The management of atrial fibrillation in heart failure

  • Rupa Bala
  • David J. Callans
Article

Opinion statement

The development of atrial fibrillation (AF) can greatly complicate the course of heart failure (HF). Although recent trials have indicated the nonsuperiority of a rhythm control strategy in the general population with AF, this may not apply to patients with HF. We feel strongly that AF be treated aggressively in patients with HF, defaulting toward an initial rhythm control strategy, to avoid the hemodynamic detriment of irregular rapid ventricular response and the development of tachycardia-related myopathy. The index episode is treated with cardioversion and antiarrhythmic therapy. If significant benefit is demonstrated, the rhythm control strategy is maintained, to the point of catheter ablation for AF if necessary. If there is no change in cardiac performance or symptoms after cardioversion, strict rate control is enforced, to the point of atrioventricular node ablation and pacing if necessary.

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References and Recommended Reading

  1. 1.
    Kannel WB, Abbott RD, Savage DD, et al: Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med 1982, 306:1018–1022.PubMedCrossRefGoogle Scholar
  2. 2.
    Maisel WH, Stevenson LW: Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy. Am J Cardiol 2003, 91:2D-8D. This paper discusses the interaction between AF and HF, with emphasis on the pathophysiology between the two disease states.PubMedCrossRefGoogle Scholar
  3. 3.
    Benjamin EJ, Wolf PA, D’Agostino RB, et al: Impact on atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation 1998, 98:946–952.PubMedGoogle Scholar
  4. 4.
    Ehrlich JR, Nattel S, Hohnloser SH: Atrial fibrillation and congestive heart failure: specific considerations at the intersection of two common and important cardiac disease sets. J Cardiovasc Electrophysiol 2002, 13:399–405.PubMedCrossRefGoogle Scholar
  5. 5.
    Carson PE, Johnson GR, Dunkman EB, et al: The influence of atrial fibrillation on prognosis in mild to moderate heart failure. Circulation 1993, 87(suppl VI):VI102-VI110.PubMedGoogle Scholar
  6. 6.
    Crijns HJ, Tjeerdsma G, de Kam PJ, et al: Prognostic value of the presence of atrial fibrillation in patients with advanced heart failure. Eur Heart J 2000, 21:1238–1245.PubMedCrossRefGoogle Scholar
  7. 7.
    Mahoney P, Kimmel S, DeNofrio D, et al: Prognostic significance of atrial fibrillation in patients at a tertiary medical center referred for heart transplantation because of severe heart failure. Am J Cardiol 1999, 83:1544–1547.PubMedCrossRefGoogle Scholar
  8. 8.
    Dries DL, Exner DV, Gersh BJ, et al: Atrial fibrillation associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials. J Am Coll Cardiol 1998, 32:695–703.PubMedCrossRefGoogle Scholar
  9. 9.
    Middlekauf HR, Stevenson WG, Stevenson LW: Prognostic significance of atrial fibrillation in advanced heart failure: a study of 390 patients. Circulation 1991, 84:40–48.Google Scholar
  10. 10.
    Mathew J, Hunsberger S, Fleg J, et al: Incidence, predictive factors, and prognostic significance of supraventricular tachyarrhythmias in congestive heart failure. Chest 2000, 118:914–922.PubMedCrossRefGoogle Scholar
  11. 11.
    Nattel S, Shiroshita A, Cardin S, et al: Mechanisms for atrial remodeling and clinical relevance. Curr Opin Cardiol 2004, 20:21–25.Google Scholar
  12. 12.
    Sanders P, Morton JB, Davidson NC, et al: Electrical remodeling of the atria in congestive heart failure: electrophysiological and electroanatomic mapping in humans. Circulation 2003, 108:1461–1468.PubMedCrossRefGoogle Scholar
  13. 13.
    Fenelon G, Wijns W, Andries E, et al: Tachycardiomyopathy: mechanisms and clinical implications. Pacing Clin Electrophysiol 1996, 19:95–106.PubMedCrossRefGoogle Scholar
  14. 14.
    Haissaguerre M, Jais P, Shah DC, et al: Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998, 339:659–666.PubMedCrossRefGoogle Scholar
  15. 15.
    Hsu LF, Jais P, Sanders P, et al: Catheter ablation for atrial fibrillation in congestive heart failure. N Engl J Med 2004, 351:2373–2383.PubMedCrossRefGoogle Scholar
  16. 16.
    Chen MS, Marrouche NF, Khaykin Y, et al: Pulmonary vein isolation for the treatment of atrial fibrillation in patients with impaired systolic function. J Am Coll Cardiol 2004, 43:1004–1009.PubMedCrossRefGoogle Scholar
  17. 17.
    Fuster V, Rydén LE, Asinger RW, et al: ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: Executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol 2001, 38:1231–1265.PubMedCrossRefGoogle Scholar
  18. 18.
