Heart Failure and Atrial Fibrillation—Chicken or Egg?

Abstract

trial fibrillation (AF) is the most common clinical arrhythmia with a projected 2-to 3-fold increase in prevalence in the coming decades. AF is associated with significant mortality and morbidity, such as stroke, heart failure (HF), and sudden death, despite optimal contemporary therapy with anticoagulation and rate control strategies. AF and HF often coexist and the presence of both portends worse outcomes. This poses the classic the chicken or the egg causality dilemma. The AFFIRM trial (Atrial Fibrillation Follow-up Investigation of Rhythm Management) was a landmark study that compared rate versus rhythm control in AF management and showed no survival advantage with a rhythm control strategy. Based on the AFFIRM results, the undesirable side effect profiles of antiarrhythmic medications and the primitive state of radiofrequency ablation therapy for AF at the time, heart rate control alone has been a core AF management strategy. Importantly, AF rate control strategies are designed to reduce excessive ventricular rate responses without altering the irregular pattern of ventricular activation. However, with recent advances in rhythm control strategies incorporating catheter ablation, better antiarrhythmic medication management and patient selection, several studies provide evidence for improved outcomes with rhythm control strategies in patients with AF, and AF associated HF. 2 Thus, there is an increasing recognition that rhythm control is superior to rate control for important clinical outcomes, including HF, mortality, cognitive dysfunction and dementia. Intriguingly, AFFIRM showed that in patients without HF at enrollment, incident symptomatic HF was increased in the rate control arm compared with the rhythm control arm and associated with increased mortality risk. Taken together, these and other findings establish a link between AF and HF and strongly suggest that controlling AF can reduce HF.

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