ReviewAtrial Fibrillation in Heart Failure: A Comprehensive Review
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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Risks of Heart Failure, Stroke, and Bleeding in Atrial Fibrillation According to Heart Failure Phenotypes
2023, JACC: Clinical ElectrophysiologyImpact of atrial fibrillation on stroke, heart failure, and mortality in diabetic patients with coronary artery disease
2021, Journal of Diabetes and its ComplicationsCitation Excerpt :This is indeed data that could be helpful in the understanding and management of the growing population of diabetic CAD adults with AF and CV events, suspected to be of high incidence and early age at onset, providing a much more insightful and impactful analysis. Although the link between AF and the occurrence of adverse CV events has been eatablished4–8; to the best of our knowledge, the mechanistically impact of AF on the risk of stroke, HF and mortality in diabetic CAD population have never been reported. To bridge the knowledge gaps, the authors take an epidemiological approach to explore the subgroup analysis of the distribution of the association in a national health insurance research database, using the appropriate justification for performing the stratified analysis.
European Heart Rhythm Association (EHRA)/Heart Rhythm Society (HRS)/Asia Pacific Heart Rhythm Society (APHRS)/Latin American Heart Rhythm Society (LAHRS) expert consensus on risk assessment in cardiac arrhythmias: use the right tool for the right outcome, in the right population
2020, Heart RhythmCitation Excerpt :The mechanisms for reduction in cardiac output include loss of atrial contribution to ventricular filling, increased mitral regurgitation and decreased left ventricular filling time. The irregular and rapid ventricular contraction in AF can lead to LV dysfunction in an unknown percentage of patients and in some patients a tachycardia-induced cardiomyopathy results.290 The irregular ventricular response also compromises ventricular performance through changes in calcium handling and reduced expression of Serca and phospholamban phosphorylation.
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.