Atrial Fibrillation in Patients With Heart Failure: Current State and Future Directions

Tuoyo O. Mene-Afejuku; Persio D. López; Adedoyin Akinlonu; Carissa Dumancas; Ferdinand Visco; Savi Mushiyev; Gerald Pekler


Am J Cardiovasc Drugs. 2018;18(5):347-360. 

In This Article

Abstract and Introduction


Heart failure affects nearly 26 million people worldwide. Patients with heart failure are frequently affected with atrial fibrillation, and the interrelation between these pathologies is complex. Atrial fibrillation shares the same risk factors as heart failure. Moreover, it is associated with a higher-risk baseline clinical status and higher mortality rates in patients with heart failure. The mechanisms by which atrial fibrillation occurs in a failing heart are incompletely understood, but animal studies suggest they differ from those that occur in a healthy heart. Data suggest that heart failure-induced atrial fibrosis and atrial ionic remodeling are the underlying abnormalities that facilitate atrial fibrillation. Therapeutic considerations for atrial fibrillation in patients with heart failure include risk factor modification and guideline-directed medical therapy, anticoagulation, rate control, and rhythm control. As recommended for atrial fibrillation in the non-failing heart, anticoagulation in patients with heart failure should be guided by a careful estimation of the risk of embolic events versus the risk of hemorrhagic episodes. The decision whether to target a rate-control or rhythm-control strategy is an evolving aspect of management. Currently, both approaches are good medical practice, but recent data suggest that rhythm control, particularly when achieved through catheter ablation, is associated with improved outcomes. A promising field of research is the application of neurohormonal modulation to prevent the creation of the ''structural substrate'' for atrial fibrillation in the failing heart.


Heart failure (HF), irrespective of its etiology, is associated with elevated healthcare costs[1] and an unfavorable prognosis.[2] Worldwide, it is estimated that 26 million are affected with HF,[3] with over 6.5 million adults in the USA[1] and at least 15 million in Europe[4] affected. The incidence of HF in the USA alone is estimated to be close to 1 million annually.[1]

Although the characteristics of patients with HF vary significantly depending on their geographical location,[5] atrial arrhythmias are significant contributors to morbidity and mortality in all patient groups.[6,7] The interrelation between HF and atrial arrhythmias is complex, and one can predispose, precipitate, or complicate the other.[7]

This article aims to review the pathophysiology, clinical significance, and therapeutics of non-valvular atrial fibrillation (AF), the most common supra-ventricular arrhythmia in patients with HF.