Important Comorbidities in HF

Atrial Fibrillation

Patients with HF are more likely than the general population to develop AF (808). There is a direct
relationship between the NYHA class and prevalence of AF in patients with HF progressing from 4%
in those who are NYHA class I to 40% in those who are NYHA class IV (809). AF is also a strong
independent risk factor for subsequent development of HF (808, 810). In addition to those with
HFrEF, patients with HFpEF are also at greater risk for AF (811). HF and AF can interact to promote
their perpetuation and worsening through mechanisms such as rate-dependent worsening of cardiac
function, fibrosis, and activation of neurohumoral vasoconstrictors. AF can worsen symptoms in
patients with HF, and, conversely, worsened HF can promote a rapid ventricular response in AF.
Similar to other patient populations, for those with AF and HF, the main goals of therapy are
prevention of thromboembolism and symptom control. Most patients with AF and HF would be
expected to be candidates for systemic anticoagulation unless otherwise contraindicated. General
principles of management include correction of underlying causes of AF and HF as well as
optimization of HF management (Table 30). As in other patient populations, the issue of rate control
versus rhythm control has been investigated. For patients who develop HF as a result of AF, a rhythm
control strategy should be pursued. It is important to recognize that AF with a rapid ventricular
response is one of the few potentially reversible causes of HF. Because of this, a patient who
presents with newly detected HF in the presence of AF with a rapid ventricular response should be
presumed to have a rate-related cardiomyopathy until proved otherwise. In this situation, 2
strategies can be considered. One is rate control of the patient’s AF and see if HF and EF improve.
The other is to try to restore and maintain sinus rhythm. In this situation, it is common practice to
initiate amiodarone and then arrange for cardioversion 1 month later. Amiodarone has the
advantage of being both an effective rate-control medication and the most effective antiarrhythmic
medication with a lower risk of proarrhythmic effect. In patients with HF who develop AF, a rhythm-
control strategy has not been shown to be superior to a ratecontrol strategy (812). If rhythm control
is chosen, limited data suggest that AF catheter ablation in HF patients may lead to improvement in
LV function and quality of life but is less likely to be effective than in patients with intact cardiac
function (813, 814). Because of their favorable effect on morbidity and mortality in patients with
systolic HF, beta-adrenergic blockers are the preferred agents for achieving rate control unless
otherwise contraindicated. Digoxin may be an effective adjunct to a beta blocker. The
nondihydropyridine calcium antagonists, such as diltiazem, should be used with caution in those
with depressed EF because of their negative inotropic effect. For those with HFpEF,
nondihydropyridine calcium antagonists can be effective for achieving rate control but may be more
effective when used in combination with digoxin. For those for whom a ratecontrol strategy is
chosen, when rate control cannot be achieved either because of drug inefficacy or intolerance,
atrioventricular node ablation and CRT device placement can be useful (78, 116, 595, 596). See
Figures 5 and 6 for AF treatment algorithms.