What is the target heart rate in patients with heart failure and atrial fibrillation?

Target Heart Rate in Patients with Heart Failure and Atrial Fibrillation

A lenient heart rate control strategy with a resting heart rate <110 beats per minute (bpm) should be considered as the initial target for patients with atrial fibrillation and heart failure, with stricter control reserved for those with continuing AF-related symptoms. 1

Initial Heart Rate Targets

• Lenient rate control (resting heart rate <110 bpm) is recommended as the initial approach for most patients with AF and heart failure 1
• This recommendation is based on evidence from the RACE II trial, which showed that lenient rate control was non-inferior to strict rate control for clinical outcomes 1
• Similar results were found in a post-hoc combined analysis from the AFFIRM and RACE trials 1

When to Consider Stricter Rate Control

• Stricter heart rate control should be considered in patients with:

  • Ongoing symptoms despite lenient control 1
  • Suspicion of tachycardia-induced cardiomyopathy 1
  • Significant exercise intolerance 1

• When implementing stricter control, targets should be:

  • Resting heart rate <80 bpm 1
  • Heart rate during moderate exercise <110 bpm 1

Medication Selection Based on LVEF

For Patients with LVEF >40%:

• First-line options include:
  • Beta-blockers
  • Diltiazem
  • Verapamil
  • Digoxin 1

For Patients with LVEF ≤40%:

• First-line options are more limited:
  • Beta-blockers
  • Digoxin (alone or in combination) 1
• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) should be avoided in patients with decompensated heart failure as they may worsen hemodynamic status 1

Combination Therapy

• Consider combination therapy if a single drug does not adequately control heart rate or symptoms 1
• Common combinations include:
  • Beta-blocker plus digoxin 1
  • For patients with HFpEF: non-dihydropyridine calcium channel blocker plus digoxin 1
• When using combination therapy, monitor carefully to avoid bradycardia 1

Advanced Options for Refractory Cases

• For patients with inadequate rate control despite optimal medical therapy:
  • AV nodal ablation with permanent pacemaker implantation should be considered 1
  • For patients with severely symptomatic permanent AF and at least one HF hospitalization, AV nodal ablation with cardiac resynchronization therapy should be considered 1

Acute Setting Management

• For patients with AF, heart failure, and hemodynamic instability or severely depressed LVEF:
  • Intravenous amiodarone, digoxin, esmolol, or landiolol may be considered for acute rate control 1
  • In hemodynamically unstable patients, electrical cardioversion is indicated 1

Monitoring Effectiveness

• Assess heart rate control during both rest and exertion 1
• Adjust pharmacological treatment as necessary to keep ventricular rate within physiological range during activity 1
• Consider 24-hour Holter monitoring to evaluate rate control throughout daily activities 1

Common Pitfalls to Avoid

• Avoid using digoxin as sole agent for rate control in active patients 2
• Do not use non-dihydropyridine calcium channel antagonists in patients with decompensated heart failure 1
• Dronedarone should not be used for rate control in patients with permanent AF 1
• AV nodal ablation should not be performed without prior attempts at pharmacological rate control 1