The management of atrial fibrillation in patients with heart failure
- Alan Cheng, MD
Alan Cheng, MD
- Section Editor — Arrhythmogenic Right Ventricular Cardiomyopathy
- Associate Professor of Medicine
- Johns Hopkins University School of Medicine
- Brian Olshansky, MD
Brian Olshansky, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- University of Iowa Medical Center
- Section Editors
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
- Bradley P Knight, MD, FACC
Bradley P Knight, MD, FACC
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
For patients with atrial fibrillation (AF), the main goals of therapy are control of symptoms, prevention of cardiac dysfunction, and prevention of arterial thromboembolism, particularly stroke. These goals are also appropriate for the relatively large subset of AF patients with heart failure (HF). In these individuals, symptoms are frequent and potentially disabling due to the interaction between the two processes.
This topic will focus on the management of AF in patients with HF. There are few differences in management between those with systolic or diastolic HF. (See "Overview of the therapy of heart failure with reduced ejection fraction" and "Use of beta blockers and ivabradine in heart failure with reduced ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction" and "Pathophysiology of diastolic heart failure" and "Clinical manifestations and diagnosis of heart failure with preserved ejection fraction".)
The reader will be referred to other AF topics for which care is relatively similar irrespective of the presence of HF. (See "Atrial fibrillation: Anticoagulant therapy to prevent embolization", section on 'Summary and recommendations' and "Control of ventricular rate in atrial fibrillation: Pharmacologic therapy" and "Catheter ablation to prevent recurrent atrial fibrillation: Clinical applications", section on 'Efficacy'.)
INCIDENCE AND PREVALENCE
Atrial fibrillation (AF) and heart failure (HF) are two cardiac diseases that may co-exist. The presence of one increases the likelihood of the other .
The incidence of AF in patients 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 (the study does not state what percent of patients had systolic or diastolic 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. An association between left ventricular diastolic dysfunction and AF was established in a study of 840 patients ≥65 years of age, 80 of whom developed AF over a mean follow-up of four years . Patients with abnormal diastolic function had an increased risk of AF compared to those with normal diastolic function. (See "Pathophysiology of diastolic heart failure" and "Clinical manifestations and diagnosis of heart failure with preserved ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction".)
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- INCIDENCE AND PREVALENCE
- EFFECT ON CARDIAC FUNCTION
- CORRECTION OF REVERSIBLE CAUSES OF AF AND HF
- ACUTE MANAGEMENT
- SYSTOLIC OR DIASTOLIC HEART FAILURE
- Rhythm versus rate control
- PATIENTS WITH SYSTOLIC HEART FAILURE
- Rhythm control
- - Our initial approach to rhythm control
- - Electrical cardioversion
- - Antiarrhythmic drug therapy
- - Beta blockers for rhythm control
- - Possible role of angiotensin inhibition
- - Catheter ablation
- Rate control
- - Our approach to rate control
- - Rate-control goal
- - AV node ablation with pacing
- PATIENTS WITH DIASTOLIC HEART FAILURE
- RECOMMENDATIONS OF OTHERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS