acute-heart-failure-and-atrial-fibrillation：急性心脏衰竭和心房颤动课件

1、Atrial fibrillation (AF) is a common rhythm in patients with acute heart failure (AHF). Registry and trial data indicate that 20% to 35% of patients with AHF who are admitted to the hospital will be in AF at presentation. In about one third of these patients, the AF will be of recent onset.Atrial fi

2、brillation (AF) is a Asirvatham and Friedman. From: Shivkumar, Weiss, Fonarow, and Narula; eds. Braunwalds Atlas of EP in HF. 2005.Asirvatham and Friedman. From:Paroxysmal AFPersistent AFPermanent AFTriggersectopic foci ElectrophysiologicRemodelingChronic Substratefibrosis Nattel et al. Circulation

3、1999;100:87-95Types of AFParoxysmal AFPersistent AFPermAF-HF interactionLoss of atrial kickRapid rateİrregular beatSympathetictoneremodellingAtrialstretchAF-HF interactionLoss of atriaSOLVD Investigators: J Am Coll Cardiol. 1998;32:695-703. SOLVD Investigators: J Am CollKey Questions to Consider Bef

4、ore Starting TherapyDoes the patient have an ICD or pacemaker in place?Does the patient have preserved or reduced systolic function at their baseline?What is the duration of the AF episode?Is the patient already on drugs for rhythm or rate control and anticoagulation?What concomitant disorders are p

5、resent?Key Questions to Consider BefoTypes of AF in AHF1-Acute symptomatic AF2-Incessant AF3-Acute on chronic AFTypes of AF in AHF1-Acute sympAcute symptomatic de novo AFEither the AF episode itself has rapidly precipitated heart failure in a previously stable patient or worsening heart failure has

6、triggered an acute episode of AF. In these patients, the potential for successful early restoration of sinus rhythm is high if the heart failure symptoms can be controlledAcute symptomatic de novo AFEiCardiomyopathy can be caused by any tachycardia (110 bpm) that occurs as little as 10-15% of daySev

7、erity related to rate and duration of HRMaximal improvement after rate control may require up to 8 months After improvement susceptibility to rapid deterioration remains if tachycardia recurs Olshansky et al Circulation 2004, Fenelon et al PACE 1996;19:95-106, Shinbane J et al. JACC 1997;29: 709-715

8、 Atrial Fibrillation and Tachycardia Induced CardiomyopathyCardiomyopathy can be caused bIncessant AFMay be subacute or acuteDepending on caardiac reserve, patients become symptomaticDuring the ensuing days and weeks, the patient gradually slips into ADHF and then presents with severe symptoms. Thes

9、e patients will probably not convert spontaneously but may be candidates for a later cardioversion attempt.Incessant AFMay be subacute orAcute on chronic AFSome patients with permanent AF that is usually well rate controlled will develop progressive heart failure and then present emergently with rap

10、id ventricular rates due to the stress of the episodeUnlikely to control the rhythmAcute on chronic AFSome patienPatients with AF and signs of acute heart failure require urgent rate control and often cardioversion. An urgent echocardiogram should be performed in haemodynamically compromised patient

11、s to assess LV and valvular function and right ventricular pressure.The Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial observed no difference in cardiovascular mortality (primary outcome) between patients with an LVEF 35%, symptoms of congestive heart failure, and a history of AF ra

12、ndomized to rate or rhythm control, or in the secondary outcomes including death from any cause and worsening of heart failurePatients with AF and signs of In the general population of patients with atrial fibrillation (AF), the main goals of therapy are the control of symptoms and the prevention of

13、 arterial embolism, particularly stroke. These goals are also true for the relatively large subset of AF patients with heart failure (HF). In such patients, the adverse hemodynamic consequences of AF can quickly lead to a decrease in exercise capacity and a worsening of symptoms, both of which may b

14、e difficult to manageIn the general population of pIn an analysis from the Framingham Heart Study, of 708 patients with heart failure (HF) who were in sinus rhythm, 159 (22 percent) developed atrial fibrillation (AF) at an average of 4.2 years of follow-up.In an analysis from the FraminThe prevalenc

15、e of AF in patients with chronic HF varies from 10 to 50 %, depending in part upon the severity of HF and New York Heart Association classThere is also an association between left ventricular diastolic dysfunction and AFIt should also be kept in mind that each (AF and HF) may predispose or promote t

16、he others persistent natureThe prevalence of AF in patienAlthough the optimal resting heart rate during AF is between 60 and 100 bpm, rates below 100 bpm may not be achievable during AHDF until volume overload and hypoxia have been corrected. A more realistic target is to achieve a heart rate below

17、120 bpm during the first hours of treatmentAlthough the optimal resting hAdverse Hemodynamic Effects of AFHeart rate changes. In cases where the ventricular response is fast and maintained, a chronic tachycardia can lead to a rate-related cardiomyopathy. In cases where the ventricular response is ex

18、ceptionally slow, patients can develop symptomatic bradycardia and possibly syncope.Activation of neurohumoral vasoconstrictors such as angiotensin II and norepinephrine, as well as other maladaptive and procoagulant biochemical mechanisms.Adverse Hemodynamic Effects ofAdverse Hemodynamic Effects of

19、 AFBeat-to-beat variations in atrial pressure (preload). The influence of preload on left ventricular ejection (Frank-Starling mechanism) is important in AF only when afterload is relatively low .Beat-to-beat variations in myocardial contractility . Among patients with AF, the preceding RR interval

