What is the assessment plan for a patient with Heart Failure with reduced ejection fraction (HFref) and paroxysmal atrial fibrillation (afib), and what are the recommendations for rhythm management with ablation, citing the CASTLE AF trial?

From the Guidelines

For a patient with heart failure with reduced ejection fraction (HFrEF) and paroxysmal atrial fibrillation (AF), I strongly recommend catheter ablation for rhythm management, particularly if the patient remains symptomatic despite optimal medical therapy, as it has been shown to significantly reduce morbidity and mortality, and improve quality of life, as demonstrated by the CASTLE-AF trial 1. The assessment plan should begin with comprehensive cardiac evaluation including:

• Echocardiography to assess ejection fraction
• Cardiac MRI if structural abnormalities are suspected
• Ambulatory monitoring to characterize AF burden Laboratory testing should include:
• Complete blood count
• Comprehensive metabolic panel
• Thyroid function
• BNP levels Prior to ablation, the patient should be optimized on guideline-directed medical therapy for HFrEF, including an ACE inhibitor/ARB/ARNI, beta-blocker, and mineralocorticoid receptor antagonist, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1. Anticoagulation with a direct oral anticoagulant, such as apixaban, should be initiated at least 3 weeks before ablation and continued afterward based on CHA₂DS₂-VASc score, as recommended by the 2024 ESC guidelines 1. Post-ablation, patients require close monitoring with ECGs and Holter monitoring at 3,6, and 12 months to assess for recurrence, along with continued optimization of heart failure therapy. The CASTLE-AF trial demonstrated that catheter ablation for AF in patients with HFrEF significantly reduced the composite endpoint of death and heart failure hospitalization compared to medical therapy alone, with particular benefit in those with ejection fraction 25-35% 1. It is essential to consider the patient's individual risk of thromboembolism and bleeding when making decisions about anticoagulation and antiarrhythmic therapy, as recommended by the 2024 ESC guidelines 1. Overall, catheter ablation is a valuable treatment option for patients with HFrEF and paroxysmal AF, and should be considered as part of a comprehensive treatment plan, as recommended by the 2024 ESC guidelines 1 and supported by the CASTLE-AF trial 1.

From the Research

Assessment Plan for Patient with HFref and Paroxysmal AFib

• The patient's medical history and physical examination will be obtained to assess the severity of heart failure with reduced ejection fraction (HFref) and paroxysmal atrial fibrillation (AFib) 2.
• Elevated natriuretic peptides and left ventricular systolic dysfunction with LVEF of 40% or less will be identified using echocardiography to confirm the diagnosis of HFref 2.
• The patient's renal function and presence of other comorbidities such as advanced renal disease and elderly age will be assessed, as these factors can influence the management and prognosis of HFref 3.

Rhythm Management with Ablation

• Catheter ablation for AFib in patients with HFref has shown superiority in improving survival, quality of life, and ventricular function, and reducing heart failure hospitalizations compared to antiarrhythmic drugs and rate control therapies 4.
• The CASTLE-AF trial demonstrated that ablation can improve outcomes in patients with HFref and AFib, and this approach is now considered a paradigm shift in management toward nonpharmacological rhythm control of AFib in HFref 4.
• The patient's suitability for ablation will be assessed, taking into account the presence of comorbidities and the potential risks and benefits of the procedure 3.

Management of HFref

• The patient will be treated with a β-blocker and one of an angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker as foundational therapy, with addition of a mineralocorticoid receptor antagonist in patients with persistent symptoms 2.
• Other medications such as ivabradine, hydralazine/isosorbide dinitrate, and vericiguat may also be considered in certain subgroups of patients with HFref 2.
• Device therapies such as cardiac resynchronization therapy, transcatheter mitral valve repair, and implantable cardiac defibrillators may be beneficial in specific subpopulations of patients with HFref 2.