From the Guidelines
Current research gaps in atrial fibrillation (AF) and heart failure (HF) include the need for better understanding of the disease continuum, downstream consequences, and optimal management strategies, as highlighted in the 2023 ACC/AHA/ACCP/HRS guideline 1. The most significant gaps in knowledge are in the areas of AF as a disease continuum, where more evidence is needed on how to best improve prevention, modification of risk factors, and incorporation of holistic approaches to AF management into daily clinical practice.
- The downstream consequences of AF over the long term must be better studied and defined, including the impact on dementia and valvular insufficiency.
- Better goal and outcome definition is needed, with a focus on patient-oriented outcomes such as quality of life (QOL) rather than simplistic metrics like ablation failure.
- The role of risk modifiers in AF stroke prevention is not well understood, and more research is needed on how to best manage patients with nonbinary or dynamic risk factors. According to the 2024 ESC guidelines for the management of atrial fibrillation 1, a patient-centred, shared decision-making approach is critical in managing AF, and education and awareness are essential for both patients and healthcare professionals.
- The guidelines also emphasize the importance of comorbidity and risk factor management, as well as the need for dynamic reassessment and evaluation of patients with AF. Furthermore, the 2024 ESC guidelines highlight the need for better understanding of the diagnostic work-up for patients with AF, including the use of ambulatory ECG monitoring, exercise ECG, and further blood tests to refine stroke and bleeding risk 1.
- The guidelines also emphasize the importance of attention to concomitant disease, as patients with AF remain at high residual risk of death despite anticoagulation therapy. Overall, addressing these research gaps is crucial to improving morbidity, mortality, and quality of life outcomes for patients with AF and HF, and requires a comprehensive and multidisciplinary approach to patient management 1.
From the Research
Current Research Gaps in Atrial Fibrillation (AF) and Heart Failure (HF)
- The interrelationships between AF and HF are complex and poorly understood, with a need for initiatives that prioritize research on the intersection between AF and HF 2
- Key knowledge gaps include characterizing the pathophysiological overlap and deleterious interactions between AF and HF, preventing HF in people with AF, preventing AF in individuals with HF, and addressing symptom burden and health status outcomes in AF and HF 2
- There is a lack of evidence-based evaluation and management of patients with concomitant HF and AF, with recent data suggesting that these patients may respond differently than those with HF or AF alone 3
- The choice of oral anticoagulant for patients with AF and HF is influenced by factors such as HF subtype and co-morbidities, with a need for further research to guide treatment decisions 4
- Medical management for rate and rhythm control of AF in HF remains hampered by variable success, intolerance, and adverse effects, with a need for further research on nonpharmacological rhythm control strategies such as catheter ablation 5
Areas for Future Research
- The pathophysiology of AF in relation to HF, including the complex ultrastructural, electrophysiologic, and neurohormonal processes involved 6
- The development of effective prevention and treatment strategies for AF in HF, including the use of non-anti-arrhythmic therapeutic agents 6
- The role of surgical and catheter-based therapies in the management of AF in HF, with a need for long-term data on their safety and efficacy 6
- The impact of HF subtype and co-morbidities on the choice of oral anticoagulant and treatment outcomes in patients with AF and HF 4, 5