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  • Review Article
  • Published:

Comorbidity of atrial fibrillation and heart failure

Key Points

  • Patients with both atrial fibrillation (AF) and heart failure (HF) present unique diagnostic and management challenges

  • No randomized trial has demonstrated that pharmacological rhythm control confers a reduction in mortality compared with rate control in patients with both AF and HF

  • Studies of highly selected populations of patients with both AF and HF indicate that, in the short term, AF ablation improves symptoms of HF, functional capacity, and left ventricular function

  • Randomized, controlled trials to evaluate hard clinical outcomes of AF ablation in patients with both AF and HF are currently in progress

Abstract

Atrial fibrillation (AF) and heart failure (HF) are evolving epidemics, together responsible for substantial human suffering and health-care expenditure. Ageing, improved cardiovascular survival, and epidemiological transition form the basis for their increasing global prevalence. Although we now have a clear picture of how HF promotes AF, gaps remain in our knowledge of how AF exacerbates or even causes HF, and how the development of HF affects the outcome of patients with AF. New data regarding HF with preserved ejection fraction and its unique relationship with AF suggest a possible role for AF in its aetiology, possibly as a trigger for ventricular fibrosis. Deciding on optimal treatment strategies for patients with both AF and HF is increasingly difficult, given that results from trials of pharmacological rhythm control are arguably obsolete in the age of catheter ablation. Restoring sinus rhythm by catheter ablation seems successful in the medium term and improves HF symptoms, functional capacity, and left ventricular function. Long-term studies to examine the effect on rates of stroke and death are ongoing. Guidelines continue to evolve to keep pace with this rapidly changing field.

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Figure 1: Changing epidemiological risk factors for cardiovascular disease.
Figure 2: Pathophysiological interactions between AF and HF.
Figure 3: Treatment options for patients with AF–HF.
Figure 4: Approach to patients with newly diagnosed AF–HF.

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Bianca J. J. M. Brundel, Xun Ai, … Natasja M. S. de Groot

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L.-H.L. researched data for the article and wrote the manuscript. All the authors contributed to discussion of content and reviewed/edited the manuscript before submission.

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Ling, LH., Kistler, P., Kalman, J. et al. Comorbidity of atrial fibrillation and heart failure. Nat Rev Cardiol 13, 131–147 (2016). https://doi.org/10.1038/nrcardio.2015.191

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