The Year in Cardiology

Heart Failure: the Year in Cardiology 2019

John G.F. Cleland; Alexander R. Lyon; Theresa McDonagh; John J.V. McMurray


Eur Heart J. 2020;41(12):1232-1248. 

In This Article

Atrial Fibrillation

About a third of outpatients, perhaps more for those with HFpEF,[53] and more than half of those admitted with heart failure will be in AF, which is associated with an adverse prognosis even after correcting for age and other risk factors.[54] Controversy continues over whether medical management focused on rate control or restoration of sinus rhythm is the better strategy for AF and heart failure. In practice, the strategy needs to be tailored to the patient. When AF is the driver of symptoms and worsening cardiac function, restoration of sinus rhythm might be appropriate but when AF reflects the progression of underlying cardiac dysfunction, it may not.[55] For new-onset or paroxysmal AF associated with a clear deterioration in symptoms, restoration of sinus rhythm may be warranted to improve symptoms. For long-standing AF and heart failure with markedly dilated atria, sustained restoration of sinus rhythm and atrial contraction is less likely. Optimal pharmacological management includes anticoagulation, avoiding toxic anti-arrhythmic agents and lenient ventricular rate control. Beta-blockers are the agent of choice for rate control, a resting day-time ventricular rate of 70–90 b.p.m. is preferred,[49] which may require only modest doses; digoxin should be used sparingly, if at all. Unfortunately, RCTs of rate vs. rhythm control for AF have failed to optimize the rate control strategy in the above fashion.

A meta-analysis of RCTs of rate vs. rhythm control included four trials (n = 2486) comparing pharmacological rhythm to rate control found no difference in mortality or thromboembolic events but an increase in hospitalizations, often due to recurrent AF, in the rhythm control group.[56] Six trials (n = 1112) comparing AF ablation with rate control reported reductions in mortality (0.51; 95% CI 0.36–0.74), hospitalizations (0.44; 95% CI 0.26–0.76), and stroke (0.59: 95% CI 0.23–1.51) and an improved quality of life.[56] However, none of the trials individually had a robust result, patients were highly selected and the rate control strategy was not optimal. As such, this meta-analysis should be considered hypothesis generating. Further trials are required with greater involvement of heart failure physicians.