Atrial Fibrillation in Heart Failure US Ambulatory Cardiology Practices and the Potential for Uptake of Catheter Ablation: An National Cardiovascular Data Registry (NCDR ® ) Research to Practice (R2P) Project

Jehu Mathew; Lucas Marzec; Kevin F. Kennedy; Philip G. Jones; Paul D. Varosy; Frederick A. Masoudi; Thomas M. Maddox; Larry A. Allen

doi:10.1161/jaha.116.005273

August 2, 2017Journal of the American Heart AssociationOpen Access

Atrial Fibrillation in Heart Failure US Ambulatory Cardiology Practices and the Potential for Uptake of Catheter Ablation: An National Cardiovascular Data Registry (NCDR ® ) Research to Practice (R2P) Project

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Why the study?

What are the contemporary treatment patterns and potential for catheter ablation uptake in US ambulatory patients with atrial fibrillation and heart failure with reduced ejection fraction?

Structured PICO

What are the contemporary treatment patterns and potential for catheter ablation uptake in US ambulatory patients with atrial fibrillation and heart failure with reduced ejection fraction?

P

Population

8,483 patients with atrial fibrillation and heart failure meeting AATAC trial inclusion criteria (from a broader cohort of 164,166 patients with AF and HF in the PINNACLE registry between 2013 and 2014). Mean age 71.2 years, with high rates of comorbidities (CAD 79.2%, hypertension 82.4%, diabetes 31.8%).

I

Intervention

Assessment of contemporary treatment patterns (catheter ablation, anti-arrhythmic drugs, rate control)

O

Outcome

Treatment with medications and procedures assessed at registry inclusion

Implication

In contemporary US ambulatory practice, patients with AF and HFrEF are predominantly managed with rate control, suggesting significant potential to increase catheter ablation use based on recent trial findings, though real-world patients are older with more comorbidities.

Abstract

BACKGROUND: Atrial fibrillation (AF) and heart failure with reduced ejection fraction frequently coexist. The AATAC (Ablation versus Amiodarone for Treatment of persistent Atrial fibrillation in patients with Congestive heart failure and an implantable device) trial suggests that catheter ablation may benefit these patients. However, applicability to contemporary ambulatory cardiology practice is unknown. METHODS AND RESULTS: Practice Innovation and Clinical Excellence Registry, we identified participants meeting AATAC enrollment criteria between 2013 and 2014. Treatment with medications and procedures was assessed at registry inclusion. From 164 166 patients with AF and heart failure, 8483 (7%) patients potentially met AATAC inclusion criteria. Eligible subjects, compared to AATAC trial participants, were older (mean age, 71.2±11.4 years) and had greater comorbidity (coronary artery disease 79.2%, hypertension 82.4%, and diabetes mellitus 31.8%). AF was predominantly paroxysmal (65.5%), rather than persistent/permanent (16.7%) or new onset (17.8%), whereas all patients in the AATAC trial had persistent AF. Commonly used atrioventricular-nodal blocking agents were carvedilol (71.2%), digoxin (31.9%), and metoprolol (27.1%). Rhythm control with anti-arrhythmic drugs was reported in 29.0% of AATAC eligible patients (predominantly amiodarone [24.6%]) and 9.3% had undergone catheter ablation. Patients who underwent ablation were more likely to be younger and have less comorbidities than those who did not. CONCLUSIONS: Among the contemporary ambulatory AF/heart failure with reduced ejection fraction population, treatment is predominantly rate control with few catheter ablations. Application of AATAC findings has the potential to markedly increase the use of catheter ablation in this population, although significant differences in clinical profiles might influence ablation outcomes in practice.