Atrial Fibrillation and Congestive Heart Failure

Key points

Epidemiology of HF and AF

AF is the most common sustained arrhythmia among adults. It imposes a considerable public health burden, currently affecting greater than 2 million people in the United States. This statistic is increasing as the population ages.¹ HF is also a significant and growing epidemic, with nearly 5.7 million American adults affected currently and greater than 500,000 new patients diagnosed annually.² Furthermore, patients with HF are now living longer; this is in part due to improved survival from

Prognostic significance of HF and AF in combination

AF and HF frequently coexist, in part because of common risk factors (eg, hypertension, coronary artery disease, diabetes mellitus, valvular disease) and also because of their common tendency to occur in patients with advanced age (Figs. 1 and 2).⁶ The overall prevalence of AF among patients with HF has been reported to be 13% to 41%.6, 7, 8 These figures include prevalence data from several HF trials, such as The Vasodilator in Heart Failure Trial, as well as the largest followed community

Pathophysiology of AF and HF

Because AF and HF share several common risk factors and commonly occur together, several authors have questioned whether one is the product of another.9, 16, 17, 18 As noted above, the Framingham observations suggest that these conditions follow one another at similar rates. Specifically, the incidence of HF among subjects with AF was 33 per 1000 person-years, and the incidence of AF among those with HF was 54 per 1000 person-years.⁶ However, direct causality between AF and HF has yet to be

Diagnosis of AF among patients with HF

The diagnosis of AF in HF patients can be made via an electrocardiogram, telemetry, or implanted device monitoring. Devices such as permanent pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy defibrillators (CRT-Ds) continuously monitor AF occurrence and burden. Because AF can lead to more frequent HF hospitalization, routine monthly surveillance for AF using implantable devices has been suggested as a preventative measure.44, 45 Sarkar and colleagues⁴⁵

Diagnosis of HF among patients with AF

The diagnosis of HF is most often made via clinical examination, but diagnostic tests such as brain natriuretic peptide (BNP) are often helpful.⁴⁶ However, AF patients have been shown to have elevated levels of BNP even in the absence of HF. In addition, a reduction in BNP level has been demonstrated after rhythm restoration by cardioversion, Maze operation, or pulmonary vein isolation (PVI), whether HF was present or absent.47, 48, 49, 50, 51 Thus, the diagnostic utility of BNP may be limited

Catheter-based ablation of the AV node and biventricular pacing (“ablate and pace”)

Implantation of a pacemaker (often, one with ventricular resynchronization therapy capacity) with subsequent radiofrequency ablation of the atrioventricular node (AVN) has been shown to be effective in AF patients with rapid ventricular response who are refractory to medical therapy.⁹⁰

Patients with an implanted CRT device with persistent/permanent AF should be also undergo AV nodal ablation. Ineffective biventricular capture due to a high prevalence of fusion and pseudo-fusion beats was

Final comments

AF and HF have a negative impact on one another and adversely affect mortality when found together. The poor prognosis of concomitant AF and HF is a consistent finding in several HF trials, leading to increased hospitalization and lengthier inpatient stays. Although comprehension of the combined AF/HF pathophysiology is progressing, further efforts are needed to elucidate the mechanisms involved. For patients with HF who are at risk for AF, frequent monitoring with the use of implantable