Review
Atrial Fibrillation in Heart Failure: A Comprehensive Review

https://doi.org/10.1016/j.amjmed.2009.06.033Get rights and content

Abstract

Chronic heart failure and atrial fibrillation are 2 major disorders that are closely linked. Their coexistence is associated with adverse prognosis. Both share several common predisposing conditions, but their interaction involves complex ultrastructural, electrophysiologic, and neurohormonal processes that go beyond mere sharing of mutual risk factors. Rate control approach remains the standard therapy for atrial fibrillation in heart failure because current strategies at rhythm control have so far failed to positively impact mortality and morbidity. This is largely because of the shortcomings of current pharmacologic anti-arrhythmic agents. Surgical and catheter-based therapies are promising, but long-term data are lacking. The role of non-anti-arrhythmic therapeutic agents also is being explored. Further progress toward improved understanding the complex relationship between atrial fibrillation and heart failure should improve management strategies.

Section snippets

Epidemiology

Chronic heart failure afflicts 5.3 million adult Americans with an equal sex distribution. It is associated with over a million hospitalizations and 3.4 million outpatient visits annually, with total costs estimated at $35 billion. The lifetime risk of developing heart failure is 1 in 5 after age 40 years,1 with an annual mortality of 20%.

Atrial fibrillation, the most common clinically significant arrhythmia, has a prevalence of over 2.2 million in the United States. It accounts for nearly a

Predictors of Atrial Fibrillation in Chronic Heart Failure

In the Framingham Study, heart failure was the strongest predictor for the development of atrial fibrillation, with a nearly 5-fold risk in men and 6-fold in women.5 The prevalence of atrial fibrillation in patients with preexisting heart failure is associated with increasing heart failure severity. In chronic heart failure clinical trials, the prevalence of atrial fibrillation was 4% in functional class I patients,6 10%-27% in those with functional class II-III,7, 8, 9, 10 and 50% in those

Pathophysiologic Interaction

Chronic heart failure and atrial fibrillation are associated with common predisposing conditions such as hypertension, diabetes, coronary artery disease, and valvular heart disease. Recent data reveal complex cellular, extracellular, neurohormonal, and electrophysiologic processes that allow significant interaction between these 2 conditions that go beyond the mere sharing of mutual risk factors.

Prognosis

Even with optimal medical therapy for heart failure, the onset of atrial fibrillation is often accompanied by cardiac decompensation as well as functional class deterioration. Peak oxygen consumption and cardiac index markedly decrease, while the severity of valvular regurgitation and cardiac chamber dimensions increase shortly after the onset of atrial fibrillation.30 Whether atrial fibrillation directly affects prognosis or is merely a marker for heart failure severity is still under debate.

Therapeutic Approaches

Beta-blockers are first-line agents common to the management of both atrial fibrillation and heart failure. Bisoprolol, metoprolol succinate, and carvedilol have been shown to have significant mortality benefit in heart failure35 and also are effective for rate-control in atrial fibrillation as well. Anticoagulation is the cornerstone of therapy for stroke prophylaxis in atrial fibrillation, and atrial fibrillation is the primary indication for anticoagulation in heart failure. In addition,

Conclusion

Atrial fibrillation and chronic heart failure frequently coexist because of common risk factors and closely linked pathophysiologic processes. Their association is correlated with adverse prognosis. Rate-control strategy remains the standard of care because rhythm control therapy has yielded mixed results in patients with atrial fibrillation and heart failure. This is primarily because of the limitations of current anti-arrhythmic agents that are not that effective in maintaining sinus rhythm

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    Funding: None.

    Conflict of Interest: Dr Lardizabal does not have any relationship with industry and financial associations that might pose a conflict of interest. Dr Deedwania was a consultant and speaker and has been on the Advisory Board of Sanofi-Aventis.

    Authorship: Both authors were significantly involved in all steps of the writing process, including the conception, design, drafting and critical revision of the manuscript, as well as final approval for its submission.

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