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Atrial fibrillation-induced tachycardiomyopathy and heart failure: an underappreciated and elusive condition

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Abstract

Many patients with persistent, chronic, or frequently recurring paroxysmal atrial fibrillation (AF) may develop a tachycardiomyopathy (TCM) with left ventricular (LV) dysfunction and heart failure (HF), which is reversible upon restoration and maintenance of sinus rhythm, when feasible, or via better and tighter ventricular rate (VR) control. Mechanisms involved in producing this leading cause of TCM (AF-TCM) include loss of atrial contraction, irregular heart rate, fast VR, neurohumoral activation, and structural myocardial changes. The most important of all mechanisms relates to optimal VR control, which seems to be an elusive target. Uncontrolled AF may also worsen preexisting LV dysfunction and exacerbate HF symptoms. Data, albeit less robust, also point to deleterious effects of slow VRs on LV function. Thus, a J-shaped relationship between VR and clinical outcome has been suggested, with the optimal VR control hovering at ~ 65 bpm, ranging between 60 and 80 bpm; VRs above and below this range may confer higher morbidity and mortality rates. A convergence of recent guidelines is noted towards a stricter rather than a more lenient VR control with target heart rate < 80 bpm at rest and < 110 bpm during moderate exercise which seems to prevent TCM or improve LV function and exercise capacity and relieve TCM-related symptoms and signs. Of course, restoring and maintaining sinus rhythm is always a most desirable target, when feasible, either with drugs or more likely with ablation. All these issues are herein reviewed, current guidelines are discussed and relevant data are tabulated and pictorially illustrated.

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Abbreviations

AF:

Atrial fibrillation

AF-TCM:

Atrial fibrillation-induced tachycardiomyopathy

AV:

Atrioventricular

CAD:

Coronary artery disease

CCB:

Calcium channel blocker

CM:

Cardiomyopathy

CMR:

Cardiac magnetic resonance imaging

CRT:

Cardiac resynchronization therapy

CRT-D:

CRT-defibrillator

CV:

Cardiovascular

DCM:

Dilated cardiomyopathy

HF:

Heart failure

HFpEF:

Heart failure with preserved ejection fraction

HFrEF:

Heart failure with reduced ejection fraction

ICD:

Implantable cardioverter defibrillator

LV:

Left ventricular

LVEF:

Left ventricular ejection fraction

NYHA:

New York Heart Association

PVI:

Pulmonary vein isolation

RCT:

Randomized controlled trial

SVT:

Supraventricular tachycardia

TCM:

Tachycardiomyopathy

VR:

Ventricular rate

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Authors and Affiliations

  1. First Department of Cardiology, Athens University School of Medicine, Athens, Greece

    Antonis S. Manolis

  2. Aghia Sofia University Hospital, Athens, Greece

    Theodora A. Manolis

  3. Patras University School of Medicine, Patras, Greece

    Antonis A. Manolis

  4. Onassis Cardiac Surgery Center, Athens, Greece

    Helen Melita

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  1. Antonis S. Manolis
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  2. Theodora A. Manolis
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  3. Antonis A. Manolis
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  4. Helen Melita
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All authors contributed to the preparation of this manuscript and approved the final version. ASM conceived and designed the project, curated/analyzed the data, wrote the initial draft, and edited/approved the final product; TAM conducted literature search, designed the figures, and edited/revised the manuscript; AAM conducted literature search, constructed the tables, and edited/revised the manuscript; HM supervised the project, analyzed the data, reviewed, revised, edited, and approved the manuscript.

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Correspondence to Antonis S. Manolis.

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Key Points

• Atrial fibrillation (AF)-induced tachycardiomyopathy (AF-TCM) is the most common type of arrhythmia-induced cardiomyopathy, causing left ventricular (LV) dysfunction and heart failure (HF)

• Mechanisms involved in AF-TCM include principally fast ventricular rates (VR), aided by loss of atrial contraction, irregular heart rate, neurohumoral activation, and structural myocardial changes

• When AF-TCM is suspected in AF patients, VR and rhythm control should be rigorously pursued

• Restoration and maintenance of sinus rhythm, e.g., via ablation, is superior to VR control for prophylaxis and/or recovery of LV function; however, when not feasible or not a choice, VR control is the next best strategy

• Data, albeit less robust, also point to deleterious effects of slow VRs on LV function

• Thus, a J-shaped relationship between VR and clinical outcome has been suggested, with an optimal VR around 65 bpm, ranging between 60 and 80 bpm; VRs above and below this range may confer higher morbidity and mortality rates

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Manolis, A.S., Manolis, T.A., Manolis, A.A. et al. Atrial fibrillation-induced tachycardiomyopathy and heart failure: an underappreciated and elusive condition. Heart Fail Rev 27, 2119–2135 (2022). https://doi.org/10.1007/s10741-022-10221-1

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  • DOI: https://doi.org/10.1007/s10741-022-10221-1

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