Relationships between maintenance of sinus rhythm and clinical outcomes in patients with heart failure with preserved ejection fraction and atrial fibrillation

Abstract

Background: Although atrial fibrillation (AF) is associated with exacerbation of heart failure with preserved ejection fraction (HFpEF), the relationships between maintenance of sinus rhythm (SR) and clinical outcomes in HFpEF is unknown. We investigated whether maintenance of SR was associated with better prognosis compared with rate control in patients with concomitant HFpEF and AF. Methods: We conducted a retrospective, observational study of 283 patients with HFpEF and AF. Of these, 107 patients achieved maintenance of SR by catheter ablation and/or antiarrhythmic drugs (rhythm control) and 176 were treated with rate control. The propensity score (PS) for each patient in both treatment groups was estimated, resulting in selectively matched subgroups of 79 patients each. All-cause death and a composite of cardiovascular death or hospitalization for heart failure (HF) were analyzed. Results: During a median follow-up period of 24 months, all-cause mortality was comparable between groups; however, maintenance of SR was significantly associated with a lower incidence of the composite endpoint [adjusted hazard ratio (HR), 0.30; 95% confidence interval, 0.18-0.98; p = 0.04] in the PSmatched cohort. The PS-adjusted multivariable analysis based on 283 pre-matched patients also revealed that rhythm control was associated with a lower rate of the composite endpoint (adjusted HR, 0.27; 95% CI, 0.12-0.61; p = 0.002). Subgroup analyses suggested that rhythm control was consistently related to the composite endpoint across a wide spectrum of HFpEF patients. Conclusions: Maintenance of SR was associated with a lower risk of composite of cardiovascular death or hospitalization for HF in patients with HFpEF and AF. A randomized trial is necessary to confirm this result.

Is rhythm control superior to rate control in patients with heart failure and preserved ejection fraction?

“…The beneficial effect of rhythm control with anti-arrhythmic drugs in HF was limited because of their low efficacy of maintenance of sinus rhythm and toxicities. In the present study [10], the rates of sinus rhythm maintenance were relatively high (72.2%) in the rhythm control group. A recent meta-analysis showed that AF catheter ablation can improve left ventricular EF, and reduce allcause mortality, and HF hospitalizations in HFrEF patients with AF [7].…”

“…In this issue of the Journal of Cardiology, a retrospective, observational, multicenter study utilizing data from 11 participating institutions was demonstrated to investigate the efficacy and safety of rhythm control therapy mainly by catheter ablation in 283 Japanese HFpEF patients with AF [10]. The authors used a propensity score matched cohort consisting of 79 patients with rhythm control therapy and 79 patients with rate control therapy.…”

Catheter ablation of atrial fibrillation reduces heart failure rehospitalization in patients with heart failure with preserved ejection fraction

“…CASTLE‐AF showed the efficacy of rhythm control by AF ablation in patients with HFrEF 10 . Recently, Machino‐Ohtsuka et al 15 reported that maintenance of sinus rhythm was associated with a lower risk of HF hospitalization in patients with HFpEF and AF. Therefore, therapeutic strategies to maintain sinus rhythm are indicated to reduce HFpEF hospitalization.…”

Atrial fibrillation ablation in congestive heart failure with preserved ejection fraction: Tackling the vicious twins

“…In another retrospective analysis, Black‐Maier et al 6 concluded that procedure success rate and functional improvement after AF ablation were similar in HFrEF and HFpEF. More recently, a propensity‐matched cohort study showed that rhythm control in AF‐HFpEF via either ablation or medication led to a significantly reduced composite of cardiovascular death and HF hospitalization compared with rate control 7 . Nonetheless, despite early promising results, there has been concern that AF ablation in AF‐HFpEF may carry a lower success rate and a potentially higher risk of procedural complications due to more complex atrial remodeling and higher comorbidity burden.…”

“…2 Furthermore, AF-HFpEF patients are known to have a worse prognosis compared with HFpEF patients without AF, 3 More recently, a propensity-matched cohort study showed that rhythm control in AF-HFpEF via either ablation or medication led to a significantly reduced composite of cardiovascular death and HF hospitalization compared with rate control. 7 Nonetheless, despite early promising results, there has been concern that AF ablation in AF-HFpEF may carry a lower success rate and a potentially higher focal ablation for atrial tachycardia/nonpulmonary vein focus, superior vena cava ablation, and cavotricuspid isthmus linear ablation at the discretion of the operators. 8 The primary outcome was rehospitalization due to HF.…”