablation can improve the prognosis of patients with HFrEF. However, it enrolled a highly selected population, 363 of 3013 patients, was not blinded, had crossovers between the two treatment strategies and the number of events observed was low: 24 (13.4%) vs. 46 (25.0%) all-cause deaths and 37 (20.7%) vs. 66 (35.9%) HF hospitalizations in the ablation and MT groups, respectively.

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The CABANA trial was an investigator-initiated, open-label, multi- centre, randomized trial enrolling 2204 patients with symptomatic AF. The trial failed to show a benefit of AF ablation strategy over medical care on the primary composite endpoint of death, disabling stroke, serious bleeding, or cardiac arrest in the overall population.

⁵⁵³

In an analysis of the 778 patients (35%) with NYHA class symptoms

>II, the primary outcome occurred in 34 patients (9.0%) in the cathe- ter ablation group vs. 49 (12.3%) in the drug therapy group (HR; 95%

CI, 0.64; 0.410.99).

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However, also in this trial, the number of events was small and HF was defined based only on symptoms with LVEF available in 73% of the patients and >50% and 4049% in 79%

and 11.7% of the cases, respectively.

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Both CASTLE-AF and CABANA showed a highly significant effect of catheter ablation on patients’ symptoms.

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Two other prospective trials enrolled patients with HFrEF and persistent AF, who were randomized to catheter ablation or MT in one trial (AMICA trial, n = 140), and to catheter ablation or amio- darone in the other one (AATAC trial, n = 203).

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The first trial failed to show any difference in the LVEF increase between the two groups.

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The second trial showed superiority of catheter ablation with respect of AF recurrence, the primary endpoint, with also a reduction in unplanned hospitalizations and mortality.

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In contrast with the AMICA trial,

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but in accordance with CASTLE-AF,

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AATAC also showed a benefit of catheter ablation on LVEF.

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In conclusion, there is insufficient evidence in favour of a strategy of rhythm control with antiarrhythmic drugs vs. rate control in patients with HF and AF.

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The results of randomized trials with

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catheter ablation vs. MT showed a consistent improvement in symp- toms whereas the results on mortality and hospitalization were obtained with a relatively small number of events not permitting to draw definitive conclusions.

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12.1.2 Ventricular arrhythmias

Ventricular arrhythmias may be a complication, and in some instan- ces, a cause of HF. Frequent ventricular premature beats (VPBs) may

lead to reversible systolic dysfunction. Possible factors may include dyssynchrony and abnormal calcium handling.

⁵⁶⁰

Initial management of ventricular arrhythmias in HF should include correction of potential precipitants (including electrolyte abnormal- ities, particularly hypo/hyperkalaemia, and pro-arrhythmic drugs) as well as the optimization of HF drug therapy. Although ischaemia may be a triggering factor, revascularization has not been shown to reduce risk of ventricular arrhythmias.

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Amiodarone is effective also for suppression of ventricular arrhythmias. However, it does not reduce the incidence of sudden cardiac death or overall mortality.

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For patients with premature ventricular contraction (PVC)-induced CMP, amiodarone administra- tion may be considered to reduce recurrent arrhythmias and improve symptoms and LV function, although its side effects should be taken into consideration. Other drugs are discussed in Supplementary text 12.1.

Radiofrequency ablation of VPBs may improve LV function and, possibly, outcomes in patients with tachycardiomyopathy when VPBs contribute to LV dysfunction.

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A sustained reduction in the baseline PVC burden has been associated with a lower risk of cardiac mortal- ity, cardiac transplantation, or hospitalization for HF during follow- up.

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12.1.3 Symptomatic bradycardia, pauses and atrio- ventricular block

Indications for pacemaker therapy do not differ in patients with HF

from those with other CV disease. There is ample evidence that RV

pacing may have an adverse effect on LV systolic function leading, in

the long term, to HF.

⁵⁶⁵

Patients with HFrEF requiring frequent ven-

tricular pacing, e.g. with AV block or slow AF, and who have systolic

dysfunction, should be implanted with CRT rather than a standard

pacemaker to avoid adverse outcomes, as shown in the BLOCK-HF

(Biventricular versus Right Ventricular Pacing in Heart Failure

Patients with Atrioventricular Block) trial.

²¹⁶

In the quest for a more

physiological alternative to RV pacing, physiological pacing is being

increasingly adopted.

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In a non-randomized comparison of 304 con-

secutive patients with His bundle pacing and 433 consecutive patients

with RV pacing, the former group had less HF hospitalization and a

trend in reduced mortality.

⁵⁶⁷

Although the technique is promising,

more data are needed to confirm its role.

Dalam dokumen 2021 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure (Halaman 59-62)