Editorial
Atrial Fibrillation and Congestive Heart Failure
The Intersection of Two Common Diseases
Melvin M. Scheinman, MD
A
trial fibrillation is the most common sustained car-
diac arrhythmia, and congestive heart failure is an
increasingly frequent diagnosis as our population
tends to age. Appropriate management of these patients has
engaged clinicians for many years. It was long appreciated
that atrial fibrillation, per se, without associated cardiac
disease could result in congestive heart failure and that
prompt treatment resulting in either restoration of sinus
rhythm or rate control could obviate the signs and symptoms
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of congestive heart failure.1–3
See p 953
More recently, a spate of observations have shown that
application of catheter ablative techniques to patients with
atrial fibrillation with rapid ventricular rates unresponsive to
drug therapy could likewise result in improved cardiac
function.4 – 8 In the latter studies, patients generally had proved
to be refractory to medical therapy before being offered
catheter ablation of the atrioventricular (AV) junction.
Elsewhere in this issue of Circulation, Brignole et al9
report a novel controlled trial comparing drug versus AV
junctional ablation for patients with atrial fibrillation and
congestive heart failure. In this study, a total of 66 patients
with chronic atrial fibrillation were randomized to receive
either drug therapy for rate control or ablation and insertion of
a VVIR pacemaker. These patients were followed up for at
least 12 months with serial questionnaires used to assess
changes in either specific symptoms (ie, palpitations, dys-
pnea), global quality-of-life issues (Minnesota LHFQ), or
NYHA functional class. In addition, cardiac performance was
assessed by serial exercise and echocardiographic studies.
It was found, not unexpectedly, that patients in both
treatment limbs showed improvement. Patients treated with
catheter ablation had a statistically significantly better re-
sponse in terms of specific symptoms (especially palpitations
or exertional dyspnea), but there was no significant difference
in global quality-of-life improvement or in objective evidence
of improved cardiac performance between the groups.
This study fills an important void in our therapeutic
approach to patients with both congestive heart failure and
atrial fibrillation. Several studies, for example, have shown
The opinions expressed in this editorial are not necessarily those of the
editors or of the American Heart Association.
From the Department of Medicine and the Cardiovascular Research
Institute, University of California, San Francisco.
Correspondence to Melvin M. Scheinman, MD, 500 Parnassus Ave,
San Francisco, CA 94143-1354. E-mail scheinman@ep4.ucsf.edu
(Circulation. 1998;98:941-942.)
© 1998 American Heart Association, Inc.
941
that rate regularity, per se, may result in improved cardiac
function in patients with atrial fibrillation.10,11 A natural
extension of these observations would suggest benefits of
catheter ablation and pacing, particularly in those patients
with atrial fibrillation and congestive heart failure. The data
provided by Brignole et al would suggest that ablation and
pacemaker insertion is clearly not of proven benefit compared
with drug-induced rate control in patients with chronic atrial
fibrillation. Hence, the clinician is not mandated to choose
ablation of the AV junction compared with drug therapy in
patients with atrial fibrillation and heart failure.
A few additional points are necessary to place this excel-
lent study in proper clinical context. First, the authors clearly
showed that there was no significant difference in either
overall mortality or the incidence of sudden death between
the 2 treatment groups. This being the case, catheter ablation
may be fruitfully applied to those patients disabled by
specific symptom complexes (ie, intractable palpitations or
exertional dyspnea). In these circumstances, one must use
careful clinical judgment before choosing the appropriate
therapy. The available data would suggest that the benefits of
ablation/pacemaker therapy outweigh any potential risks for
this patient subset.
It must also be appreciated that current practice advises use
of catheter ablation for patients with drug-refractory atrial
fibrillation associated with rapid ventricular response. It
should be emphasized that nothing in this particular study
contravenes current practice guidelines. The patients in this
study were randomly assigned to treatment with either drugs
or ablation. In the usual clinical context, patients are referred
for possible ablation after they have failed a multitude of
available drugs. These patients generally show significant
benefit in both specific symptoms and overall lifestyle, as
well as in improved cardiac function.12–15
Earlier studies16 –20 emphasized a possible relationship be-
tween sudden cardiac death and catheter ablation of the AV
junction. Factors that were implicated included use of high-
energy DC discharge for ablation, presence of ischemia, or
relatively low postablation pacing rates. This study using
modern radiofrequency procedures provides reassurance that
there are no increased adverse effects, either in terms of
worsening of symptoms of congestive heart failure or in the
incidence of cardiac (including sudden) deaths between the
treatment modalities. They described 2 adverse periablation
procedure complications, including 1 episode of ventricular
fibrillation that occurred 12 hours after the procedure in a
patient with a night heart rate drop to 50 bpm. Another patient
suffered a nonfatal pulmonary embolus. No further compli-
cations were observed in these patients on follow-up. This
experience does emphasize the need for continued pacing at
 942 Atrial Fibrillation and Heart Failure
rates of 80 to 90 bpm for several days after catheter ablation.
It also serves to emphasize the need for a 2- to 3-day hospital
stay for patients with atrial fibrillation treated with ablation
and pacemaker.
One additional finding merits attention. Of the 34 patients
randomized to drug therapy, a total of 10 (30%) ultimately
crossed over to ablation and pacemaker therapy because of
worsening of symptoms. Four patients crossed over to abla-
tion before completion of the study, and 6 patients were
treated with ablation immediately after completion of the
12-month visit. These findings suggest that although patients
with atrial fibrillation (with moderate ventricular response)
and congestive heart failure appear to respond equally well to
either drug or ablative therapy during the first year, subse-
quent follow-up shows an increasing crossover to ablative
therapy.
Summary and Conclusions
Brignole and associates have provided an interesting study of
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patients with atrial fibrillation and congestive heart failure.
They have clearly shown that at least early on (12-month
follow-up), drug therapy is as effective as catheter ablation in
terms of changes in quality-of-life and cardiac-performance
indices. Catheter ablation, however, appeared to confer ben-
efit to those with specific symptoms (ie, palpitations or
exertional dyspnea) and therefore remains a useful therapeu-
tic tool for patients with disabling effects related to these
symptoms. Of interest was the significant (30%) crossover to
ablation both during and just after completion of the study.
Patients with atrial fibrillation whose rate cannot be con-
trolled with drug therapy clearly remain candidates for and
would be expected to show improvement after ablation and
pacing.
References
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KEY WORDS: Editorials n fibrillation n heart failure
 Atrial Fibrillation and Congestive Heart Failure: The Intersection of Two Common
Diseases
Melvin M. Scheinman

Circulation. 1998;98:941-942
doi: 10.1161/01.CIR.98.10.941
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