What is the best management plan for a patient with atrial fibrillation, severely reduced left ventricular systolic function, moderate mitral and tricuspid regurgitations, and mild left ventricular hypertrophy, with a heart rate of 80-110 bpm and an LVEF of 25-30%?

Management of Atrial Fibrillation with Severely Reduced Left Ventricular Ejection Fraction

For this patient with atrial fibrillation, LVEF 25-30%, and moderate valvular regurgitation, the management priorities are: (1) immediate initiation of oral anticoagulation with a direct oral anticoagulant, (2) rate control using beta-blockers and/or digoxin targeting lenient control (<110 bpm at rest), and (3) consideration of early rhythm control with catheter ablation given the severely reduced ejection fraction and potential for tachycardia-mediated cardiomyopathy. 1, 2, 3

Anticoagulation Strategy (Highest Priority)

This patient requires immediate oral anticoagulation regardless of rhythm control strategy. The CHA₂DS₂-VASc score is elevated (heart failure = 1 point, hypertension evident from BP 153/92 = 1 point, likely age ≥65 based on clinical context = 1-2 points, totaling ≥3 points), placing this patient at high stroke risk. 1, 2

• Direct oral anticoagulants (DOACs) are strongly preferred over warfarin in this patient without mechanical valves or moderate-to-severe mitral stenosis. 1, 4
• Apixaban 5 mg twice daily is recommended (or 2.5 mg twice daily if patient meets ≥2 of: age ≥80 years, weight ≤60 kg, creatinine ≥1.5 mg/dL). 2
• Alternative DOACs include rivaroxaban, edoxaban, or dabigatran, all of which reduce stroke risk by 60-80% compared to placebo and have lower intracranial hemorrhage risk than warfarin. 3, 1
• Anticoagulation must continue indefinitely regardless of whether sinus rhythm is restored, as stroke risk is determined by underlying risk factors, not current rhythm. 1, 2

Rate Control Strategy

Beta-blockers and/or digoxin are the only appropriate rate control agents for this patient with LVEF ≤40%. 1, 2, 5

• Avoid calcium channel blockers (diltiazem, verapamil) entirely in this patient with severely reduced ejection fraction, as they can exacerbate hemodynamic compromise and worsen heart failure. 1, 2
• Target lenient rate control initially: resting heart rate <110 bpm. The current rate of 80-110 bpm is acceptable as an initial target. 1, 2
• Stricter rate control (targeting <80 bpm) should only be pursued if symptoms persist despite lenient control, as overly aggressive rate control can cause bradyarrhythmias and worsen outcomes. 1, 6
• Beta-blockers are preferred as first-line therapy due to mortality benefit in heart failure with reduced ejection fraction. 2, 5
• Digoxin can be added to beta-blockers if monotherapy provides inadequate rate control, avoiding bradycardia. 1, 2
• The combination of beta-blocker plus digoxin provides better control at rest and during exercise compared to monotherapy. 1, 2

Rhythm Control Considerations

This patient is a strong candidate for early rhythm control strategy, specifically catheter ablation, given the severely reduced LVEF and potential for AF-induced or AF-exacerbated cardiomyopathy. 3, 7

Evidence Supporting Rhythm Control in Heart Failure with Reduced Ejection Fraction:

• Catheter ablation in patients with AF and HFrEF has demonstrated superiority over medical therapy in improving survival, quality of life, ventricular function, and reducing heart failure hospitalizations. 7
• This represents a paradigm shift toward nonpharmacological rhythm control in HFrEF patients with AF. 7
• Early rhythm control with catheter ablation is first-line therapy for symptomatic patients with AF and HFrEF to improve cardiovascular outcomes including mortality and heart failure hospitalization rates. 3

Antiarrhythmic Drug Limitations:

• If catheter ablation is not immediately available or patient declines, amiodarone is the only safe antiarrhythmic drug for patients with LVEF <35%. 1, 2
• Sotalol, flecainide, propafenone, and disopyramide are contraindicated due to proarrhythmic risk and negative inotropic effects in severe LV dysfunction. 1, 2
• Membrane-active antiarrhythmic drugs can increase risk of pump failure and arrhythmic deaths in heart failure patients, making them less desirable than ablation. 6

