Dr. Giuseppe M C Rosano,
Session number: 127
Session title: Heart failure and atrial fibrillation: vicious twins
Authors: Giuseppe Rosano (Roma, Italy)
Heart failure (HF) and atrial fibrillation (AF) are the two fastest growing cardiovascular diseases. It is predicted that 25 million patients will suffer from AF by 2050. Patients with AF may initially fluctuate between AF and sinus rhythm (SR), but will inevitably develop permanent AF. Heart failure drugs such as metoprolol, candesartan and eplerenone have been shown to reduce the occurrence of AF. However, the effects of these drugs may be related to the improvement of AF rather than to a direct effect on AF. The AFFIRM and RACE studies have both shown that rate control should be the preferred initial strategy in patients with AF. Furthermore, the AF-CHF study showed no difference between rate or rhythm control in terms of events in 1400 patients. The RACE I study suggested that patients with AF and higher heart rate (HR) do better than those with lower HR, while the RACE II study showed that lenient HR control showed a better event rate than strict heart rate control. Data from CHARM showed a greater risk of adverse events in patients with HF with preserved ejection fraction (HFpEF) compared to HF with reduced EF (HFrEF), and the best therapeutic approach to AF in patients with preserved EF is still largely unknown.
Anti-arrhythmics are used in 30% of patients with HF. These drugs are used in AF not just for chronic rhythm control but also for the acute cardioversion of symptomatic AF and to slow HR in chronic AF. In patients with new onset AF, at least one attempt to restore SR with drugs should be attempted. Amiodarone is still considered the drug of choice, while sotalol is a reasonable choice in renal dysfunction. For the management of acute HF, the guidelines of the Heart Failure Association outline the most appropriate treatment strategies in patients with HFpEF and HFrEF. Newer data suggest that ranolazine may be effective in patients with AF in HF. In a meta-analysis, beta-blockers have recently been shown to confer no survival benefit in patients with both HF and AF.
It is well established that oral anticoagulation reduces stroke incidence in patients with AF. According to the present treatment algorithms, almost all patients with AF and HF must be anticoagulated for the prevention of stroke. The WARCEF study did not show any benefit of anticoagulation in patients with HF and sinus rhythm. It must also be considered that a proportion of patients with SR have AF episodes and could be considered for anticoagulation. However, there is no evidence at present to implement anticoagulation in these patients.
Catheter ablation may improve left ventricular (LV) ejection fraction in patients with AF, especially in those with non-ischemic HF. However, the long term benefit of this approach in HF is largely unknown. The assessment of LV function after catheter ablation is most probably overestimated because none of these data are blinded. For symptomatic patients with AF and HF, catheter ablation is effective. In patients with preserved EF, catheter ablation of AF is more complex, and recurrence of AF is more frequent. Several prospective randomized clinical trials are undergoing to assess the effect of catheter ablation of AF in patients with left ventricular dysfunction and will be useful to provide evidence for the implementation of this therapy in patients with heart failure.
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