- Atrial fibrillation & HFpEF Dipak Kotecha, MD PhD FESC FHEA - PowerPoint PPT Presentation

Novel concepts and treatments of comorbidities in Heart Failure with Preserved Ejection Fraction - Atrial fibrillation & HFpEF Dipak Kotecha, MD PhD FESC FHEA Groningen HF Symposium, Vienna 2018

Disclosures No conflicts of interest or financial disclosures. Historical grants, personal fees and consultancy: Menarini (unrestricted research grant), AtriCure (lecture fees), Daiichi Sankyo (professional development). Funding: National Institute for Health Research - Career Development Fellowship ( UK Department of Health).

HF hospital admissions at Mayo Clinic (n=6076, 1987-2001) Trends in heart failure Owan: N Engl J Med 2006; 355:251-259

Incident AF in 57,818 patients in United Kingdom 1998-2010 Prevalenc valence Incidenc dence Mortali tality ty AF per 1000 increasing rapidly and p=0.84 mortality high in elderly p<0.001 Lane / Kotecha: J Am Heart Assoc. 2017;6:e005155

Heart RealiseAF registry: 9816 AF failure patients from 26 countries 33-56% Clinical heart failure High rates Mean LVEF AF of HF in AF Chiang: Circ Arrhythm EP. 2012;5:632-639 (adapted) Kotecha & Piccini: Eur Heart J. 2015;36:3250-3257

Heart Framingham Heart Study USA: failure New-onset AF (n=1737) or HF 33-56% (n= 1166) 1980-2012 30-41% Prevalent and AF future AF common in HF Santhanakrishnan: Circulation. 2016;133:484-492 Kotecha & Piccini: Eur Heart J. 2015;36:3250-3257

Other precipitating conditions Chicken or Egg? Kotecha/Lam/Rienstra et al: JACC 2016;68:2217

Summary 1. HFpEF and AF are increasingly common, with linked pathophysiology

Comparing AF + HFpEF vs AF + HFrEF Meta-analysis of published studies: Different types of HF affect outcomes in AF Kotecha et al: Int J Cardiol. 2016;203:660-6 Kotecha et al: Int J Cardiol. 2016;214:516-7

? ? Echo in AF and HF ? ? Kotecha et al: Europace. 2017;19:1427-1438

Study (year) n Parameter Correlation with invasive filling pressure Kusunose (2009) 56 E/e’ r = 0.57** Li (2010) 49 E/e’ E/e’ Lateral : r = 0.49* E/e’ Septal: r = 0.40* Senechal (2008) 24 E/e’ E/e’ Lateral : r = 0.47* E/e’ Septal: r = 0.46* Sohn (1999) 27 E/e’ r = 0.79*** Diastolic Wada (2012) 45 E/e’ r = 0.57 *** function Oyama (2004) 68 E/Vp r = 0.63** in AF Nagueh (1996) 30 E/Vp r = 0.65*** IVRT r = -0.76*** Temporelli (1999) 35 DT r = -0.79** IVRT r = -0.95*** Matsukida (2001) 37 DT r = -0.65*** Traversi (2001) 51 DT r = -0.60*** Chirillo (1997) 35 DT r = -0.50 Diwan (2005) 13 IVRT r = -0.92** Kotecha et al: Europace. 2017;19:1427-1438

10 Coefficient of variation (%) Index beat method: Two preceding 9 8 RR intervals are similar and equivalent 7 6 heart rate is <100 bpm 5 4 3 2 1 Improving 0 assessment of function n=20 in AF Mitral E Bunting / Kotecha (unpublished)

Current guidelines still recommend standard ECG for diagnosis “Irregular RR intervals and no distinct p waves for at least 30 seconds” * New technologies mean that diagnosis in the future may be very different… Novel AF detection methods * Kirchhof, Benussi, Kotecha, et al: Eur Heart J. 2016;37:2893-2962 Kotecha et al: Europace 2018;20:395-407

AFNET & EHRA Consensus Conference 2017 Guidance on AF detection Kotecha et al: Europace 2018;20:395-407

Diagnosis of AF and HFpEF Kotecha/Lam/Rienstra et al: JACC 2016;68:2217

Summary 1. HFpEF and AF are increasingly common, with linked pathophysiology 2. Outcomes depend on type of HF, but diagnosis can be challenging 3. Novel methods of detecting AF have already arrived

Lack of effective treatment options Ponikowski et al: Eur Heart J 2016;37:2129-2200

Beta-blockers in Heart Failure Collaborative Group Individual patient data from n=11 double-blind, placebo-controlled randomised trials Beta-blockers & efficacy according to LVEF Cleland/Kotecha: Eur Heart J 2018;39:26

Beta-blockers in Heart Failure Collaborative Group Individual patient data from n=11 double-blind, placebo-controlled randomised trials Beta-blockers & change in LVEF n=4601 n=996 Cleland/Kotecha: Eur Heart J 2018;39:26

1. Aldosterone antagonists Un- 2. ARNI answered 3. Anti-diabetic therapies questions in AF + 4. Implanted devices (ICD/CRT) HFpEF 5. AF ablation 6. Non-pharmacology interventions

AF + HFpEF treatment options Kotecha/Lam/Rienstra et al: JACC 2016;68:2217

Summary 1. HFpEF and AF are increasingly common, with linked pathophysiology 2. Outcomes depend on type of HF, but diagnosis can be challenging 3. Novel methods of detecting AF have already arrived 4. Treatment trials in HFpEF have had disappointing results; prognostic effects of AF treatment in HFpEF under evaluation

ESC 2016 AF Guidelines Improving management by better phenotyping Kirchhof, Bennussi, Kotecha et al: Eur Heart J 2016:37:2893

AFNET & EHRA Consensus 2017 Improving management by better phenotyping Kotecha et al: Europace 2018;20:395-407

Re-define AF / HF and AF + HF www.bigdata-heart.eu Eur Heart J. 2018;39:1481-95

Summary 1. HFpEF and AF are increasingly common, with linked pathophysiology 2. Outcomes depend on type of HF, but diagnosis can be challenging 3. Novel methods of detecting AF have already arrived 4. Treatment trials in HFpEF have had disappointing results; prognostic effects of AF treatment in HFpEF under evaluation 5. Better phenotyping offers a new perspective and stratified (personalised) treatment options for patients with AF + HFpEF