20、has a significant positive correlation with left ventricular ejection, as a shorter RR interval (more rapid ventricular response) reduces the LVEF . This effect is independent of end-diastolic volume, indicating that it cannot be explained by the Frank-Starling mechanism. In addition, the pre-preced

21、ing RR interval has anegativecorrelation with left ventricular ejection, which has been ascribed to postextrasystolic potentiation .Inefficient ventricular mechanics due to abrupt changes in cycle length .Adverse Hemodynamic Effects of*p 0.01 NSR AF VVI VVI VVT 60 AVG VVI -AVG VVT Cardiac Output (L/

22、Min) Cardiac Output (L/Min)Clark DM. JACC 1997; 30:1039-45Adverse Hemodynamic Effects of AF Irregular RR Intervals Impair Cardiac PerformanceN=16*p 0.01 NSR AF VVIAtrial systoleContraction of the left atrium injects a volume of blood under pressure into the left ventricle, leading to increments in v

23、entricular diastolic volume, end-diastolic pressure, and stroke volume . Loss of atrial systole can therefore diminish the stroke volume. This may be particularly important when left ventricular compliance is reduced and in mitral stenosis.The importance of atrial systole has been demonstrated in pa

24、tients with hypertrophic cardiomyopathy, which is typically associated with an increased atrial contribution to ventricular filling (31 versus 16 percent in controls in one report)Adverse Hemodynamic Effects of AFAtrial systoleContraction oImpact on Prognosis in Chronic HFA three-year follow-up of 6

25、517 patients in the SOLVD trials (patients with asymptomatic left ventricular dysfunction or NYHA class II to III HF) found that AF (present in 6.4 percent) was a significant predictor of all-cause mortality (34 versus 23 percent in those without AF), even after multivariate analysis 7.The V-HeFT I

26、and II trials included 1427 patients with NYHA class II to III HF, 206 of whom (14 percent) had AF 5. There was no significant difference in mortality at two years in either trial (34 versus 30 percent and 20 versus 21 percent, respectively) or in hospitalization for HFImpact on Prognosis in Chronic

27、EHFS II: A survey on hospitalized AHF patientsEHFS II: A survey on hospitaliAF may worsen symptoms in patients with HF and uncontrolled HF can precipitate or speed the ventricular response of AFAF may worsen symptoms in patiMost patients with AF will have unacceptable symptoms attributable in part t

28、o a rapid ventricular rate. These patients require a slowing of the ventricular rate prior to a decision about rhythm or rate control as a long-term strategy to control symptoms. In the general population of patients with AF, rate control strategy for many might be preferable.Most patients with AF w

29、ill havThe AF-CHF trial was the first large, randomized trial to test the hypothesis that long-term rhythm control is better than rate control in patients with HF and paroxysmal AF In this trial, 1376 patients with a left ventricular ejection fraction 65 yrsAtrial Fibrillation is IncreasingWattigney

30、, W. A. et al. CirculDevelopment of AF is Associated with Clinical Deterioration in Heart Failureprospective follow-up of 344 patients with CHF and sinus rhythm for 19 12 months.28 patients developed AF which became chronic in 18 ptsWhen AF occurredNYHA class worsened (from 2.4 0.5 to 2.9 0.6, p = 0

31、.0001), peak exercise O2 consumption declined (from 16 5 to 11 5 ml/kg per min, p = 0.002), cardiac index decreased (from 2.2 0.4 to 1.8 0.4, p = 0.0008), mitral and tricuspid regurgitation increased thromboembolism occurred in 3 of the 18 patients with AF. 9 of 18 patients died after AF occurrence

32、of AF was a predictor of major cardiac events. Pozolli et al, JACC 1999Development of AF is AssociateAtrial Fibrillation is Associated with Increased Mortality in Chronic HFRR 1.34 (1.11 - 1.61) adjusted for severity, medicationAtrial Fib-Sinuspn4196098Mortality34%23%0.0001Heart Failure Death17%9%0.

33、0001Arrhythmic Death7%6%NSDries et al, SOLVD, JACC 1998Atrial Fibrillation is AssociaA) Impact of Treatment of Heart Failure on Atrial Fibrillation - RAASTargeting atrial-specific ion channels and developing antiarrhythmic drugs with selected channel-blocking profiles are very attractive approaches.

34、 Success in preventing components of AF pathophysiology, including the prevention of AF-promoting structural remodelling by suppressing reninangiotensin activation, has been achieved in animal experiments. Clinical trials indicate the value of inhibiting angiotensin-converting enzyme or blocking ang

35、iotensin type-1 receptors in preventing AF recurrence (RAAS). Antiarrhythmic drugs for atrial fibrillation: Do we need better use, better drugs or a randomized trial of ablation as primary therapy? Stanley Nattel, Montreal Heart Institute Research Center, CMAJ 2004 ; 171 (7). A) Impact of Treatment

36、of HearPrevention of Atrial Fib With Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers: A Meta-Analysis 11 studies with 56,308 patientsOverall, ACEIs and ARBs reduced the relative risk of AF by 28% (95% C 15% to 40%Benefit is similar for ACE-inhibitors and AII blockersReduct

37、ion in AF was greatest in patients with heart failure (relative risk reduction 44%, p = 0.007). Healey, et al JACC 2005;45:1832Prevention of Atrial Fib With A) Impact of Treatment of Heart Failure on Atrial Fibrillation - RAASAldosterone has a wide range of both genomic and non-genomic actions and is a