Abstract
Heart failure (HF) and atrial fibrillation (AF) frequently coexist and each complicates the course of the other. The purpose of this review is to analyse the prognostic impact of AF in patients with HF and assess whether there is an advantage in targeting therapies towards the maintenance of sinus rhythm (SR) in this cohort of patients. The presence of AF in patients with HF has been reported to be independently associated with an increase in mortality in many studies and this increased risk is observed in those with both preserved and impaired LV systolic function. The optimal strategy for targeting AF in patients with HF is unclear but recent randomised controlled studies indicate no significant prognostic advantage associated with a rhythm control strategy as compared to a rate control strategy. A number of small studies have investigated the role of both cardiac resynchronization therapy (CRT) and AF catheter ablation for the maintenance of / conversion to SR in patients with HF with initial promising results although larger randomised controlled studies will need to be performed to define the role of these modalities in the treatment of this cohort and whether preliminary benefits observed in these studies translate to improvements in longer term prognosis. Finally, there has been a focus on modifying the arrythmogenic atrial substrate and neurohormonal milieu by pharmacological means in order to prevent AF although it remains to be seen whether this approach proves to be efficacious with improvements in clinically relevant outcomes.
Highlights
Heart failure (HF) and atrial fibrillation (AF) are amongst the commonest cardiovascular conditions encountered in clinical practice and frequently coexist
There has been a focus on modifying the arrythmogenic atrial substrate and neurohormonal milieu in order to prevent AF in heart failure patients
HF and AF frequently co-exist and the presence of AF in patients with HF has been reported to be independently associated with an increase in mortality in many studies and this increased risk is observed in those with both preserved and impaired LV systolic function
Summary
Heart failure (HF) and atrial fibrillation (AF) are amongst the commonest cardiovascular conditions encountered in clinical practice and frequently coexist. Heart failure prevalence has reached the proportions of a global epidemic with an estimated prevalence of 3-20 cases /1000 population rising to above 100 cases /1000 population in those aged over 65 years [2]. The annual incidence of heart failure in middle aged men and women is 0.1-0.2 % rising steadily to 2-3 % in those aged above 85 years [2]. Extrapolating from available evidence, as many as 30 million people in Europe may have heart failure [3]. National Health and Nutrition Examination Survey (NHANES) data from 2005 to 2008 indicates that the prevalence of heart failure in Americans (over 20 years of age) is around 5.7 million. The lifetime likelihood of developing heart failure has been estimated as 1 in 5 and this risk rises with an ageing population. HF incidence approaches 10 per 1000 in above 65 year old group [4]
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