Both heart failure and atrial fibrillation are significant health problems affecting approximately 1-2% of the adult population. Atrial fibrillation (AF) increases the incidence of thromboembolic complications, increases the frequency of hospitalization, morbidity due to heart failure, and is an independent risk factor for death. AF is the most common arrhythmia occurring in patients with heart failure.
Patients with heart failure and implantable devices
Atrial fibrillation with rapid ventricular response remains one of the most common causes of inadequate interventions of implanted cardioverter-defibrillator (ICD) or resynchronization systems with cardioverter-defibrillator function (CRT-D). Both AF and inadequate interventions are strongly associated with worse prognosis and increased risk of all-cause death. Furthermore, in presence of multiple inapproriate shocks the patients’ prognosis worsens. Thus they require more frequent interventions most frequently reprogramming of the device, modification of pharmacotherapy and correction of accompanying irregularities such as electrolyte disturbances. AF is also a major cause of loss of biventricular pacing in patients with an implanted resynchronizing system, which leads into an exacerbation of heart failure symptoms, an increase in hospitalization and mortality.
No clear advantage has been demonstrated for rate or rhythm control strategy for survival in patients with AF. In the European registry EORP-AF a higher mortality rate was observed in the group treated with rate control strategy. However, after considering the effects of associated diseases, the difference in mortality among patients undergoing rhythm control and rate control was not statistically significant.
Recently, several studies comparing antiarrhythmic therapy with atrial fibrillation ablation have been published. The article briefly discusses some of them, such as the CASTLE-AF study, AATAC, CAMERA-MRI, the CABANA study. Despite the different results of these studies, reports on the effectiveness of atrial fibrillation ablation among patients with heart failure are promising. According to updated guidelines of American cardiology societies from 2019, ablation of atrial fibrillation can be considered in patients with symptomatic AF and heart failure with reduced left ventricular ejection fraction to reduce mortality and the frequency of hospitalization for heart failure.
Patients with atrial fibrillation and heart failure have a worse prognosis than patients with heart failure and sinus rhythm. However, we can improve it by diagnosing atrial fibrillation and implementing adequate treatment, including invasive atrial fibrillation therapy.
PROGNOSTIC ROLE OF ATRIAL FIBRILLATION AND HEART RATE CONTROL IN CHRONIC HEART FAILURE PATIENTS
