CONFIRM-AF: Insertable Cardiac Monitor for Atrial Fibrillation Detection in Heart Failure Patients
Study Details
Study Description
Brief Summary
Patients with heart failure (HF) represent a large population of patients who are at high risk for complications related to undiagnosed atrial fibrillation (AF). However, currently there are limited modalities for early AF detection and subsequent stroke prevention in this high-risk population. An implantable cardiac monitor (ICM) is inserted subcutaneously and can provide long term arrhythmia information via remote monitoring.
The Confirm-AF trial seeks to accurately define the burden of AF and other arrhythmias in high-risk HF patients using a Confirm Rx ICM.
Condition or Disease | Intervention/Treatment | Phase |
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N/A |
Detailed Description
Over 6 million people in the United States suffer from heart failure (HF). By the year 2030 the prevalence of HF is expected to exceed 8 million people. Heart failure accounts for 1 million hospital admissions each year, costing our economy in excess of $30 billion dollars per year. Mortality in patients with HF remains high, and nearly half of all patients diagnosed with HF will die within 5 years. More than half of all patients admitted with HF decompensation have preserved left ventricular systolic function. Patients with HF and mildly reduced or preserved left ventricular systolic function are at high risk for developing atrial fibrillation (AF), the occurrence of which often contributes to HF decompensation and increases morbidity and all-cause mortality. Similarly, patients with AF are at high risk for developing HF due to loss of atrio-ventricular synchrony and rapid uncontrolled ventricular rates. Detection of AF can be challenging and may go undiagnosed in asymptomatic or minimally symptomatic patients through conventional monitoring methods. Patients with HF represent a large population who are at risk for complications related to undiagnosed AF. AF increases the risk of stroke five-fold and the risk of death nearly two-fold. Moreover, strokes related to AF are twice as likely to be fatal or severely disabling compared to strokes due to other causes, such as ischemic small vessel disease or atheromatous large vessel disease. Cardiac implantable electronic devices (CIEDs), can be used for the early detection of AF in asymptomatic or mildly symptomatic patients with HF. However, current guidelines provide an indication for prophylactic implantable cardioverter defibrillator (ICD) only in HF patients with left ventricular ejection fraction (LVEF) ≤ 35%, whereas there are limited data for device-based detection of AF in HF patients with more preserved LVEF.
Implantable cardiac monitors (ICM) are devices that can be injected into the subcutaneous tissue and can provide automatic electrocardiographic recordings of asymptomatic arrhythmias as well as patient triggered electrocardiographic recordings of symptomatic episodes during long term follow-up. Implantable cardiac monitors are be paired with remote monitoring systems, capable of rapid remote review of electrograms. Accordingly, we hypothesize that a management strategy that incorporates ICM implantation in patients with HF and LVEF >35% will result in a significantly higher rate of AF detection leading to arrhythmia related interventions compared to conventional monitoring and follow-up in patients with HF.
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
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Experimental: Confirm Rx insertable cardiac monitor The Confirm RX implantable cardiac monitor (ICM) is an FDA-approved device that can be injected into the subcutaneous tissue and can provide automatic as well as patient triggered electrocardiographic recordings of symptomatic episodes during long term follow-up. This Implantable cardiac monitor is paired with a remote monitoring smartphone application called My Merlin that capable of rapid remote review of electrograms to be utilized in this study for arrhythmia detection. The Confirm Rx ICM is indicated for the monitoring and diagnostic evaluation of patients who experience unexplained symptoms such as: dizziness, palpitations, chest pain, syncope, and shortness of breath, as well as patients who are at risk for cardiac arrhythmias. It is also indicated for patients who have been previously diagnosed with atrial fibrillation or who are susceptible to developing atrial fibrillation. |
Device: Confirm Rx Insertable Cardiac Monitor
Subjects will be subcutaneously implanted with an Abbott Confirm Rx ICM with the device implant procedure per standard of care and current labelling. Data related to subjects' arrhythmias, via the Merlin.net Patient CareNetwork will be transmitted on a monthly basis to the treating physician and subsequently to the study coordination and database center (CDC) at the University of Rochester. Data on the frequency/types of symptomatic (patient triggered) versus ICM detected (asymptomatic) arrhythmic events will be collected and adjudicated. Clinical data on medication, device interventions, cardiovascular events will be collected at follow-up visits.
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Active Comparator: Conventional Management The conventional management arm will use arrhythmia signs and symptoms to determine occurrence of arrhythmias. |
Other: Conventional Management and monitoring
Subjects randomized to the conventional management arm of the trial will undergo arrhythmia monitoring based on clinical indications and per standard available modalities including periodic electrocardiograms (ECG), Holter and/or event monitoring.
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Outcome Measures
Primary Outcome Measures
- Median Time to first detection of AF lasting > 5 minutes [24 months]
Defined as ICM detected AF in the intervention (implantable cardiac monitor) arm or captured by clinical symptoms and documented by ECG or Holter in the conventional arm.
Secondary Outcome Measures
- Time to initiation of guideline directed arrhythmic and HF interventions [24 months]
Interventions such AF ablation, initiation of antiarrhythmic, anticoagulation, beta-blocker therapy and others.
- Number cardiovascular hospitalizations or death [24 months]
Total number of cardiovascular hospitalizations or death in each arm.
