In the general population of patients with atrial fibrillation (AF), the main goals of therapy are the control of symptoms and the prevention of arterial thromboembolism, particularly stroke. (See "Antithrombotic therapy to prevent embolization in atrial fibrillation", section on 'Summary and recommendations'.) These goals are also true for the relatively large subset of AF patients with heart failure (HF). In such patients, the adverse hemodynamic consequences of AF can quickly lead to a decrease in exercise capacity and a worsening of symptoms, both of which may be difficult to manage [1,2]. Similar to the general population, no survival advantage has conclusively been demonstrated with either a rate- or a rhythm-control strategy to manage the abnormal rhythm. (See 'Effect on cardiac function' below.)
This topic will discuss the epidemiology, prognosis, and management of AF in patients with HF. This discussion will focus mainly on the ways in which the control of rate and rhythm may differ from the general population of patients with AF. An overview of the evaluation and management of AF is discussed separately. (See "Overview of atrial fibrillation".)
For the purposes of this topic, HF refers to patients with symptomatic systolic left ventricular dysfunction, unless otherwise stated.
INCIDENCE AND PREVALENCE
The incidence of atrial fibrillation (AF) in patients with heart failure (HF) was examined in an analysis from the Framingham Heart Study in which 1470 participants developed AF, HF, or both over a 47-year interval . Among the 708 who developed HF without prior AF, 159 (22 percent) subsequently developed AF over a mean follow-up of 4.2 years (incidence rate 5.4 percent per year) (figure 1). Somewhat similar findings were noted for patients who developed AF first; the subsequent incidence of HF was 3.3 percent per year. In another report from the Framingham Heart Study, the odds ratio for developing AF over a two-year interval among patients with HF was 4.5 for men and 4.9 for women .
The prevalence of AF in patients with HF varies from <10 to 50 percent, depending in part upon the severity of HF and New York Heart Association (NYHA) class [5-10]. In the V-HeFT trials of patients with mild to moderate HF, AF was present in 14 percent . In three cohorts of patients with more advanced HF referred for heart transplant evaluation, AF was present in 20 to 27 percent, respectively [6,9]. African Americans in general have lower incidences of AF and this is also true for AF in HF (20 versus 38 percent in one report) . The reasons for this are unclear.