Atrial fibrillation in heart failure: what should we do?

Abstract

Heart failure (HF) and atrial fibrillation (AF) are two conditions that are likely to dominate the next 50 years of cardiovascular (CV) care. Both are increasingly prevalent and associated with high morbidity, mortality, and healthcare cost. They are closely inter-related with similar risk factors and shared pathophysiology. Patients with concomitant HF and AF suffer from even worse symptoms and poorer prognosis, yet evidence-based evaluation and management of this group of patients is lacking. In this review, we evaluate the common mechanisms for the development of AF in HF patients and vice versa, focusing on the evidence for potential treatment strategies. Recent data have suggested that these patients may respond differently than those with HF or AF alone. These results highlight the clear clinical need to identify and treat according to best evidence, in order to prevent adverse outcomes and reduce the huge burden that HF and AF are expected to have on global healthcare systems in the future. We propose an easy-to-use clinical mnemonic to aid the initial management of newly discovered concomitant HF and AF, the CAN-TREAT HFrEF + AF algorithm (Cardioversion if compromised; Anticoagulation unless contraindication; Normalize fluid balance; Target initial heart rate <110 b.p.m.; Renin-angiotensin-aldosterone modification; Early consideration of rhythm control; Advanced HF therapies; Treatment of other CV disease).

Keywords: Atrial fibrillation; Heart failure; Management; Review.

Figure 1

Shared and synergistic mechanisms in heart failure and atrial fibrillation. There is a cycle of interdependence between heart failure and atrial fibrillation and each makes the other more likely to occur. RAAS, renin–angiotensin–aldosterone system.

Figure 2

Major priorities of management in patients with heart failure and reduced ejection fraction and those with atrial fibrillation. HFrEF, heart failure with reduced ejection fraction; AF, atrial fibrillation; CV, cardiovascular; HF, heart failure; LV, left ventricle; RV, right ventricle.

Figure 3

CAN-TREAT initial management algorithm for patients with newly identified heart failure and reduced ejection fraction and atrial fibrillation. ACEi, angiotensin converting enzyme inhibitors; ARB, angiotensin receptor blockers; CV, cardiovascular.

Figure 4

β-Blockers in heart failure and reduced ejection fraction with sinus rhythm and atrial fibrillation. Kaplan–Meier survival curves for β-blocker vs. placebo in heart failure patients with (A) sinus rhythm and (B) atrial fibrillation. Data are unadjusted survival curves for all reported deaths. Hazard ratios are derived from an adjusted one-stage Cox regression model, stratified by study and censored at 1200 days (3.3 years). Reproduced from Kotecha et al.