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 due to systolic dysfunction" and "Use of beta blockers and ivabradine in heart failure with reduced ejection fraction" and "Treatment and prognosis of diastolic heart failure" and "Pathophysiology of diastolic heart failure" and "Clinical manifestations and diagnosis of diastolic heart failure".)
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 application", 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 diastolic heart failure" and "Treatment and prognosis of diastolic heart failure".)
- Cha YM, Redfield MM, Shen WK, Gersh BJ. Atrial fibrillation and ventricular dysfunction: a vicious electromechanical cycle. Circulation 2004; 109:2839.
- Wang TJ, Larson MG, Levy D, et al. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation 2003; 107:2920.
- Tsang TS, Gersh BJ, Appleton CP, et al. Left ventricular diastolic dysfunction as a predictor of the first diagnosed nonvalvular atrial fibrillation in 840 elderly men and women. J Am Coll Cardiol 2002; 40:1636.
- Carson PE, Johnson GR, Dunkman WB, et al. The influence of atrial fibrillation on prognosis in mild to moderate heart failure. The V-HeFT Studies. The V-HeFT VA Cooperative Studies Group. Circulation 1993; 87:VI102.
- Stevenson WG, Stevenson LW, Middlekauff HR, et al. Improving survival for patients with atrial fibrillation and advanced heart failure. J Am Coll Cardiol 1996; 28:1458.
- Dries DL, Exner DV, Gersh BJ, et al. Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials. Studies of Left Ventricular Dysfunction. J Am Coll Cardiol 1998; 32:695.
- Joglar JA, Acusta AP, Shusterman NH, et al. Effect of carvedilol on survival and hemodynamics in patients with atrial fibrillation and left ventricular dysfunction: retrospective analysis of the US Carvedilol Heart Failure Trials Program. Am Heart J 2001; 142:498.
- Mahoney P, Kimmel S, DeNofrio D, et al. Prognostic significance of atrial fibrillation in patients at a tertiary medical center referred for heart transplantation because of severe heart failure. Am J Cardiol 1999; 83:1544.
- Maisel WH, Stevenson LW. Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy. Am J Cardiol 2003; 91:2D.
- Cohn JN, Johnson G, Ziesche S, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991; 325:303.
- Cohn JN, Archibald DG, Ziesche S, et al. Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. N Engl J Med 1986; 314:1547.
- Doval HC, Nul DR, Grancelli HO, et al. Randomised trial of low-dose amiodarone in severe congestive heart failure. Grupo de Estudio de la Sobrevida en la Insuficiencia Cardiaca en Argentina (GESICA). Lancet 1994; 344:493.
- Johnstone D, Limacher M, Rousseau M, et al. Clinical characteristics of patients in studies of left ventricular dysfunction (SOLVD). Am J Cardiol 1992; 70:894.
- Packer M, Poole-Wilson PA, Armstrong PW, et al. Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. ATLAS Study Group. Circulation 1999; 100:2312.
- Singh SN, Fletcher RD, Fisher SG, et al. Amiodarone in patients with congestive heart failure and asymptomatic ventricular arrhythmia. Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure. N Engl J Med 1995; 333:77.
- Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group. N Engl J Med 1987; 316:1429.
- Yusuf S, Pepine CJ, Garces C, et al. Effect of enalapril on myocardial infarction and unstable angina in patients with low ejection fractions. Lancet 1992; 340:1173.
- Pozzoli M, Cioffi G, Traversi E, et al. Predictors of primary atrial fibrillation and concomitant clinical and hemodynamic changes in patients with chronic heart failure: a prospective study in 344 patients with baseline sinus rhythm. J Am Coll Cardiol 1998; 32:197.
- Grogan M, Smith HC, Gersh BJ, Wood DL. Left ventricular dysfunction due to atrial fibrillation in patients initially believed to have idiopathic dilated cardiomyopathy. Am J Cardiol 1992; 69:1570.
- Kieny JR, Sacrez A, Facello A, et al. Increase in radionuclide left ventricular ejection fraction after cardioversion of chronic atrial fibrillation in idiopathic dilated cardiomyopathy. Eur Heart J 1992; 13:1290.
- Redfield MM, Kay GN, Jenkins LS, et al. Tachycardia-related cardiomyopathy: a common cause of ventricular dysfunction in patients with atrial fibrillation referred for atrioventricular ablation. Mayo Clin Proc 2000; 75:790.
- Crijns HJ, Tjeerdsma G, de Kam PJ, et al. Prognostic value of the presence and development of atrial fibrillation in patients with advanced chronic heart failure. Eur Heart J 2000; 21:1238.
