The American Heart Association (AHA) has this week issued a scientific statement on the management of atrial fibrillation (AF) in patients with heart failure and reduced ejection fraction (HFrEF).
Published in Circulation: Arrhythmia and Electrophysiology, the statement reviews available evidence on the epidemiology and pathophysiology of AF in relation to heart failure (HF), and provides guidance on the latest advances in management of patients with AF and HFrEF. Among the conclusions offered by the statement’s authors is that catheter ablation (CA) could be a suitable first-line treatment among these patients.
According to the authors, who include writing committee chair Rakesh Gopinathannair (Kansas City Heart Rhythm Institute, Kansas City, USA) and vice chair Jose A Joglar (University of Texas Southwestern Medical Center, Lawton, USA), managing AF in patients with systolic HF or HFrEF remains a therapeutic challenge with several important considerations.
They note that although pharmacological therapies aimed to reduce the risk of stroke and to treat HF may improve patient outcomes, no specific pharmacological approach using rate or rhythm control strategies to manage AF have shown superiority for HF hospitalisation or survival.
Furthermore, the authors add, recent randomised controlled trials and meta-analyses have demonstrated the effectiveness of CA in improving hard endpoints such as survival, HF hospitalisations, functional capacity, and quality of life (QOL), with acceptable safety, in patients with AF and HFrEF.
The authors of the statement acknowledge that AF and HFrEF are increasing in prevalence and, when present together, are associated with significant mortality and morbidity—while AF can be both a cause and a consequence of HFrEF.
“In patients with AF and HFrEF, standard HF therapy, appropriate anticoagulation, and lifestyle and risk factor management should be standard of care,” the authors suggest, adding that in addition, aggressive attempts at rate or rhythm control should be instituted because a proportion of these patients will have AF-mediated HF and cardiomyopathy, which can be partially or completely reversed.
Furthermore, they note, although randomised clinical trials comparing medical rate control with antiarrhythmic therapy for rhythm control showed no significant difference in outcomes, recent randomised studies comparing CA with rate control or pharmacological rhythm control have shown that restoration and maintenance of sinus rhythm in patients with HFrEF, when accomplished by ablation, “improves hard clinical endpoints in this complex population”.
The authors acknowledge that although the exact mechanisms of these improvements need further elucidation”, the association of improved outcomes with reduced AF burden suggests that patients with HF and LV [left ventricular] dysfunction likely have an occult AF-induced or AF-mediated cardiomyopathy that is reversed, to varying degrees, with CA compared with rate control or antiarrhythmic therapy.
“Given these data and the fact that only limited therapeutic options are available for patients with advanced HF, it is plausible to consider CA as first-line therapy for patients with AF and HFrEF, recognising, however, that patients with severe HFrEF may derive less benefit,” the statement’s authors suggest. “Achieving sinus rhythm maintenance without antiarrhythmic drugs in this population may indeed be a worthy quest.”
Finally, the authors of the statement suggest that further studies are needed to better refine patient selection and appropriate timing for ablation, as well as long-term outcomes. Close collaboration between the HF and electrophysiology specialists is essential in the early recognition and appropriate care of these patients, they add.