Cardioversion Considerations:

• If cardioversion is planned and AF duration is >48 hours or unknown, therapeutic anticoagulation for ≥3 weeks before cardioversion is mandatory, with continuation for ≥4 weeks after. 1, 8, 9
• Alternative approach: immediate anticoagulation with heparin/LMWH plus transesophageal echocardiography to exclude left atrial thrombus before proceeding with cardioversion. 9

Assessment for Tachycardia-Mediated Cardiomyopathy

The severe global hypokinesis with LVEF 25-30% may represent pure AF-induced tachycardiomyopathy, mixed cardiomyopathy, or AF exacerbating underlying cardiomyopathy. 10

• The notation "LVEF is variable depending on the RR interval" suggests rate-dependent dysfunction, supporting a tachycardia-mediated component. 10
• AF-induced tachycardiomyopathy is reversible upon restoration of sinus rhythm or optimal rate control, making rhythm control particularly attractive. 10
• The optimal ventricular rate appears to be ~65 bpm (range 60-80 bpm), with a J-shaped relationship between rate and outcomes. 10
• Rates above and below this range confer higher morbidity and mortality, emphasizing the importance of avoiding both excessive tachycardia and iatrogenic bradycardia. 10

Management of Valvular Regurgitation

• The moderate mitral regurgitation (bicommissural pattern) and moderate tricuspid regurgitation are likely functional, secondary to atrial dilatation and ventricular dysfunction. 1
• These valvular lesions may improve with restoration of sinus rhythm and improvement in ventricular function following successful rhythm control. 7
• The mild-to-moderate aortic regurgitation does not alter anticoagulation strategy, as this patient does not have moderate-to-severe mitral stenosis or mechanical valves. 1, 4

Right Ventricular Dysfunction Considerations

• The mild decrease in RV systolic function (TAPSE 1.4 cm, which is below normal of ≥1.6 cm) and mildly elevated PA systolic pressure (RVSP 27 mmHg) suggest RV involvement. 1
• RV dysfunction in AF with HFrEF portends worse prognosis and further supports aggressive rhythm control strategy. 7
• The presence of a lead in the right ventricle suggests this patient has a pacemaker or ICD, which may facilitate monitoring and potentially AV node ablation if rate control fails. 1

Comorbidity and Risk Factor Management

Addressing modifiable risk factors is essential to prevent AF progression and improve outcomes. 1

• Hypertension control is critical (current BP 153/92 mmHg is inadequate). Target BP should be optimized per heart failure guidelines. 1
• Evaluate for and treat obstructive sleep apnea, obesity, diabetes, and encourage physical activity as part of comprehensive AF-CARE approach. 1
• Optimize guideline-directed medical therapy for heart failure, including ACE inhibitors/ARBs/ARNI, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors. 1

Monitoring and Follow-up

• Renal function should be assessed at least annually when using DOACs, more frequently if clinically indicated. 2, 5
• Ambulatory ECG monitoring (Holter or event monitor) should be performed to assess adequacy of rate control during daily activities and exercise. 1, 2
• Repeat echocardiography in 3-6 months after optimizing rate control or achieving rhythm control to assess for improvement in LVEF, which would support AF-induced cardiomyopathy component. 10

Common Pitfalls to Avoid

• Do not use calcium channel blockers (diltiazem, verapamil) in this patient with LVEF 25-30%, as they can precipitate acute decompensation. 1, 2
• Do not use digoxin as sole agent for rate control in AF, as it is ineffective for controlling rate during exercise and paroxysmal episodes. 1, 2
• Do not discontinue anticoagulation after successful cardioversion in patients with stroke risk factors—most strokes occur after anticoagulation is stopped. 1, 2
• Do not pursue overly strict rate control (<60 bpm) without careful monitoring, as bradycardia can trigger lethal arrhythmias and worsen hemodynamics. 6, 10
• Do not delay catheter ablation referral in symptomatic patients with HFrEF, as ablation has proven mortality benefit and should not be reserved only after multiple failed antiarrhythmic drug trials. 3, 7