What is the best treatment approach for a patient with atrial fibrillation (AF) and congestive heart failure (CHF)?

Management of Atrial Fibrillation with Congestive Heart Failure

For patients with atrial fibrillation and heart failure with reduced ejection fraction (HFrEF), initiate a beta-blocker or digoxin for rate control, start oral anticoagulation with a direct oral anticoagulant (DOAC), and optimize guideline-directed heart failure therapy before considering rhythm control strategies. 1

Initial Assessment and Optimization

Identify and correct precipitating factors including electrolyte abnormalities, hyperthyroidism, alcohol consumption, acute ischemia, infection, and uncontrolled hypertension before initiating specific AF management. 1

Re-evaluate and optimize background heart failure treatment as the foundation of management, ensuring patients are on appropriate guideline-directed medical therapy for HF. 1

Rate Control Strategy (First-Line Approach)

For Patients with Reduced LVEF (≤40%)

Beta-blockers and/or digoxin are the recommended first-line agents for rate control in patients with HF and left ventricular systolic dysfunction (Class I recommendation, Level of Evidence B). 1, 2

• Combination therapy with digoxin plus a beta-blocker should be considered to control heart rate both at rest and during exercise, providing superior control compared to monotherapy. 1

• In hemodynamically unstable patients with LV systolic dysfunction, digoxin is the recommended initial treatment. 1

• Intravenous digoxin or amiodarone is recommended to control heart rate in patients with AF and HF who do not have an accessory pathway (Class I recommendation, Level of Evidence B). 1

For Patients with Preserved LVEF (>40%)

Non-dihydropyridine calcium channel antagonists (diltiazem or verapamil), alone or in combination with digoxin, should be considered for rate control (Class IIa recommendation, Level of Evidence C). 1

Target Heart Rate

Lenient rate control (resting heart rate <110 bpm) is acceptable as long as patients remain asymptomatic and left ventricular systolic function is preserved. 3

Strict rate control (resting heart rate <80 bpm) may be considered in symptomatic patients or those with inadequate control. 3

Anticoagulation for Stroke Prevention (Mandatory)

Oral anticoagulation is recommended for all patients with AF and heart failure unless contraindicated, as heart failure itself is a moderate risk factor for stroke (Class I recommendation, Level of Evidence A). 1

DOAC Selection and Dosing

Direct oral anticoagulants (DOACs) are preferred over warfarin due to lower risk of intracranial hemorrhage and more predictable pharmacokinetics. 1, 2, 3

Apixaban dosing:

• Standard dose: 5 mg twice daily 4
• Reduced dose: 2.5 mg twice daily if patient meets ≥2 of the following criteria: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 4

Rivaroxaban dosing:

• Standard dose: 20 mg once daily with food 5
• Dose adjustment based on renal function per prescribing information 5

Warfarin Alternative

If warfarin is used, maintain INR between 2.0-3.0 with weekly monitoring during initiation and monthly monitoring when stable. 1, 3

Patients on warfarin in clinical trials achieved mean time in therapeutic range of 55-62%, which represents real-world effectiveness benchmarks. 4, 5

Rhythm Control Considerations

There is no clear evidence that restoring and maintaining sinus rhythm is superior to rate control in reducing morbidity and mortality in patients with persistent AF and heart failure. 1

When to Consider Rhythm Control

Immediate electrical cardioversion is recommended for patients with new-onset AF causing myocardial ischemia, symptomatic hypotension, symptoms of pulmonary congestion, or rapid ventricular response not controlled by pharmacological measures (Class I recommendation, Level of Evidence C). 1

Electrical cardioversion should be considered in patients with symptomatic HF and persistent AF, though success rates depend on duration of arrhythmia and left atrial size (Class IIa recommendation, Level of Evidence C). 1

Antiarrhythmic Drug Selection

Amiodarone is the only antiarrhythmic drug recommended for maintaining sinus rhythm in patients with AF and HF and/or depressed LV function (Class I recommendation, Level of Evidence C). 1

• Intravenous amiodarone is a reasonable option for pharmacological cardioversion when rapid restoration of sinus rhythm is not required (Class IIa recommendation, Level of Evidence A). 1

• All other antiarrhythmic agents are contraindicated in patients with HFrEF due to proarrhythmic risk and negative inotropic effects. 1, 3

Catheter Ablation

Catheter ablation is recommended in patients with AF and HFrEF with high probability of tachycardia-induced cardiomyopathy to reverse left ventricular dysfunction. 1

Invasive catheter-based ablation procedures (pulmonary vein isolation) should be considered in refractory patients but have not been extensively evaluated in clinical trials in the HF population. 1

Anticoagulation During Cardioversion

If AF duration is >48 hours or unknown, therapeutic anticoagulation is required for at least 3 weeks before cardioversion. 1, 3

For immediate cardioversion due to hemodynamic instability, administer heparin by IV bolus followed by continuous infusion (or subcutaneous low molecular weight heparin as alternative), and consider transesophageal echocardiography. 1

Continue oral anticoagulation for at least 4 weeks after cardioversion, and long-term based on stroke risk factors regardless of rhythm status. 1, 3

AV Node Ablation and Pacing

Atrioventricular node ablation and pacing should be considered to control heart rate when other measures are unsuccessful or contraindicated. 1

AV node ablation combined with cardiac resynchronization therapy may be considered in severely symptomatic patients with permanent AF and at least one hospitalization for heart failure. 2

Common Pitfalls to Avoid

Do not use calcium channel blockers in patients with HFrEF (LVEF ≤40%), as they have negative inotropic effects and can worsen heart failure. 1

Do not use digoxin as monotherapy for rate control in active patients, as it only controls rate at rest and is ineffective during exercise. 2, 3

Do not use flecainide, propafenone, or sotalol in patients with structural heart disease or HFrEF, as these agents increase mortality risk. 1, 3

Do not discontinue anticoagulation after successful cardioversion or ablation if stroke risk factors persist—continue based on CHA₂DS₂-VASc score, not rhythm status. 1, 3

Avoid underdosing DOACs, as this increases stroke risk; however, research suggests that non-recommended DOAC doses in HF patients did not significantly impact all-cause mortality in observational studies. 6

When transitioning from rhythm control to rate control or vice versa (which occurs in approximately 15% of patients, more commonly abandoning rhythm control at 21% vs. 9.1% for rate control), recognize that inefficacy drives crossover from rhythm control while worsening heart failure drives crossover from rate control, and that changing strategies does not impact survival. 7