The following are key points to remember from a state-of-the-art review on management of patients with coexisting atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF):

1. Similar to heart failure (HF), the 2023 American College of Cardiology/American Heart Association multisociety guideline for the diagnosis and management of AF suggests viewing AF as disease progression along the spectrum, with stage 1 representing patients at risk for AF (with comorbidities such as obesity, hypertension, sleep apnea, advanced age, etc.), stage 2 representing pre-AF (with structural or electrical findings that predisposed to AF like atrial enlargement, atrial flutter, etc.), stage 3 representing a range of clinical AF (paroxysmal, persistent, long-standing persistent, successful ablation), and stage 4 representing permanent AF. Of note, HF and AF have many shared risk factors and changes associated with pre-disease states.
2. AF remains an important problem, with prevalence in the United States predicted to be approximately 12 million by the year 2030. Similarly, HF prevalence is predicted to be over 8 million by the year 2030. Comorbid AF and HF is common and can complicate the other’s disease course.
3. AF can lead to myocardial inflammation, fibrosis, and an atrial myopathy. This adverse remodeling predisposes to further AF and ongoing adverse changes. AF can also lead to arrhythmia-induced cardiomyopathies and HFrEF. Conversely, development of HF also increases the odds of developing AF.
4. When there is comorbid AF and HF, treatments must adequately address both conditions. Use of traditional HF guideline-directed medical therapy is key and may help address both underlying conditions. Of note, use of ivabradine may increase the risk of incident AF. Newer HF therapeutic agents may also affect incident AF, such as sacubitril/valsartan (possible neutral impact) or sodium-glucose cotransporter inhibitors (possible reduction in incident AF).
5. Rate control strategies for AF remain important, especially in the acute setting. In patients with HFrEF, rate control options include HF-specific beta-blockers (use with caution if HF is decompensated or if HF is progressive), digoxin (can be used when beta-blockers are not indicated or in combination; narrow therapeutic window and drug-drug interactions possible), and amiodarone (both rate and rhythm control, has some negative inotropy). Nondihydropyridine calcium channel blockers in HFrEF are contraindicated.
6. Rhythm control, via antiarrhythmic drugs or ablation, is increasingly becoming an option for many patients with HF. Of note, catheter ablation of AF is in general well tolerated and safe, and evidence suggests improved outcomes in patients with HF. Early ablation of AF in patients with HFrEF should be considered. Use of antiarrhythmic drugs (amiodarone, dofetilide, sotalol, dronedarone) does carry risk of being pro-arrhythmic and needs to be monitored closely, especially when there is comorbid chronic kidney disease or drug-drug interactions. Atrioventricular nodal ablation combined with ventricular pacing is another option in select cases.
7. In patients with AF in acutely decompensated HF, rate control is a reasonable first step with rhythm control strategies an option when that patient is more compensated from an HF perspective.
8. AF-related thromboembolic risk is increased in the setting of HFrEF, which is included in the commonly used CHA₂DS₂-VASc score. Warfarin and the direct oral anticoagulants are safe to use when indicated to reduce the risk of stroke. It is less clear what to do with anticoagulation for incident AF detected by cardiac implantable electronic devices, as risk of stroke is likely not as high compared to clinically detected AF. Surgical or percutaneous left atrial appendage occlusion is another option for reducing stroke risk in patients who are intolerant of long-term anticoagulation or, in the case of surgical closure, can be considered if undergoing cardiac surgery for other reasons.
9. Knowledge gaps still exist despite many recent advances. These include areas such as optimal and individualized risk factor modification, understanding the interplay between AF and HF pathophysiology, optimal rate and rhythm control strategies, optimal time of interventions, and optimal management of device-detected AF.

Clinical Topics: Arrhythmias and Clinical EP, EP Basic Science, Atrial Fibrillation/Supraventricular Arrhythmias, Heart Failure and Cardiomyopathies

Keywords: Anti-Arrhythmia Agents, Atrial Fibrillation, Heart Failure, Reduced Ejection Fraction

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