Objectives This study sought to assess the impact of rhythm- versus rate-control treatment strategies and of underlying rhythm on quality of life and functional capacity in patients with atrial ...fibrillation (AF) and congestive heart failure (CHF). Background Although intention-to-treat and efficacy analyses have demonstrated similar cardiovascular outcomes in patients with AF and CHF randomized to rhythm or rate control, effects on quality of life remain to be determined. Methods The AF-CHF (Atrial Fibrillation and Congestive Heart Failure) trial randomized 1,376 patients to rhythm- or rate-control strategies. For this pre-specified substudy, Medical Outcomes Short Form-36 questionnaires were administered at baseline and 4 months. Six-min walk tests were conducted at baseline, 3 weeks, 4 months, and 1 year. Results Quality of life improved across all domains to a similar extent with rhythm and rate control. However, a higher proportion of time spent in sinus rhythm was associated with a modestly greater improvement in quality of life scores. Six-min walk distance (p = 0.2328) and New York Heart Association functional class (p = 0.1712) improved to a similar degree with rhythm and rate control. A higher proportion of time spent in sinus rhythm was associated with a greater improvement in New York Heart Association functional class (p < 0.0001) but not in 6-min walk distance (p = 0.1308). Conclusions Improvements in quality of life and functional capacity were similar in patients with AF and CHF randomized to rhythm- versus rate-control strategies. By contrast, sinus rhythm was associated with beneficial effects on New York Heart Association functional class and modest gains in quality of life. (Atrial Fibrillation and Congestive Heart Failure AF-CHF; NCT88597077 )
Objectives The goal of this study was to evaluate the relationship between the presence of sinus rhythm and outcomes in patients with a history of congestive heart failure (CHF) and atrial ...fibrillation (AF). Background The value of sinus rhythm maintenance in patients with AF and heart failure (HF) is uncertain. Methods A total of 1,376 patients with AF, ejection fraction ≤35%, and heart failure symptoms were randomized to a rhythm- or rate-control strategy. Detailed efficacy analyses were used to evaluate the independent effects of treatment strategy and the presence of sinus rhythm on cardiovascular outcomes. Results Overall, 445 (32%) patients died and 402 (29%) experienced worsening HF. The rhythm-control strategy was not predictive of cardiovascular mortality (hazard ratio HR: 0.90, 95% confidence interval CI: 0.70 to 1.16; p = 0.41), all-cause death (HR: 0.86, 95% CI: 0.69 to 1.08; p = 0.19), or worsening HF (HR: 0.86, 95% CI: 0.68 to 1.10; p = 0.23). In analyses devised to isolate the effect of underlying rhythm, sinus rhythm was not associated with cardiovascular mortality HR: 1.22, 95% CI: 0.80 to 1.87; p = 0.35), total mortality HR: 1.11, 95% CI: 0.78 to 1.58; p = 0.57), or worsening HF HR: 0.62, 95% CI: 0.37 to 1.02; p = 0.059). Conclusions A rhythm-control strategy or the presence of sinus rhythm are not associated with better outcomes in patients with AF and CHF.
Abstract The Canadian Cardiovascular Society (CCS) Atrial Fibrillation (AF) Guidelines Committee provides periodic reviews of new data to produce focused updates that address clinically important ...advances in AF management. This 2016 Focused Update deals with: (1) the management of antithrombotic therapy for AF patients in the context of the various clinical presentations of coronary artery disease; (2) real-life data with non-vitamin K antagonist oral anticoagulants; (3) the use of antidotes for the reversal of non-vitamin K antagonist oral anticoagulants; (4) digoxin as a rate control agent; (5) perioperative anticoagulation management; and (6) AF surgical therapy including the prevention and treatment of AF after cardiac surgery. The recommendations were developed with the same methodology used for the initial 2010 guidelines and the 2012 and 2014 Focused Updates. Using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards, individual studies and literature were reviewed for quality and bias; the literature review process and evidence tables are included in the Supplementary Material, and on the CCS Web site. The section on concomitant AF and coronary artery disease was developed in collaboration with the CCS Antiplatelet Guidelines Committee. Details of the updated recommendations are presented, along with their background and rationale. This document is linked to an updated summary of all CCS AF Guidelines recommendations, from 2010 to the present 2016 Focused Update.