    Naccarelli GV, Hynes BJ, Wolbrette DL, et al: Atrial fibrillation in heart failure: prognostic significance and management. J Cardiovasc Electrophysiol 2003, 14(suppl):S281-S286.PubMedCrossRefGoogle Scholar
  19. 19.
    Hohnloser SH, Kuck KH, Lilienthal J: Rhythm or rate control in atrial fibrillation—Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomized trial. Lancet 2000, 356:1789–1794.PubMedCrossRefGoogle Scholar
  20. 20.
    Van Gelder IC, Hagens VE, Bosker HA, et al: A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002, 347:1834–1840.PubMedCrossRefGoogle Scholar
  21. 21.
    Wyse DG, Waldo AL, DiMarco JP, et al: A comparison of rate control and rhythm control in patients with atrial fibrillation. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. N Engl J Med 2002, 347:1825–1833. A large prospective study comparing rate control to rhythm control in patients with AF. One of the landmark trials challenging the assumption that rate control is an inferior option.PubMedCrossRefGoogle Scholar
  22. 22.
    Rationale and design of a study assessing treatment strategies of atrial fibrillation in patients with heart failure: the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial [no authors listed]. Am Heart J 2002, 144:597–607.Google Scholar
  23. 23.
    Khand AU, Rankin AC, Martin W, et al: Carvedilol alone or in combination with digoxin for the management of atrial fibrillation in patients with heart failure. J Am Coll Cardiol 2003, 42:1944–1951.PubMedCrossRefGoogle Scholar
  24. 24.
    Naccarelli GV, Wolbrette DL, Khan M, et al: Old and new antiarrhythmic drugs for converting and maintaining sinus rhythm in atrial fibrillation: comparative efficacy and results of trials. Am J Cardiol 2003, 91(suppl):15D-26D.PubMedCrossRefGoogle Scholar
  25. 25.
    Echt DS, Liebson PR, Mitchell LB, et al: Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med 1991, 324:781–788.PubMedCrossRefGoogle Scholar
  26. 26.
    Deedwania PC, Singh BN, Ellenbogen K, et al: Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation: observations from the Veterans Affairs Congestive Heart Failure Survival Trial of Antiarrhythmic Therapy (CHF-STAT). Circulation 1998, 98:2574–2579.PubMedGoogle Scholar
  27. 27.
    Singh S, Zoble RG, Yellen L, et al: Efficacy and safety of oral dofetilide in converting to and maintaining sinus rhythm in patients with chronic atrial fibrillation or atrial flutter: the Symptomatic Atrial Fibrillation Investigative Research on Dofetilide (SAFIRE-D) Study. Circulation 2000, 102:2385–2390.PubMedGoogle Scholar
  28. 28.
    Pederson OD, Bagger H, Keller N, et al: Efficacy of dofetilide in the treatment of atrial fibrillation-flutter in patients with reduced left ventricular function: a Danish Investigations of Arrhythmia and Mortality ON Dofetilide (DIAMOND) Substudy. Circulation 2001, 104:292–296.Google Scholar
  29. 29.
    Pratt CM, Singh S, Hussein R, et al: The efficacy of azmilide in the treatment of atrial fibrillation in the presence of left ventricularsystolic function: results from the Azimilide Postinfarct Survival Evaluation (ALIVE) trial. J Am Coll Cardiol 2004, 43;1211–1216.PubMedCrossRefGoogle Scholar
  30. 30.
    Nakashima H, Kumagai K, Urata H, et al: Angiotensin II antagonist prevents electrical remodeling in atrial fibrillation. Circulation 2000, 101:2612–2617.PubMedGoogle Scholar
  31. 31.
    Pedersen OD, Bagger H, Køber L, et al: Trandolapril reduces the incidence of atrial fibrillation after acute myocardial infarction in patients with left ventricular dysfunction. Circulation 1999, 100:376–380.PubMedGoogle Scholar
  32. 32.
    Madrid AH, Bueno MG, Rebollo JMG, et al: Use of irbesartan to maintain sinus rhythm in patients with long-lasting persistent atrial fibrillation: a prospective and randomized study. Circulation 2002, 106:331–336.PubMedCrossRefGoogle Scholar
  33. 33.
    Wood MA, Brown-Mahoney C, Kay GN, et al: Clinical outcomes after ablation and pacing therapy for atrial fibrillation—a meta-analysis. Circulation 2000, 101:1138–1144.PubMedGoogle Scholar
  34. 34.
    Doshi RN, Daoud EG, Fellows C, et al: Left ventricularbased cardiac stimulation Post AV Nodal Ablation Evaluation (The PAVE Study). J Cardiovasc Electrophysiol 2005, 16:1160–1165.PubMedCrossRefGoogle Scholar
  35. 35.
    Khargi K, Hutten BA, Lemke B, et al: Surgical treatment of atrial fibrillation; a systematic review. Eur J Cardiothorac Surg 2005, 27:258–265.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2006

Authors and Affiliations

  • Rupa Bala
  • David J. Callans
    • 1
  1. 1.Cardiovascular Division, Department of ElectrophysiologyHospital of The University of PennsylvaniaPhiladelphiaUSA

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