The following are key points to remember from an in-depth review on atrial fibrillation (AF) in patients with heart failure with reduced ejection fraction (HFrEF) and HF with preserved EF (HFpEF):

1. AF develops in more than half of patients with HFpEF and HFrEF with prognostic and functional significance.
2. Despite the high coexistence of AF and HF, the existing pathophysiological and trial evidence base is not sufficient to answer many of the fundamental questions about the management of AF in both HFpEF and HFrEF. AF in HFrEF develops in two distinct settings: a tachycardia-mediated cardiomyopathy or secondary AF as a consequence of the cardiomyopathy.
3. If HF persists despite medical therapy and rate control in tachycardia cardiomyopathy, rhythm control is indicated with either antiarrhythmics or catheter ablation. Catheter ablation remains the most effective strategy to maintain sinus rhythm.
4. For secondary AF in HFrEF with persistent symptoms despite medical therapy, catheter ablation is associated with improved functional outcomes, but data on mortality reduction are conflicting.
5. Beta-blockers may have decreased benefit in rate-controlled permanent AF in HFrEF. Beta-blockers maintain efficacy in paroxysmal AF in HFrEF.
6. All patients with AF and HF should be anticoagulated with direct oral anticoagulants (DOACs) without antiplatelet agents.
7. Atrioventricular (AV) node ablation and cardiac resynchronization therapy (CRT) should be performed in HFrEF with AF that is difficult to rate control if pulmonary vein isolation is not an option. In patients undergoing CRT for a wide QRS, AV node ablation may be beneficial to optimize CRT.
8. AF can cause atrial mitral regurgitation and tricuspid regurgitation from annular enlargement. If AF is of recent onset, consideration of rhythm control may be warranted to decrease the regurgitation.
9. HFpEF is associated with atrial noncompliance, atrial myopathy, and a high risk of progressive AF. Many symptomatic patients with AF and a preserved EF have occult HFpEF that is frequently unrecognized and an independent contributor to symptoms beyond the AF.
10. Finally, the role of catheter ablation in HFpEF with AF requires dedicated randomized trials, which are currently lacking in the literature.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Mitral Regurgitation

Keywords: Adrenergic beta-Antagonists, Anti-Arrhythmia Agents, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Atrioventricular Node, Cardiac Resynchronization Therapy, Cardiomyopathies, Catheter Ablation, Heart Failure, Mitral Valve Insufficiency, Platelet Aggregation Inhibitors, Secondary Prevention, Stroke Volume, Tachycardia, Tricuspid Valve Insufficiency

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