Background The benefit of a primary prevention implantable cardioverter-defibrillator (ICD) among patients with chronic kidney disease is uncertain. Study Design Meta-analysis of patient-level data ...from randomized controlled trials. Setting & Population Patients with symptomatic heart failure and left ventricular ejection fraction < 35%. Selection Criteria for Studies From 7 available randomized controlled studies with patient-level data, we selected studies with available data for important covariates. Studies without patient-level data for baseline estimated glomerular filtration rate (eGFR) were excluded. Intervention Primary prevention ICD versus usual care effect modification by eGFR. Outcomes Mortality, rehospitalizations, and effect modification by eGFR. Results We included data from the Multicenter Automatic Defibrillator Implantation Trial I (MADIT-I), MADIT-II, and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). 2,867 patients were included; 36.3% had eGFR < 60 mL/min/1.73 m2 . Kaplan-Meier estimate of the probability of death during follow-up was 43.3% for 1,334 patients receiving usual care and 35.8% for 1,533 ICD recipients. After adjustment for baseline differences, there was evidence that the survival benefit of ICDs in comparison to usual care depends on eGFR (posterior probability for null interaction P < 0.001). The ICD was associated with survival benefit for patients with eGFR ≥ 60 mL/min/1.73 m2 (adjusted HR, 0.49; 95% posterior credible interval, 0.24-0.95), but not for patients with eGFR < 60 mL/min/1.73 m2 (adjusted HR, 0.80; 95% posterior credible interval, 0.40-1.53). eGFR did not modify the association between the ICD and rehospitalizations. Limitations Few patients with eGFR < 30 mL/min/1.73 m2 were available. Differences in trial-to-trial measurement techniques may lead to residual confounding. Conclusions Reductions in baseline eGFR decrease the survival benefit associated with the ICD. These findings should be confirmed by additional studies specifically targeting patients with varying eGFRs.
Abstract Atrial fibrillation (AF) is an extremely common clinical problem with an important population morbidity and mortality burden. The management of AF is complex and fraught with many uncertain ...and contentious issues, which are being addressed by extensive ongoing basic and clinical research. The Canadian Cardiovascular Society AF Guidelines Committee produced an extensive set of evidence-based AF management guidelines in 2010 and updated them in the areas of anticoagulation and rate/rhythm control in 2012. In late 2013, the committee judged that sufficient new information regarding AF management had become available since 2012 to warrant an update to the Canadian Cardiovascular Society AF Guidelines. After extensive evaluation of the new evidence, the committee has updated the guidelines for: (1) stroke prevention principles; (2) anticoagulation of AF patients with chronic kidney disease; (3) detection of AF in patients with stroke; (4) investigation and management of subclinical AF; (5) left atrial appendage closure in stroke prevention; (6) emergency department management of AF; (7) periprocedural anticoagulation management; and (8) rate and rhythm control including catheter ablation. This report presents the details of the updated recommendations, along with their background and rationale. In addition, a complete set of presently applicable recommendations, those that have been updated and those that remain in force from previous guideline versions, is provided in the Supplementary Material.
Abstract Using data collected from 2 national atrial fibrillation (AF) primary care physician chart audits (Facilitating REview and EDucation to OptiMize stroke prevention in Atrial Fibrillation ...FREEDOM AF and CO-ordinated National Network to Engage physicians in the Care and Treatment of patients with Atrial Fibrillation CONNECT AF), we evaluated the frequency of, and factors associated with, the use of cardiovascular (CV) evidence-based therapies in Canadian AF outpatients with at least one CV risk factor or comorbidity. Among the 11,264 patients enrolled, 9,495 (84.3%) patients were eligible for one or more CV evidence-based therapies. The proportions of AF patients receiving all eligible guideline-recommended therapies were: 40.8% of patients with coronary artery disease, 48.9% of patients with diabetes mellitus, 40.2% of patients with heart failure, 96.7% of patients with hypertension, and 55.1% of patients with peripheral arterial disease. Factors that were independently associated with non-receipt of all indicated evidence-based therapies included sinus rhythm rather than AF at baseline and liver disease. In conclusion, although the majority of Canadian AF outpatients have CV risk factors or comorbidities, a substantial portion of these patients did not receive all guideline-recommended therapies. These findings suggest there is an opportunity to improve the quality of care for AF patients in Canada.
Abstract β-Blockers are among the most frequently used drugs in patients with atrial fibrillation. They are often used for ventricular rate control, acutely in emergency situations and chronically, ...in patients with persistent or permanent atrial fibrillation. They are also used, with less evidence of benefit, to prevent the first occurrence or recurrence of atrial fibrillation, particularly in patients with hypertension. They are effective in reducing ventricular rate, potentially leading to an improvement in symptoms and well-being. They are particularly indicated in patients with heart failure and atrial fibrillation; the choice of β-blockers in this condition should be guided by tolerability and effects on symptoms and well-being.
