Focus on the efficacy of cardiac resynchronisation therapy in HF plus concomitant AF

No significant association between the presence of atrial fibrillation (AF) in patients with heart failure (HF) and the efficacy of cardiac resynchronisation therapy (CRT) was observed in an analysis including 5 major clinical trials. However, the results were not conclusive, and further studies are warranted to address this issue.

Although the efficacy of CRT in patients with HF has been established in landmark trials, it has been suggested that the efficacy of CRT may be reduced in patients with HF and concomitant AF. This issue has not been thoroughly investigated, since patients with HF plus AF were limited in the conducted CRT trials. However, approximately 25% of the patients who receive CRT in the real world have AF. Dr Frederik Dalgaard (Herlev and Gentofte Hospital, Denmark) investigated the association between CRT and AF status in patients who were included in 5 landmark CRT trials (i.e. MIRACLE, MADIT-CRT, BLOCK-HF, RESERVE, and COMPANION) [1]. In total, 4,062 patients were analysed, of whom 661 had a history of paroxysmal AF. The clinical outcomes of this study were a combination of HF hospitalisation and all-cause mortality, and all-cause mortality alone.

After a median follow-up of 21 months, 837 patients had been hospitalised for HF, and 555 patients had deceased. The results showed that the ratio of hazard ratios between patients with and without AF was not significant (HR 1.24; P=0.16). Similarly, the secondary outcome of all-cause mortality did not display a significant interaction effect of CRT efficacy for those with and without AF (HR 1.34; P=0.19). Results did confirm that the overall population benefitted from CRT compared with no-CRT in terms of HF hospitalisation plus all-cause mortality (HR 0.74; 95% CI 0.62–0.87; P=0.005). The effect was smaller and non-significant in patients with concomitant AF (HR 0.87; P=0.37).

Including data from 5 landmark trials did not unambiguously confirm the efficacy of CRT in patients with HF and concomitant AF. Larger trials, focusing specifically on this sub-population of patients, are needed to address the efficacy of CRT in this group of patients.

1. Dalgaard F, et al. Cardiac resynchronization therapy in patients with a history of atrial fibrillation: insights from five major clinical trials. CRT News, EHRA 2022, 3–5 April, Copenhagen, Denmark.

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Posted on 1 June 202213 June 2022