Atrial Fibrillation in the Setting of Heart Failure

Abstract

In the treatment and management of atrial fibrillation (AF), the debate over ‘rate versus rhythm’ has largely been answered by several large randomised prospective clinical trials that have shown no distinct advantage for one strategy over the other in terms of clinical outcomes. Prior to the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial, these studies were largely conducted on patients without heart failure (HF) and included patients with paroxysmal AF. Notably, only 23% of patients enrolled in the largest rate versus rhythm AF trial to date, Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM), had HF. However, the treatment of patients with both AF and HF remains a specific challenge. While anticoagulation treatment is necessary in all cases, the definition of the optimal therapy prescribed to control arrhythmia itself is much more difficult. There appear to be specific advantages of sinus rhythm in patients who have AF and HF. These might include a salutary effect of sinus rhythm due to at least three factors: regularisation of the rhythm, physiological rate control and restoration of atrial contribution to cardiac output. It would be prudent to assess carefully whether patients presenting with both AF and HF will benefit from improved outcomes following restoration and maintenance of sinus rhythm, whether achieved by drug therapy or catheter ablation.