What is the recommended treatment approach for patients with atrial fibrillation (AFib) and heart failure (HF)?

Management of Atrial Fibrillation in Patients with Heart Failure

For patients with atrial fibrillation and heart failure, a comprehensive treatment approach should include rate control with beta-blockers and/or digoxin as first-line therapy, anticoagulation to prevent thromboembolism, and consideration of rhythm control in selected cases. 1

General Approach

• Identify and correct precipitating factors and comorbidities (e.g., electrolyte abnormalities, hyperthyroidism, alcohol consumption, mitral valve disease, acute ischemia) 2
• Optimize background heart failure treatment 2
• Management involves three key objectives: rate control, prevention of thromboembolism, and in selected cases, correction of rhythm disturbance 2

Rate Control Strategy

For Heart Failure with Reduced Ejection Fraction (HFrEF):

• Beta-blockers are recommended as first-line therapy due to their positive effects on mortality and morbidity 1, 3
• Digoxin is recommended as initial treatment in hemodynamically unstable patients 2
• A combination of digoxin and beta-blocker is reasonable to control both resting and exercise heart rate 2, 1
• Intravenous digoxin or amiodarone is recommended to control heart rate acutely 2

For Heart Failure with Preserved Ejection Fraction (HFpEF):

• Beta-blockers, nondihydropyridine calcium channel antagonists (diltiazem, verapamil), or digoxin are recommended 2, 1
• A nondihydropyridine calcium channel antagonist alone or in combination with digoxin should be considered 2, 1

When First-Line Treatments Fail:

• Oral amiodarone may be considered when heart rate cannot be adequately controlled using beta-blockers, calcium channel antagonists, or digoxin 2
• AV node ablation with ventricular pacing should be considered when pharmacological therapy is insufficient or not tolerated 2
• AV node ablation should not be performed without a prior pharmacological trial 2

Anticoagulation

• Antithrombotic therapy is recommended for all patients with AF and heart failure unless contraindicated 2, 1
• For patients at highest risk of stroke (prior stroke, TIA, or systemic embolism), oral anticoagulant therapy with a vitamin K antagonist (target INR 2.0-3.0) is recommended 2, 1

Rhythm Control Considerations

• Immediate electrical cardioversion is recommended for patients with new-onset AF and:
  • Myocardial ischemia
  • Symptomatic hypotension
  • Pulmonary congestion
  • Rapid ventricular response not controlled by pharmacological measures 2, 1
• For patients with AF and rapid ventricular response causing or suspected of causing tachycardia-induced cardiomyopathy, either AV nodal blockade or a rhythm-control strategy is reasonable 2
• For patients with chronic heart failure who remain symptomatic from AF despite a rate-control strategy, a rhythm-control strategy may be reasonable 2, 1
• Catheter ablation may be considered in heart failure patients with refractory symptomatic AF 1, 4

Special Considerations

• Nondihydropyridine calcium channel antagonists (diltiazem, verapamil) should be avoided in patients with decompensated heart failure or reduced ejection fraction due to negative inotropic effects 1, 3
• Digitalis should not be used as the sole agent to control ventricular response in physically active patients 1
• Assessment of heart rate control during exercise and adjustment of pharmacological treatment is useful in symptomatic patients during activity 2

Recent Advances

• Catheter ablation has received strong recommendation for patients with AF and HF, particularly in heart failure with reduced ejection fraction 4
• Beta-blockers have been shown to reduce the incidence of new-onset atrial fibrillation in patients with systolic heart failure by approximately 27% 1
• Recent evidence has begun to question beta-blockers as the preferred rate-control therapy in patients with atrial fibrillation, suggesting the need for ongoing research in this area 5