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Atrial Fibrillation in Patients with Heart Failure: Current State and Future Directions

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Abstract

Heart failure affects nearly 26 million people worldwide. Patients with heart failure are frequently affected with atrial fibrillation, and the interrelation between these pathologies is complex. Atrial fibrillation shares the same risk factors as heart failure. Moreover, it is associated with a higher-risk baseline clinical status and higher mortality rates in patients with heart failure. The mechanisms by which atrial fibrillation occurs in a failing heart are incompletely understood, but animal studies suggest they differ from those that occur in a healthy heart. Data suggest that heart failure-induced atrial fibrosis and atrial ionic remodeling are the underlying abnormalities that facilitate atrial fibrillation. Therapeutic considerations for atrial fibrillation in patients with heart failure include risk factor modification and guideline-directed medical therapy, anticoagulation, rate control, and rhythm control. As recommended for atrial fibrillation in the non-failing heart, anticoagulation in patients with heart failure should be guided by a careful estimation of the risk of embolic events versus the risk of hemorrhagic episodes. The decision whether to target a rate-control or rhythm-control strategy is an evolving aspect of management. Currently, both approaches are good medical practice, but recent data suggest that rhythm control, particularly when achieved through catheter ablation, is associated with improved outcomes. A promising field of research is the application of neurohormonal modulation to prevent the creation of the “structural substrate” for atrial fibrillation in the failing heart.

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Acknowledgements

The authors wholeheartedly thank Dr. Nora Bergasa for dedicating her time to proofreading this paper and providing valuable insight.

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  1. Tuoyo O. Mene-Afejuku and Persio D. López contributed equally to this paper.

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  1. Department of Medicine, Health + Hospitals/Metropolitan, New York, NY, USA

    Tuoyo O. Mene-Afejuku, Persio D. López, Adedoyin Akinlonu & Carissa Dumancas

  2. New York Medical College, Valhalla, NY, USA

    Tuoyo O. Mene-Afejuku, Persio D. López, Adedoyin Akinlonu, Carissa Dumancas, Ferdinand Visco, Savi Mushiyev & Gerald Pekler

  3. Division of Cardiology, Department of Medicine, Health + Hospitals/Metropolitan, New York, NY, USA

    Ferdinand Visco, Savi Mushiyev & Gerald Pekler

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Mene-Afejuku, T.O., López, P.D., Akinlonu, A. et al. Atrial Fibrillation in Patients with Heart Failure: Current State and Future Directions. Am J Cardiovasc Drugs 18, 347–360 (2018). https://doi.org/10.1007/s40256-018-0276-1

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