Atrial fibrillation and heart failure: Medical management and catheter ablation

Atrial fibrillation (AF) and heart failure (HF) are two important coexisting epidemics that are expected to rise in prevalence as the growing population ages. Epidemiologic studies have demonstrated that the presence of both conditions as comorbidities leads to worse outcomes than those of either AF or HF alone. The existing literature has yet to demonstrate a clear superiority of either rate or rhythm control pharmacologic strategies for the treatment of atrial fibrillation in all HF patients. Regardless, some degree of rate control (using beta-blockade and occasionally digoxin) is warranted in almost all patients with HF albeit the definition of optimal rate control has not been well-defined for this population. There is emerging evidence for the role of invasive therapeutic approaches such as pulmonary vein isolation as a method for improving reverse remodeling and left ventricular systolic function. While we are learning to tailor rhythm versus rate control therapies in this complex and heterogeneous population, anticoagulation remains a mainstay of therapy for stroke prevention in this high-risk population. Nevertheless, the purpose of this chapter is to first summarize the literature as it applies to AF in HF with a specific focus on the evidence for rhythm versus rate control strategies, including both pharmacologic and catheter-based interventions. Following the literature review we will discuss practical approaches to the medical and catheter-based management of these patients.