Abstract The Canadian Cardiovascular Society (CCS) published the complete set of 2010 Atrial Fibrillation (AF) Guidelines in the January, 2011 issue of the Canadian Journal of Cardiology . During its ...deliberations, the CCS Guidelines Committee engaged to a timely review of future evidence, with periodic composition of focused updates to address clinically important advances. In 2011, results were published from 3 pivotal AF trials: the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonist for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET-AF), the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) study, and the Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of Standard Therapy (PALLAS), comparing dronedarone with placebo in patients with permanent AF and additional cardiovascular disease risk-factor burden. Each of these large randomized trials provided clear results with major implications for AF management. Other important evidence that has emerged since the 2010 Guidelines includes findings about prediction instruments for AF-associated stroke and bleeding risk, stroke risk in paroxysmal-AF patients, risk-benefit considerations related to oral anticoagulation in patients with chronic kidney disease, and risk/benefit considerations in the use of antiplatelet agents, alone and in combination with each other or with oral anticoagulants, in AF patients. The Guidelines Committee judged that this extensive and important new evidence required focused updating of the 2010 Guidelines with respect to stroke prevention and rate/rhythm control. This report presents the details of the new recommendations, along with the background and rationale.
Abstract Background Indications for the primary prevention of sudden death using an implantable cardioverter defibrillator (ICD) are based predominantly on left ventricular ejection fraction (LVEF). ...However, right ventricular ejection fraction (RVEF) is also a known prognostic factor in a variety of structural heart diseases that predispose to sudden cardiac death. We sought to investigate the relationship between right and left ventricular parameters (function and volume) measured by cardiovascular magnetic resonance (CMR) among a broad spectrum of patients considered for an ICD. Methods In this retrospective, single tertiary-care center study, consecutive patients considered for ICD implantation who were referred for LVEF assessment by CMR were included. Right and left ventricular function and volumes were measured. Results In total, 102 patients (age 62±14 years; 23% women) had a mean LVEF of 28±11% and RVEF of 44±12%. The left ventricular and right ventricular end diastolic volume index was 140±42 mL/m2 and 81±27 mL/m2 , respectively. Eighty-six (84%) patients had a LVEF <35%, and 63 (62%) patients had right ventricular systolic dysfunction. Although there was a significant and moderate correlation between LVEF and RVEF ( r =0.40, p <0.001), 32 of 86 patients (37%) with LVEF <35% had preserved RVEF, while 9 of 16 patients (56%) with LVEF ≥35% had right ventricular systolic dysfunction (Kappa=0.041). Conclusions Among patients being considered for an ICD, there is a positive but moderate correlation between LVEF and RVEF. A considerable proportion of patients who qualify for an ICD based on low LVEF have preserved RVEF, and vice versa.
Abstract Background Canadian atrial fibrillation (AF) guidelines recommend that all AF patients be risk stratified with respect to stroke and bleeding, and that most should receive antithrombotic ...therapy. Methods As part of the Canadian F acilitating Re view and Ed ucation to O pti m ize Stroke Prevention in A trial F ibrillation (FREEDOM AF) chart audit, data were collected on 4670 patients ≥ 18 years old without significant valvular heart disease from the primary care practices of 474 physicians (February to September, 2011). Results Physicians did not provide an estimate of stroke and bleeding risk in 15% and 25% of patients, respectively. When risks were provided, they were on the basis of a predictive stroke and bleeding risk index in only 50% and 26% of patients, respectively. There were over- and underestimation of stroke and bleeding risk in a large proportion of patients. Antithrombotic therapy included warfarin (90%); 24% of patients had a time in the therapeutic range (TTR) < 50%, 9% between 50% and 60%, 11% between 60% and 70%, and 56% had a TTR ≥ 70%. Conclusions In a large Canadian AF population, primary care physicians did not provide a stroke or bleeding risk in a substantial proportion of their AF patients. When estimates were provided, they were on the basis of a predictive stroke and bleeding risk index in less than half of the patients. Furthermore, there was under- and overestimation of stroke and bleeding risk in a substantial proportion of patients. As many as 1 in 3 patients receiving warfarin have their TTR < 60%. These findings suggest an opportunity to enhance knowledge translation to primary care physicians.
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