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Mustafa U, Atkins J, Mina G, Dawson D, Vanchiere C, Duddyala N, Jones R, Reddy P, Dominic P. Outcomes of cardiac resynchronisation therapy in patients with heart failure with atrial fibrillation: a systematic review and meta-analysis of observational studies. Open Heart 2019; 6:e000937. [PMID: 31217991 PMCID: PMC6546263 DOI: 10.1136/openhrt-2018-000937] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/22/2018] [Accepted: 01/20/2019] [Indexed: 01/02/2023] Open
Abstract
Background Cardiac resynchronisation therapy (CRT) is beneficial in selected patients with heart failure (HF) in normal sinus rhythm (NSR). We sought to evaluate the impact of CRT with or without atrioventricular junction (AVJ) ablation in patients with HF with concomitant atrial fibrillation (AF). Methods and results Literature was searched (inception through 30 August 2017) for observational studies that reported outcomes in patients with HF with CRT and AF that reported all-cause and cardiovascular mortality. Thirty-one studies with 83, 571 patients were included. CRT did not decrease mortality compared with internal cardioverter defibrillator or medical therapy alone in patients with HF and AF with indications for CRT (OR: 0.851, 95% CI 0.616 to 1.176, p=0.328, I2=86.954). CRT-AF patients had significantly higher all-cause and cardiovascular mortality than CRT-NSR patients ([OR: 1.472, 95% CI 1.301 to 1.664, p=0.000] and [OR: 1.857, 95% CI 1.350 to 2.554, p=0.000] respectively). Change in left ventricular ejection fraction was not different between CRT patients with and without AF (p=0.705). AVJ ablation, however, improved all-cause mortality in CRT-AF patients when compared with CRT-AF patients without AVJ ablation (OR: 0.485, 95% CI 0.247 to 0.952, p=0.035). With AVJ ablation, there was no difference in all-cause mortality in CRT-AF patients compared with CRT-NSR patients (OR: 1.245, 95% CI 0.914 to 1.696, p=0.165). Conclusion The results of our meta-analysis suggest that AF was associated with decreased CRT benefits in patients with HF. CRT, however, benefits patients with AF with AVJ ablation.
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Affiliation(s)
- Usman Mustafa
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Heatlh Sciences Center, Shreveport, Louisiana, USA
| | - Jessica Atkins
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Heatlh Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - George Mina
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Heatlh Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Desiree Dawson
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Heatlh Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Catherine Vanchiere
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Heatlh Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Narendra Duddyala
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Heatlh Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Ryan Jones
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Heatlh Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Pratap Reddy
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Heatlh Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Paari Dominic
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Heatlh Sciences Center, Shreveport, Louisiana, USA
- Department of Medicine/Division of Cardiology and Center for Cardiovascular Disease & Sciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
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Lopes C, Pereira T, Barra S. Cardiac resynchronization therapy in patients with atrial fibrillation: a meta-analysis. Rev Port Cardiol 2016; 33:717-25. [PMID: 25457476 DOI: 10.1016/j.repc.2014.05.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 02/25/2014] [Accepted: 05/17/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVE To combine the results of the best scientific evidence in order to compare the effects of cardiac resynchronization therapy (CRT) in heart failure patients with atrial fibrillation (AF) and in sinus rhythm (SR) and to determine the effect of atrioventricular nodal ablation in AF patients. METHODS The electronic databases PubMed, B-On and Cochrane CENTRAL were searched, and manual searches were performed, for randomized controlled trials and cohort studies up to November 2012. The endpoints analyzed were all-cause and cardiovascular mortality and response to CRT. RESULTS We included 19 studies involving 5324 patients: 1399 in AF and 3925 in SR. All-cause mortality was more likely in patients with AF compared to patients in SR (OR = 1.69; 95% CI: 1.20–2.37; p = 0.002). There were no statistically significant differences in cardiovascular mortality (OR = 1.36; 95% CI: 0.92–2.01; p = 0.12). AF was associated with an increased likelihood of lack of response to CRT (OR = 1.41; 95% CI: 1.15–1.73; p = 0.001). Among subjects with AF, ablation of the atrioventricular node was associated with a reduction in all-cause mortality (OR = 0.42; 95% CI: 0.22–0.80; p = 0.008), cardiovascular death (OR = 0.39; 95% CI: 0.20–0.75; p = 0.005) and the number of non-responders to CRT (OR = 0.30; 95% CI: 0.10–0.90; p = 0.03). CONCLUSIONS The presence of AF is associated with increased likelihood of all-cause death and non-response to CRT, compared to patients in SR. However, many patients with AF benefit from CRT. Atrioventricular nodal ablation appears to increase the benefits of CRT in patients with AF.
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Affiliation(s)
- Cláudia Lopes
- Escola Superior de Tecnologia das Saúde de Coimbra, Departamento de Cardiopneumologia, Coimbra, Portugal.
