Atrial Fibrillation, Heart Failure
Conditions
Keywords
Heart failure, Atrial fibrillation, Catheter ablation, Treatment, Outcome
Brief summary
The DanAblate-HF trial will investigate whether early catheter ablation treatment for atrial fibrillation in patients with heart failure is superior to standard treatment.
Detailed description
Atrial fibrillation (AF) is the most common arrhythmia in patients with heart failure (HF), with rates ranging between 20-65%, depending on age, severity of HF, subtypes of HF and duration of HF. The two conditions have an intricate and often overlapping pathophysiology, with each condition leading to development of the other, as well as progression of disease. Studies have shown that the presence of AF in HF patients is associated with increased morbidity and mortality, deterioration in HF, exacerbated HF symptoms, and reduced quality of life. The optimal treatment of AF in the presence of HF remains unknown. Currently, there is a pull towards catheter ablation as first-line therapy for AF in HF patients. However, there is no solid scientific evidence to support this approach. Furthermore, it is unknown whether early rhythm control by catheter ablation in HF patients is beneficial. The investigators aim to conduct a pragmatic, randomized clinical trial designed to evaluate the efficacy and safety of early catheter ablation for AF in patients with HF compared with standard treatment. Eligible patients with HF and AF will be prospectively screened from all Danish hospitals and randomized 1:1 to early catheter ablation with pulmonary vein isolation (within 6 weeks) or standard guideline directed treatment for AF. Patients with reversible causes for AF, conditions that preclude the use of catheter ablation or previous catheter ablation for AF will be excluded from the study. Randomization and follow-up will be conducted at six specialized sites in Denmark. There will be one scheduled on-site 12-months follow-up visit after randomization. All clinical follow-up will be conducted at the patient's local hospital, according to standard practice and out of trial setting. Information regarding hospital visits/admissions, events, adverse events, changes in medication, cross-over, heart rhythm and rate, and results of relevant blood-work will be ascertained through systematic patient chart-review at pre-specified time-points. The results from this trial will mold future treatment of AF in HF patients. The investigators hypothesize that early catheter ablation reduces the risk of HF hospitalizations and mortality when compared with standard treatment, thereby significantly improving the clinical prognosis for patients with HF and AF.
Interventions
PROCEDURECatheter ablation
Catheter ablation with pulmonary vein isolation will be the study intervention. Patients randomized to the intervention arm will undergo catheter ablation within six weeks of randomization. In the waiting-time for ablation, patients will receive standard treatment for AF and HF, as per current guideline recommendations. Catheter ablation will be performed at one of six high-volume ablation centers in Denmark. Mode of catheter ablation will be at the discretion of the operator. Radiofrequency ablation, cryo-balloon ablation and pulsed-field ablation will be utilized. The treating physician should ensure successful pulmonary vein isolation after ablation with either post-procedural mapping or pacing, as per current standards. Only pulmonary vein isolation will be performed during the ablation procedure.
Sponsors
Rigshospitalet, Denmark
Odense University Hospital
Aarhus University Hospital
Zealand University Hospital
Herlev and Gentofte Hospital
Aalborg University Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
The DanAblate-HF trial is a pragmatic, investigator-initiated, prospective, multicenter, open-labeled, randomized, controlled trial. Patients will be randomized 1:1 to either early catheter ablation or standard treatment.
Eligibility
Sex/Gender
ALL
Age
18 Years to 80 Years
Healthy volunteers
No
Inclusion criteria
1. HF patients with AF within the past 12 months HF is defined as all of the below (all must apply) * Clinically assessed Heart Failure with Reduced Ejection Fraction (HFrEF) * An indication for initiation or ongoing guideline directed medical therapy for HFrEF, according to current Heart Failure guidelines * LVEF \< 50% at any point during the past 12 months AF is defined as one or more of the following: A. Symptomatic AF, documented by ECG, Holter of CIED B. Asymptomatic AF with one or more of the following: * Clinical indication for rhythm or rate control (documented by ECG, telemetry, Holter, CIED) * ≥2 ECG detected AF episodes within 3 months (on separate dates) * Holter detected AF with a continuous duration of more than 6 hours * CIED detected AF with continuous duration \>24 hours 2. 18 years ≤ Age \<80 years 3. Optimal medical therapy for HFrEF or planned/current uptitration in guideline directed medical therapy for HFrEF 4. Treatment with anticoagulation for stroke prevention, initiated according to guidelines for treatment of AF
Exclusion criteria
1. Life-expectancy \< 1 year 2. BMI \> 40 3. Contraindications or unacceptable side effects to rate limiting drugs AND amiodarone 4. LA size (indexed for BSA) \> 60 ml/m2 (volume) on echo within the last year 5. Documented persistent/permanent AF \> 1 year 6. Previous AF ablation/surgery 7. Reversible causes of AF (including, but not limited to, infection within 14 days, untreated thyroid disease, surgery) 8. Severe valvular disease 9. Acute myocardial infarction, cardiothoracic surgery or stroke within the past 3 months 10. Planned cardiothoracic surgery 11. Listed for heart transplant 12. Contraindications for anticoagulation therapy or catheter ablation 13. Severe kidney disease (CKD≥5) 14. Pregnancy 15. Patient unwilling to try medical therapy for AF 16. Patient unwilling/unable to give informed consent for study participation