- Mean quality of life measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ) [24 months]
All KCCQ scores are scaled from 0 to 100 and frequently summarized in 25-point ranges, where scores represent health status as follows: 0 to 24: very poor to poor; 25 to 49: poor to fair; 50 to 74: fair to good; and 75 to 100: good to excellent.
- Mean percentage of time spent in atrial fibrillation (AF Burden) [24 months]
AF burden, defined as average percentage of time spent in AF (i.e. amount of time spent in AF divided by the total amount of time a patient was monitored). AF burden will be quantified only in the intervention arm.
- Time to detection of composite of arrhythmic events endpoint [24 months]
Arrhythmic events consisting of AF, sustained ventricular tachycardia, and high-risk bradyarrhythmias (high degree AV block or sinus pause > 5 seconds), whichever occurs first.
Eligibility Criteria
Criteria
Inclusion Criteria:
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Male and female patients more than 18 years of age (no upper age limit)
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HF exacerbation requiring treatment with intravenous decongestive therapy in a hospital setting for an acute HF event during the past 12 calendar months.
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LVEF > 35% on a cardiac imaging study (echocardiogram, nuclear imaging, cardiac magnetic resonance imaging) performed during the past 12 calendar months.
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Shortness of breath associated with New York Heart Association (NYHA) functional class II, II, or ambulatory class IV.
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Willing to undergo an Abbott ICM implant and agree to remote ICM monitoring.
Exclusion Criteria:
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Existing implantable cardioverter defibrillator (ICD), biventricular ICD, implantable cardiac monitor or pacemaker.
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Known or documented history AF or atrial flutter any time in past.
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Class I indication for primary or secondary prevention ICD
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Documented ST elevation myocardial infarction in the past 1calendar month.
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Life expectancy less than 1 year
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Unwilling or unable to cooperate with the protocol
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Participation in other clinical trials (observational registries are allowed with approval from the CDC).
Contacts and Locations
Locations
Site | City | State | Country | Postal Code | |
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1 | University of Rochester Medical Center | Rochester | New York | United States | 14642 |
Sponsors and Collaborators
- University of Rochester
- Abbott
Investigators
- Principal Investigator: Ilan Goldenberg, MD, University of Rochester
Study Documents (Full-Text)
None provided.More Information
Publications
- Anter E, Jessup M, Callans DJ. Atrial fibrillation and heart failure: treatment considerations for a dual epidemic. Circulation. 2009 May 12;119(18):2516-25. doi: 10.1161/CIRCULATIONAHA.108.821306. Review.
- Colilla S, Crow A, Petkun W, Singer DE, Simon T, Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. 2013 Oct 15;112(8):1142-7. doi: 10.1016/j.amjcard.2013.05.063. Epub 2013 Jul 4.
- Ducharme A, Swedberg K, Pfeffer MA, Cohen-Solal A, Granger CB, Maggioni AP, Michelson EL, McMurray JJ, Olsson L, Rouleau JL, Young JB, Olofsson B, Puu M, Yusuf S; CHARM Investigators. Prevention of atrial fibrillation in patients with symptomatic chronic heart failure by candesartan in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) program. Am Heart J. 2006 Jul;152(1):86-92.
- Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001 May 9;285(18):2370-5.
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- Lin HJ, Wolf PA, Benjamin EJ, Belanger AJ, D'Agostino RB. Newly diagnosed atrial fibrillation and acute stroke. The Framingham Study. Stroke. 1995 Sep;26(9):1527-30.
- Lin HJ, Wolf PA, Kelly-Hayes M, Beiser AS, Kase CS, Benjamin EJ, D'Agostino RB. Stroke severity in atrial fibrillation. The Framingham Study. Stroke. 1996 Oct;27(10):1760-4.
- Maisel WH, Stevenson LW. Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy. Am J Cardiol. 2003 Mar 20;91(6A):2D-8D. Review.
- Miyasaka Y, Barnes ME, Gersh BJ, Cha SS, Bailey KR, Abhayaratna WP, Seward JB, Tsang TS. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation. 2006 Jul 11;114(2):119-25. Epub 2006 Jul 3. Erratum in: Circulation. 2006 Sep 12;114(11):e498.
- Pellicori P, Urbinati A, Kaur K, Zhang J, Shah P, Kazmi S, Capucci A, Cleland JGF, Clark AL. Prevalence and Incidence of Atrial Fibrillation in Ambulatory Patients With Heart Failure. Am J Cardiol. 2019 Nov 15;124(10):1554-1560. doi: 10.1016/j.amjcard.2019.08.018. Epub 2019 Aug 23.
- Reiffel JA, Verma A, Kowey PR, Halperin JL, Gersh BJ, Wachter R, Pouliot E, Ziegler PD; REVEAL AF Investigators. Incidence of Previously Undiagnosed Atrial Fibrillation Using Insertable Cardiac Monitors in a High-Risk Population: The REVEAL AF Study. JAMA Cardiol. 2017 Oct 1;2(10):1120-1127. doi: 10.1001/jamacardio.2017.3180.
- Trulock KM, Narayan SM, Piccini JP. Rhythm control in heart failure patients with atrial fibrillation: contemporary challenges including the role of ablation. J Am Coll Cardiol. 2014 Aug 19;64(7):710-21. doi: 10.1016/j.jacc.2014.06.1169. Review.
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