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Bajraktari G, Rönn F, Ibrahimi P, Jashari F, Lindmark K, Jensen SM, Henein MY. Combined electrical and global markers of dyssynchrony predict clinical response to cardiac resynchronization therapy. SCAND CARDIOVASC J 2014; 48:304-10. [PMID: 25117854 DOI: 10.3109/14017431.2014.950601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIM To assess potential additional value of global left ventricular (LV) dyssynchrony markers in predicting cardiac resynchronization therapy (CRT) response in heart failure (HF) patients. METHODS We included 103 HF patients (mean age 67 ± 12 years, 83% male) who fulfilled the guidelines criteria for CRT treatment. All patients had undergone full clinical assessment, NT-proBNP and echocardiographic examination. Global LV dyssynchrony was assessed using total isovolumic time (t-IVT) and Tei index. On the basis of reduction in the NYHA class after CRT, patients were divided into responders and non-responders. RESULTS Prolonged t-IVT [0.878 (range, 0.802-0.962), p = 0.005], long QRS duration [0.978 (range, 0.960-0.996), p = 0.02] and high tricuspid regurgitation pressure drop [1.047 (range, 1.001-1.096), p = 0.046] independently predicted response to CRT. A t-IVT ≥ 11.6 s/min was 67% sensitive and 62% specific (AUC 0.69, p = 0.001) in predicting CRT response. Respective values for a QRS ≥ 151 ms were 66% and 62% (AUC 0.65, p = 0.01). Combining the two variables had higher specificity (88%) in predicting CRT response. In atrial fibrillation (AF) patients, only prolonged t-IVT [0.690 (range, 0.509-0.937), p = 0.03] independently predicted CRT response. CONCLUSION Combining prolonged t-IVT and the conventionally used broad QRS duration has a significantly higher specificity in identifying patients likely to respond to CRT. Moreover, in AF patients, only prolonged t-IVT independently predicted CRT response.
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Affiliation(s)
- Gani Bajraktari
- Public Health and Clinical Medicine, Umeå University , Umeå , Sweden
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Khan MA, Ahmed F, Neyses L, Mamas MA. Atrial fibrillation in heart failure: The sword of Damocles revisited. World J Cardiol 2013; 5:215-227. [PMID: 23888191 PMCID: PMC3722419 DOI: 10.4330/wjc.v5.i7.215] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Revised: 06/06/2013] [Accepted: 06/20/2013] [Indexed: 02/06/2023] Open
Abstract
Heart failure (HF) and atrial fibrillation (AF) frequently coexist and have emerged as major cardiovascular epidemics. There is growing evidence that AF is an independent prognostic marker in HF and affects patients with both reduced as well as preserved LV systolic function. There has been a general move in clinical practice from a rhythm control to a rate control strategy in HF patients with AF, although recent data suggests that rhythm control strategies may provide better outcomes in selected subgroups of HF patients. Furthermore, various therapeutic modalities including pace and ablate strategies with cardiac resynchronisation or radiofrequency ablation have become increasingly adopted, although their role in the management of AF in patients with HF remains uncertain. This article presents an overview of the multidimensional impact of AF in patients with HF. Relevant literature is highlighted and the effect of various therapeutic modalities on prognosis is discussed. Finally, while novel anticoagulants usher in a new era in thromboprophylaxis, research continues in a variety of new pathways including selective atrial anti-arrhythmic agents and genomic polymorphisms in AF with HF.
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Hess PL, Jackson KP, Hasselblad V, Al-Khatib SM. Is cardiac resynchronization therapy an antiarrhythmic therapy for atrial fibrillation? A systematic review and meta-analysis. Curr Cardiol Rep 2013; 15:330. [PMID: 23299710 DOI: 10.1007/s11886-012-0330-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The impact of cardiac resynchronization therapy (CRT) on atrial fibrillation (AF) burden is poorly characterized. To assess the influence of CRT on AF, we performed a systematic literature search in MEDLINE using the MeSH headings "cardiac resynchronization therapy" or "cardiac pacing, artificial" and "atrial fibrillation." Selected studies were peer-reviewed and written in English. Most studies enrolled patients meeting traditional CRT criteria. Ten observational studies and two secondary analyses of clinical trials were identified. Although ten studies suggest that CRT favorably impacts AF, one secondary analysis of a clinical trial showed no effect of CRT on new-onset AF. In a meta-analysis of three studies examining the effect of CRT on persistent or permanent AF, the combined rate of conversion from persistent or permanent AF to sinus rhythm was 0.107 (95 % confidence interval 0.069-0.163). Prospective studies, particularly among patients not meeting traditional CRT criteria, are needed.
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Affiliation(s)
- Paul L Hess
- Duke Clinical Research Institute, Duke University School of Medicine, PO Box 17969, Durham, NC 27715, USA.
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Khan MA, Neyses L, Mamas MA. Atrial fibrillation in heart failure: an innocent bystander? Curr Cardiol Rev 2013; 8:273-80. [PMID: 22920477 PMCID: PMC3492811 DOI: 10.2174/157340312803760839] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 05/01/2012] [Accepted: 06/20/2012] [Indexed: 12/21/2022] Open
Abstract
Heart failure (HF) and atrial fibrillation (AF) frequently coexist and each complicates the course of the other. The purpose of this review is to analyse the prognostic impact of AF in patients with HF and assess whether there is an advantage in targeting therapies towards the maintenance of sinus rhythm (SR) in this cohort of patients. The presence of AF in patients with HF has been reported to be independently associated with an increase in mortality in many studies and this increased risk is observed in those with both preserved and impaired LV systolic function. The optimal strategy for targeting AF in patients with HF is unclear but recent randomised controlled studies indicate no significant prognostic advantage associated with a rhythm control strategy as compared to a rate control strategy. A number of small studies have investigated the role of both cardiac resynchronization therapy (CRT) and AF catheter ablation for the maintenance of / conversion to SR in patients with HF with initial promising results although larger randomised controlled studies will need to be performed to define the role of these modalities in the treatment of this cohort and whether preliminary benefits observed in these studies translate to improvements in longer term prognosis. Finally, there has been a focus on modifying the arrhythmogenic atrial substrate and neurohormonal milieu by pharmacological means in order to prevent AF although it remains to be seen whether this approach proves to be efficacious with improvements in clinically relevant outcomes.
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Affiliation(s)
- M A Khan
- Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9PT, UK
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