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Time to hospitalization for worsening HF or cardiovascular death | From baseline to study completion, with a minimum of 1 year | The primary outcome of the trial is defined as the time from randomization to the composite of one the following, whichever comes first * Hospitalization for worsening HF * Cardiovascular (CV) mortality Hospitalization for worsening HF will be defined as hospital admission primarily for HF (as deemed so by the event adjudication committee) with a duration of at least 24 hours and requiring intensification of diuretic treatment. CV mortality will be defined as all deaths resulting from one or more of the following: HF, stroke, acute myocardial infarction, CV procedural deaths, CV hemorrhage, arrythmia, sudden cardiac death, death due to other CV causes and death of undetermined cause. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Time to first heart failure hospitalization | From baseline to study completion, with a minimum of 1 year | Time from randomization to first hospitalization for heart failure, as defined in the primary endpoint |
| Time to primary outcome stratified by age | From baseline to study completion, with a minimum of 1 year | Time from randomization to trial primary outcome stratified by median age at baseline |
| Time to primary outcome stratified by sex | From baseline to study completion, with a minimum of 1 year | Time from randomization to trial primary outcome stratified by sex |
| Time to primary outcome stratified by symptomatic and asymptomatic AF | From baseline to study completion, with a minimum of 1 year | Time from randomization to trial primary outcome stratified by whether patients have symptomatic or asymptomatic AF at baseline |
| Time to primary outcome stratified by paroxysmal or persistent AF | From baseline to study completion, with a minimum of 1 year | Time from randomization to trial primary outcome stratified by paroxysmal or persistent AF at baseline |
| Time to primary outcome stratified by left ventricular ejection fraction (LVEF) | From baseline to study completion, with a minimum of 1 year | Time from randomization to trial primary outcome stratified by LVEF \<=40% and LVEF\>40% at baseline |
| Change in Quality of Life | From baseline to 12 months | Change in Quality of Life will be assessed through Kansas City Cardiomyopathy Questionnaire (KCCQ-23) at baseline and 12 months. The KCCQ-23 quantifies physical function/limitations, symptoms, quality of life, social function/limitations and self-efficacy. Scores are generated for each domain and scaled from 0 to 100, with higher scores reflecting better health outcome. |
| Change in self-assessed health | From baseline to 12 months | Change in self-assessed health will be assessed through short form-36 (SF-36) questionnaire at baseline and 12 months. The SF-36 questionnaire consists of 8 domains: Physical functioning, limitions due to physical health, limitations due to emotional problems, fatigue, emotional well-being, social functioning, general bodily pain and general health. Each domain is scored from 0 to 100, with higher scores reflecting better self-assessed health. |
| Change in New York Heart Association (NYHA) class | From baseline to 12 months | Change in NYHA class assessed at baseline and 12 months visit |
| Change in European Heart Rhythm Association score of atrial fibrillation (EHRA class) | From baseline to 12 months | Change in EHRA class assessed at baseline and 12 months visit |
| Time to cardiovascular death | From baseline to study completion, with a minimum of 1 year | Time from randomization to cardiovascular death. Cardiovascular death will be defined as in the primary endpoint. |
| Time to all-cause mortality | From baseline to study completion, with a minimum of 1 year | Time from randomization to all-cause mortality |
| Time to first-time AF hospitalization | From baseline to study completion, with a minimum of 1 year | Time from randomization to first hospitalization for AF |
Other
| Measure | Time frame | Description |
|---|---|---|
| Change in left atrial (LA) volume | From baseline to 12 months | Change in LA volume assessed at baseline echocardiography and 12 months echocardiography |
| Change in NT-pro-BNP | From baseline to 12 months | Change in NT-pro-BNP assessed at baseline and 12 month |
| Time to hospitalization or death due to stroke | From baseline to study completion, with a minimum of 1 year | Time from randomization to hospitalization or death due to stroke |
| Cumulative heart failure hospitalization | From baseline to study completion, with a minimum of 1 year | Total cumulative number (first and recurrent) of hospitalization for heart failure from randomization to study completion. |
| Cumulative hospitalizations for AF | From baseline to study completion, with a minimum of 1 year | Total cumulative number (first and recurrent) of hospitalization for AF from randomization to study completion. |
| Time to first-time all-cause hospitalization | From baseline to study completion, with a minimum of 1 year | Time from randomization to first all-cause hospitalization |
| Cumulative all-cause hospitalizations | From baseline to study completion, with a minimum of 1 year | Total cumulative number (first and recurrent) of all-cause hospitalization from randomization to study completion. |
| Change in LVEF | From baseline to 12 months | Change in LVEF assessed at baseline echocardiography and 12 months echocardiography |
| Change in left ventricular (LV) volume | From baseline to 12 months | Change in LV volume assessed at baseline echocardiography and 12 months echocardiography |
Countries
Denmark
Contacts
Primary ContactAnne-Christine Ruwald, MD, PhD
Backup ContactSam Riahi, MD, PhD
Outcome results
None listed