Canadian Journal of Cardiology

Atrial Fibrillation in Heart Failure: A Practical Approach for the Clinician

Published:February 10, 2022DOI:
      Atrial fibrillation (AF) and heart failure (HF) are both cardiovascular epidemics. The coexistence of both conditions confers important pathophysiological and clinical implications, but how best to treat AF in the presence of HF remains unclear. Herein, we provide a brief practical review focused on the arrhythmic management of AF in HF, which includes pharmacological and nonpharmacological approaches such as catheter ablation and atrioventricular (AV) nodal ablation. A summary of recommendations is provided in Table 1. In keeping with the Contemporary Issues style, this article has only 5 references. A version with expanded references is available in the Supplementary Material.
      Table 1Special considerations in the approach to HF management for AF patients
      Individualization of care
      Rate or rhythm control
      • Favouring a rhythm control approach
      • Significant symptoms attributed to AF
      • Tachycardia-induced cardiomyopathy
      • Recent diagnosis of AF
      Pharmacological rhythm control
      • HFrEF: amiodarone
      • HFpEF: amiodarone, sotalol (no LVH, no risk factors for TdP, and caution in women, patients with renal dysfunction, or diuretic use)
      Nonpharmacological approaches Modifiable risk factors: hypertension, diabetes mellitus, sleep apnea, obesity, tobacco use, alcohol consumption
      Catheter ablation Favouring catheter ablation in a subset of patients
      • Arrhythmia-induced cardiomyopathy
      • HF patients with optimal medical therapy and persistent symptoms attributed to AF
      Device therapy Indications for ICD and CRT do not differ for HF patients with or without AF
      • Patients with AF and CRT should be receiving maximally tolerated rate control to minimize ventricular dyssynchrony
      • Consider AF ablation or AV node ablation for patients with suboptimal pacing (< 95%)
      AF, atrial fibrillation; AV, atrio-ventricular; CRT, cardiac resynchronization therapy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter defibrillator; LVH, left ventricular hypertrophy; TdP, torsades de pointes.
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