Atrial Fibrillation and Heart Failure

TMED Blog

| 23 March 2024

Written by Cassidy Laub, MSc 25' (Candidate)

On February 1, 2024, Queen’s University Department of Medicine hosted Medical Grand Rounds (MGR), welcoming Dr. Victor Neira Vidal, Dr. Aws Almufleh, and Danielle Hart (NP). Their presentation “Keep the beat, lose the weight” discussed the impact of atrial fibrillation (AF) among heart failure (HF) patients, therapeutic strategies, and the Atrial Fibrillation Clinic. The key takeaways emphasized patient-centred care. Following their presentation, students from the Translational Medicine Graduate Program (TMED) were fortunate to engage in a captivating discussion with Dr. Neira Vidal and Danielle Hart.

AF was introduced as the most common cardiac arrhythmia, with a global prevalence of 37.6 million cases in 20171,2. It is estimated that 1 in 3 people will develop AF in their lifetime3. The incidence of AF is increasing due to a globally aging population1. This increase is a major concern since AF is associated with increased cardiovascular events and morbidity and a decreased quality of life, functional status, cardiac performance, and survival2,4,5. As a chronic disorder, AF costs billions of healthcare dollars annually2.

Sudden abnormal electrical signals from the atria cause AF by overriding the heart’s pacemaker function5. AF is described as irregular fast atrial contractions5. In the presentation, it was highlighted that AF can precipitate and be a consequence of HF6. Their association is likely related to shared risk factors including aging, hypertension, sleep apnea, diabetes, and structural heart disease6,7. For example, AF can lead to HF by causing tachycardiomyopathy, damage to the heart due to a sustained high heart rate, and a known cause of HF8. Conversely, the structural and neurohormonal changes in HF increase the likelihood of developing AF9.

Dr. Neira Vidal discussed treatments for AF and HF patients using high-quality evidence10–12. He emphasized that rhythm control therapies are vital for new diagnoses of AF and HF to eliminate AF episodes by restoring normal sinus rhythm11,13. Described as a first-line rhythm control therapy, catheter ablation aims to destroy the trigger initiating AF or the underlying arrhythmogenic substrate4,5,10. For patients with AF and HF, compared to medical therapy, catheter ablation is associated with a lower rate of death from any cause, arrhythmia recurrence, stroke, and hospitalization from HF10,11.

The most impactful part of the discussion was hearing about Kingston’s Atrial Fibrillation Clinic, led by Danielle. Here, a multidisciplinary team works to optimize holistic care through individualized approaches, patient education, comprehensive AF management and timely access to care. In her practice, Danielle promotes patient autonomy by providing quality resources and realistic goals to reduce unhealthy habits. The clinic uses the following ABCD model: Avoid stroke, Better symptom management, Cardiovascular considerations and Deciding about referral for ablation. The evidence-based approach of Kingston’s specialized clinic promotes quality care. There is inherent potential for this model to be applied in other health centres with the specific needs of their patients to improve AF and HF care.

Danielle presented a case study of an 85-year-old, that demonstrates that AF multidisciplinary treatment can lead to symptom resolvement. Dr. Almufleh also presented a clinical case of a 32-year-old with previous cardioversions and pulmonary vein isolation, presenting with HF and AF with right ventricle regurgitation due to an enlarged right ventricle. Treating the AF was prioritized to decrease the likelihood of poor outcomes. Thus, this patient underwent advanced medical therapy, another AF ablation, and cardiac resynchronization therapy. These cases signify the need for patient-centred care and multiple therapies in practice.