- Olsson LG, Swedberg K, Ducharme A, et al. Atrial fibrillation and risk of clinical events in chronic heart failure with and without left ventricular systolic dysfunction: results from the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) program. J Am Coll Cardiol 2006; 47:1997.
- Wasywich CA, Whalley GA, Gamble GD, et al. Does rhythm matter? The prognostic importance of atrial fibrillation in heart failure. Heart Lung Circ 2006; 15:353.
- Mamas MA, Caldwell JC, Chacko S, et al. A meta-analysis of the prognostic significance of atrial fibrillation in chronic heart failure. Eur J Heart Fail 2009; 11:676.
- Aleong RG, Sauer WH, Davis G, Bristow MR. New-onset atrial fibrillation predicts heart failure progression. Am J Med 2014; 127:963.
- Lévy S, Maarek M, Coumel P, et al. Characterization of different subsets of atrial fibrillation in general practice in France: the ALFA study. The College of French Cardiologists. Circulation 1999; 99:3028.
- Roy D, Talajic M, Nattel S, et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med 2008; 358:2667.
- Suman-Horduna I, Roy D, Frasure-Smith N, et al. Quality of life and functional capacity in patients with atrial fibrillation and congestive heart failure. J Am Coll Cardiol 2013; 61:455.
- Jones DG, Haldar SK, Hussain W, et al. A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure. J Am Coll Cardiol 2013; 61:1894.
- Khan MN, Jaïs P, Cummings J, et al. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N Engl J Med 2008; 359:1778.
- Hunter RJ, Berriman TJ, Diab I, et al. A randomized controlled trial of catheter ablation versus medical treatment of atrial fibrillation in heart failure (the CAMTAF trial). Circ Arrhythm Electrophysiol 2014; 7:31.
- Flaker GC, Blackshear JL, McBride R, et al. Antiarrhythmic drug therapy and cardiac mortality in atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators. J Am Coll Cardiol 1992; 20:527.
- January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:2071.
- January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:e199.
- Pedersen OD, Bagger H, Keller N, et al. Efficacy of dofetilide in the treatment of atrial fibrillation-flutter in patients with reduced left ventricular function: a Danish investigations of arrhythmia and mortality on dofetilide (diamond) substudy. Circulation 2001; 104:292.
- Torp-Pedersen C, Møller M, Bloch-Thomsen PE, et al. Dofetilide in patients with congestive heart failure and left ventricular dysfunction. Danish Investigations of Arrhythmia and Mortality on Dofetilide Study Group. N Engl J Med 1999; 341:857.
- Vorperian VR, Havighurst TC, Miller S, January CT. Adverse effects of low dose amiodarone: a meta-analysis. J Am Coll Cardiol 1997; 30:791.
- Deedwania PC, Singh BN, Ellenbogen K, et al. Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation: observations from the veterans affairs congestive heart failure survival trial of antiarrhythmic therapy (CHF-STAT). The Department of Veterans Affairs CHF-STAT Investigators. Circulation 1998; 98:2574.
- Weinfeld MS, Drazner MH, Stevenson WG, Stevenson LW. Early outcome of initiating amiodarone for atrial fibrillation in advanced heart failure. J Heart Lung Transplant 2000; 19:638.
- Lehmann MH, Hardy S, Archibald D, et al. Sex difference in risk of torsade de pointes with d,l-sotalol. Circulation 1996; 94:2535.
- Piccini JP, Hasselblad V, Peterson ED, et al. Comparative efficacy of dronedarone and amiodarone for the maintenance of sinus rhythm in patients with atrial fibrillation. J Am Coll Cardiol 2009; 54:1089.
- Køber L, Torp-Pedersen C, McMurray JJ, et al. Increased mortality after dronedarone therapy for severe heart failure. N Engl J Med 2008; 358:2678.
- Anselmino M, Matta M, D'Ascenzo F, et al. Catheter ablation of atrial fibrillation in patients with left ventricular systolic dysfunction: a systematic review and meta-analysis. Circ Arrhythm Electrophysiol 2014; 7:1011.
- Machino-Ohtsuka T, Seo Y, Ishizu T, et al. Efficacy, safety, and outcomes of catheter ablation of atrial fibrillation in patients with heart failure with preserved ejection fraction. J Am Coll Cardiol 2013; 62:1857.
- Gasparini M, Regoli F, Galimberti P, et al. Cardiac resynchronization therapy in heart failure patients with atrial fibrillation. Europace 2009; 11 Suppl 5:v82.
- 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