What are the latest recommendations for managing atrial fibrillation (AF) in patients with heart failure?

Management of Atrial Fibrillation in Heart Failure: Latest Recommendations

Beta-blockers and/or digoxin are the recommended first-line agents for rate control in AF patients with heart failure and reduced ejection fraction (LVEF ≤40%), while beta-blockers, diltiazem, verapamil, or digoxin are recommended for those with preserved ejection fraction (LVEF >40%). 1

Initial Assessment

Determine ejection fraction status immediately, as this fundamentally determines medication selection:

• HFrEF (LVEF ≤40%): Use beta-blockers and/or digoxin only 1
• HFpEF (LVEF >40%): Beta-blockers, diltiazem, verapamil, or digoxin are all acceptable 1

Evaluate for reversible precipitants including electrolyte abnormalities, thyroid dysfunction, and acute decompensation 1, 2

Acute Rate Control Strategy

For Hemodynamically Unstable Patients

Proceed immediately to electrical cardioversion when rapid ventricular rate causes acute hemodynamic instability, symptomatic hypotension, ongoing myocardial ischemia, or pulmonary congestion 1

For Hemodynamically Stable Patients with HFrEF

Intravenous digoxin or amiodarone are the recommended first-line agents for acute rate control in the absence of pre-excitation 1, 2

Critical contraindication: Beta-blockers and nondihydropyridine calcium channel blockers should be used with extreme caution or avoided entirely in patients with overt congestion, hypotension, or decompensated heart failure 1, 2

For Patients with HFpEF

Intravenous beta-blockers or nondihydropyridine calcium channel antagonists (verapamil, diltiazem) can be used cautiously 1

Long-Term Rate Control

Medication Selection by Heart Failure Type

For HFrEF patients:

• Beta-blockers are preferred as monotherapy due to mortality benefits in systolic heart failure 1, 3
• Digoxin is particularly effective for controlling resting heart rate and is indicated for sedentary individuals 1
• Combination therapy with digoxin plus beta-blocker is reasonable when single-agent therapy is inadequate, providing superior rate control at rest and during exercise 1

For HFpEF patients:

• Beta-blockers or nondihydropyridine calcium channel antagonists are recommended 1
• Combination with digoxin can be considered for enhanced control 1

Heart Rate Targets

Lenient rate control with resting heart rate <110 bpm should be the initial target, with stricter control (<80 bpm at rest) reserved only for patients with continuing AF-related symptoms 1

This lenient approach is non-inferior to strict rate control for clinical outcomes and is easier to achieve 1

Assess heart rate control during exercise in symptomatic patients and adjust pharmacological treatment to keep the rate in the physiological range 1

Rhythm Control Considerations

When to Consider Rhythm Control

For patients with chronic heart failure who remain symptomatic despite adequate rate control, a rhythm control strategy is reasonable 1, 2

For AF with rapid ventricular response causing or suspected of causing tachycardia-induced cardiomyopathy, either AV nodal blockade or rhythm control strategy is reasonable 1, 2

Rhythm Control Medications

Amiodarone is the only antiarrhythmic drug recommended for rhythm control in heart failure patients, particularly those with NYHA class III-IV or recent unstable heart failure 1

Amiodarone can be used for:

• Pharmacological cardioversion 1
• Facilitating electrical cardioversion 1
• Long-term maintenance of sinus rhythm when rate control is insufficient 1

Dronedarone should be considered in stable heart failure (NYHA class I-II) to reduce cardiovascular hospitalizations 1

Catheter Ablation

Catheter ablation (pulmonary vein isolation) may be considered in heart failure patients with refractory symptomatic AF despite optimal medical therapy 1

Recent evidence suggests catheter ablation in HFrEF patients improves survival, quality of life, ventricular function, and reduces heart failure hospitalizations compared to medical therapy alone 4

AV Node Ablation with Pacing

AV node ablation combined with pacemaker implantation should be considered when patients are unresponsive to or ineligible for intensive rate and rhythm control therapy 1

AV node ablation combined with cardiac resynchronization therapy should be considered in severely symptomatic patients with permanent AF and at least one hospitalization for heart failure, as this reduces symptoms, physical limitations, recurrent hospitalizations, and mortality 1

Important caveat: AV node ablation should not be performed without a prior pharmacological trial to achieve ventricular rate control 2

Anticoagulation

Oral anticoagulation is mandatory in AF patients with heart failure, as heart failure due to systolic dysfunction is itself a risk factor for stroke and thromboembolism 1

Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists in eligible patients 1

Aspirin is not recommended due to increased bleeding risk when combined with oral anticoagulation and evidence suggesting it may increase heart failure hospitalizations 1

Common Pitfalls to Avoid

Do not use nondihydropyridine calcium channel blockers (diltiazem, verapamil) in HFrEF patients, as they adversely suppress myocardial contraction and increase the risk of heart failure decompensation 1

Do not use digoxin as the sole agent for rate control in active patients, as it is ineffective during exercise 1

Do not pursue aggressive strict rate control initially unless symptoms specifically warrant it, as lenient control is equally effective and easier to achieve 1

Do not delay anticoagulation based on achievement of rate or rhythm control—anticoagulation decisions are based on stroke risk factors, not heart rate control 1, 2