How to manage heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AFib)?

Management of Heart Failure with Preserved Ejection Fraction and Atrial Fibrillation

For patients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF), management should focus on rate control with beta-blockers or non-dihydropyridine calcium channel blockers, anticoagulation for stroke prevention, and SGLT2 inhibitors as disease-modifying therapy.

Understanding the HFpEF-AF Relationship

• AF and HFpEF frequently coexist, with AF prevalence increasing with heart failure severity, from 4% in NYHA class I to 40% in NYHA class IV patients 1
• These conditions can perpetuate and exacerbate each other through mechanisms such as rate-dependent worsening of cardiac function, fibrosis, and activation of neurohumoral vasoconstrictors 1
• AF can worsen HFpEF symptoms, and conversely, worsening HF can promote a rapid ventricular response in AF 1

First-Line Disease-Modifying Therapy

• SGLT2 inhibitors (empagliflozin or dapagliflozin) should be initiated as first-line disease-modifying therapy for most HFpEF patients, including those with AF 1, 2
• EMPEROR-Preserved demonstrated a significant 21% reduction in the primary composite endpoint of HF hospitalization or cardiovascular death with empagliflozin, driven mostly by a 29% reduction in HF hospitalizations 1
• SGLT2 inhibitors provide benefit regardless of diabetes status and should not be delayed in eligible patients 2, 3

Management of Atrial Fibrillation in HFpEF

Rate Control Strategy

• For HFpEF patients with AF, rate control is generally the preferred initial strategy over rhythm control 1
• Beta-blockers are the preferred agents for achieving rate control in HFpEF patients with AF due to their favorable effects on controlling ventricular response 1
• For patients with HFpEF, non-dihydropyridine calcium channel antagonists (such as diltiazem) can be effective for rate control, particularly when used in combination with digoxin 1
• Avoid intravenous non-dihydropyridine calcium channel antagonists, intravenous beta-blockers, and dronedarone in patients with decompensated HF 1

Rhythm Control Considerations

• If rate control is ineffective or poorly tolerated, a rhythm control strategy may be considered 1
• For patients who develop HF as a result of AF with rapid ventricular response, a rhythm-control strategy should be pursued as this may be a reversible cause of HF 1
• In patients with newly detected HF and AF with rapid ventricular response, amiodarone can be initiated for both rate control and rhythm control, followed by cardioversion approximately one month later 1

Anticoagulation

• Assess thromboembolic risk and initiate appropriate anticoagulation therapy as most patients with AF and HFpEF will be candidates for systemic anticoagulation unless contraindicated 1
• Direct oral anticoagulants such as rivaroxaban have demonstrated efficacy in preventing stroke in patients with nonvalvular AF, including those with heart failure 4

Additional Pharmacological Management

• Loop diuretics should be used at the lowest effective dose to manage congestion and improve symptoms 1, 5
• Consider mineralocorticoid receptor antagonists (MRAs) like spironolactone, particularly in patients with LVEF on the lower end of the preserved spectrum (closer to 50%) 1, 2
• Angiotensin receptor-neprilysin inhibitors (ARNi) or angiotensin receptor blockers (ARBs) may be beneficial in selected patients, especially those with LVEF on the lower end of the preserved spectrum 1
• Avoid routine use of nitrates or phosphodiesterase-5 inhibitors as they are ineffective for increasing activity or quality of life in HFpEF patients 1

Management of Comorbidities

• Optimize blood pressure control to target <130/80 mmHg using appropriate antihypertensive medications 1, 3
• Manage diabetes with preference for SGLT2 inhibitors given their additional heart failure benefits 2
• Address other common comorbidities such as obesity, coronary artery disease, chronic kidney disease, and sleep apnea 6

Common Pitfalls to Avoid

• Do not treat HFpEF patients the same as those with reduced ejection fraction, as response to therapies differs 2
• Avoid excessive diuresis which can lead to hypotension and impaired tolerance of other medications 3
• Do not delay initiation of SGLT2 inhibitors which have proven mortality benefits 2, 3
• AV node ablation should not be performed without a pharmacological trial to achieve ventricular rate control 1

When to Consider Advanced Therapies

• Consider AV node ablation and cardiac resynchronization therapy device placement when rate control cannot be achieved either because of drug inefficacy or intolerance 1
• Refer to an advanced heart failure specialist team for patients with advanced HFpEF refractory to standard therapies 5