Our TMED cohort was fortunate to have an engaging discussion with Dr. Neira Vidal and Danielle that reinforced the presentation’s key takeaways including prioritizing early diagnosis and treatment, management of non-cardiovascular comorbidities to decrease morbidity and mortality, and for patients with AF, preventing stroke and HF has the most significant impact on quality of life. We learned that gaps in AF research should be filled by addressing prevention, including promoting healthy behaviours in community settings. Similarly, we discussed the need for health policy and funding to address the entire patient journey. As a recent example, Kingston is to receive $4,000,000 from the Ontario government to connect up to 10,000 people with primary care14, which has the inherent potential to improve long-term patient outcomes in our community. Our discussion also highlighted similarities between barriers faced by the Atrial Fibrillation Clinic and other clinics discussed in previous MGRs: lack of procedure space, anesthesiologists, and access to primary care.

This discussion inspired us to consider how we can improve patient care in the future as clinicians, researchers, policymakers and educators.

References

1. Lippi G, Sanchis-Gomar F, Cervellin G. Global epidemiology of atrial fibrillation: An increasing epidemic and public health challenge. Int J Stroke. 2021;16(2):217-221. doi:10.1177/1747493019897870

2. Nesheiwat Z, Goyal A, Jagtap M. Atrial Fibrillation. In: StatPearls. StatPearls Publishing; 2024. Accessed February 2, 2024. http://www.ncbi.nlm.nih.gov/books/NBK526072/

3. Weng LC, Preis SR, Hulme OL, et al. Genetic Predisposition, Clinical Risk Factor Burden, and Lifetime Risk of Atrial Fibrillation. Circulation. 2018;137(10):1027-1038. doi:10.1161/CIRCULATIONAHA.117.031431

4. Andrade JG, Aguilar M, Atzema C, et al. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2020;36(12):1847-1948. doi:10.1016/j.cjca.2020.09.001

5. Brundel BJJM, Ai X, Hills MT, Kuipers MF, Lip GYH, De Groot NMS. Atrial fibrillation. Nat Rev Dis Primer. 2022;8(1):21. doi:10.1038/s41572-022-00347-9

6. Gopinathannair R, Chen LY, Chung MK, et al. Managing Atrial Fibrillation in Patients With Heart Failure and Reduced Ejection Fraction: A Scientific Statement From the American Heart Association. Circ Arrhythm Electrophysiol. 2021;14(7):e000078. doi:10.1161/HAE.0000000000000078

7. Batul SA, Gopinathannair R. Atrial Fibrillation in Heart Failure: a Therapeutic Challenge of Our Times. Korean Circ J. 2017;47(5):644-662. doi:10.4070/kcj.2017.0040

8. Ermert L, Kreimer F, Quast DR, Pflaumbaum A, Mügge A, Gotzmann M. Rate of atrial fibrillation and flutter induced tachycardiomyopathy in a cohort of hospitalized patients with heart failure and detection of indicators for improved diagnosis. Front Cardiovasc Med. 2023;9:940060. doi:10.3389/fcvm.2022.940060

9. Kotecha D, Piccini JP. Atrial fibrillation in heart failure: what should we do? Eur Heart J. 2015;36(46):3250-3257. doi:10.1093/eurheartj/ehv513

10. Marrouche NF, Brachmann J, Andresen D, et al. Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med. 2018;378(5):417-427. doi:10.1056/NEJMoa1707855

11. Saglietto A, De Ponti R, Di Biase L, et al. Impact of atrial fibrillation catheter ablation on mortality, stroke, and heart failure hospitalizations: A meta-analysis. J Cardiovasc Electrophysiol. 2020;31(5):1040-1047. doi:10.1111/jce.14429

12. Sohns C, Fox H, Marrouche NF, et al. Catheter Ablation in End-Stage Heart Failure with Atrial Fibrillation. N Engl J Med. 2023;389(15):1380-1389. doi:10.1056/NEJMoa2306037

13. Kim D, Yang PS, Joung B. Optimal Rhythm Control Strategy in Patients With Atrial Fibrillation. Korean Circ J. 2022;52(7):496-512. doi:10.4070/kcj.2022.0078

14. Ontario Connecting Over 300,000 People to Primary Care Teams. news.ontario.ca. Accessed February 5, 2024. https://news.ontario.ca/en/release/1004143/ontario-connecting-over-3000…