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ARTICLE CONTRIBUTORS

National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand

Clinical Articles, Lead Article

UPDATED CHF GUIDELINES ADVISE ON AF TREATMENT

Chronic heart failure (CHF) is a complex and lethal clinical syndrome accounting for an increasing number of Australian hospital admissions and more than 2,700 deaths in Australia in 2008, according to a recent update to the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Guidelines for the prevention, detection and management of chronic heart failure in Australia.1

The article summarises recent updates to earlier guidelines from the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand from 2006.  In some cases, new evidence strengthens the recommendations made in the original guidelines; in others, it provides new approaches to current recommended practice. The updated version of the guidelines is available on the National Heart Foundation of Australia website (http://www.heartfoundation.org.au).

There is a comprehensive section on cardiac arrhythmias, in particular atrial fibrillation (AF).  The earlier 2006 guidelines indicated that pharmacotherapy remains an important mainstay for patients with CHF who develop AF, although episodic electrical cardioversion may be required for those who experience symptomatic deterioration.  If sinus rhythm cannot be maintained for prolonged periods, the guidelines advised that therapy should be directed at controlling ventricular response rate (with digoxin, β-blockers or amiodarone) and reducing thromboembolic risk with warfarin. While it was noted that electrophysiological ablation prevents recurrence of atrial flutter in about 95% of cases, the role of curative ablation for AF was considered controversial.

The grades of recommendation used in the summary reflect the two highest grades in the 2006 guidelines (A: rich body of high-quality randomised controlled trial [RCT] data; and B: limited body of RCT data or high-quality non-RCT data).  The new guidelines recommend that rate control (rather than rhythm control), together with warfarin anticoagulation, should be the preferred method of treating patients with CHF and AF if their condition permits this (Grade B recommendation). The role of atrioventricular node ablation and pulmonary vein isolation for these patients requires further research, and no specific recommendation can be made at this stage.

In addition to the 2006 recommendations for cardiac resynchronisation therapy (CRT), for patients in whom implantation of an implantable cardioverter defibrillator is planned to reduce the risk of sudden death, the report claims that it is reasonable to also consider CRT to reduce the risk of death and heart failure events if the left-ventricular ejection fraction is ≤30% and the QRS duration is ≥150 ms (left bundle branch block morphology), with associated mild symptoms (NYHA Class II) despite optimal medical therapy (Grade A recommendation).

References

1 Krum H, Jelinek MV, Stewart S, Sindone A and Atherton JJ.  2011 Update to National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006. MJA 2011;194: No.8.

Published on: July 12, 2011

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ENDORSED BY

  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association
 

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