Rhythm control versus rate control for atrial fibrillation and heart failure

Genetics of atrial fibrillation-practical applications for clinical management: if not now, when and how?

The prevalence and economic burden of atrial fibrillation (AF) are predicted to more than double over the next few decades. In addition to anticoagulation and treatment of concomitant cardiovascular conditions, early and standardized rhythm control therapy reduces cardiovascular outcomes as compared with a rate control approach, favouring the restoration, and maintenance of sinus rhythm safely. Current therapies for rhythm control of AF include antiarrhythmic drugs (AADs) and catheter ablation (CA). However, response in an individual patient is highly variable with some remaining free of AF for long periods on antiarrhythmic therapy, while others require repeat AF ablation within weeks. The limited success of rhythm control therapy for AF is in part related to incomplete understanding of the pathophysiological mechanisms and our inability to predict responses in individual patients. Thus, a major knowledge gap is predicting which patients with AF are likely to respond to rhythm control approach. Over the last decade, tremendous progress has been made in defining the genetic architecture of AF with the identification of rare mutations in cardiac ion channels, signalling molecules, and myocardial structural proteins associated with familial (early-onset) AF. Conversely, genome-wide association studies have identified common variants at over 100 genetic loci and the development of polygenic risk scores has identified high-risk individuals. Although retrospective studies suggest that response to AADs and CA is modulated in part by common genetic variation, the development of a comprehensive clinical and genetic risk score may enable the translation of genetic data to the bedside care of AF patients. Given the economic impact of the AF epidemic, even small changes in therapeutic efficacy may lead to substantial improvements for patients and health care systems.

Treatment timing and the effects of rhythm control strategy in patients with atrial fibrillation: nationwide cohort study

OBJECTIVE

To investigate whether the results of a rhythm control strategy differ according to the duration between diagnosis of atrial fibrillation and treatment initiation.

DESIGN

Longitudinal observational cohort study.

SETTING

Population based cohort from the Korean National Health Insurance Service database.

PARTICIPANTS

22 635 adults with atrial fibrillation and cardiovascular conditions, newly treated with rhythm control (antiarrhythmic drugs or ablation) or rate control strategies between 28 July 2011 and 31 December 2015.

MAIN OUTCOME MEASURE

A composite outcome of death from cardiovascular causes, ischaemic stroke, admission to hospital for heart failure, or acute myocardial infarction.

RESULTS

Of the study population, 12 200 (53.9%) were male, the median age was 70, and the median follow-up duration was 2.1 years. Among patients with early treatment for atrial fibrillation (initiated within one year since diagnosis), compared with rate control, rhythm control was associated with a lower risk of the primary composite outcome (weighted incidence rate per 100 person years 7.42 in rhythm control v 9.25 in rate control; hazard ratio 0.81, 95% confidence interval 0.71 to 0.93; P=0.002). No difference in the risk of the primary composite outcome was found between rhythm and rate control (weighted incidence rate per 100 person years 8.67 in rhythm control v 8.99 in rate control; 0.97, 0.78 to 1.20; P=0.76) in patients with late treatment for atrial fibrillation (initiated after one year since diagnosis). No significant differences in safety outcomes were found between the rhythm and rate control strategies across different treatment timings. Earlier initiation of treatment was linearly associated with more favourable cardiovascular outcomes for rhythm control compared with rate control.

CONCLUSIONS

Early initiation of rhythm control treatment was associated with a lower risk of adverse cardiovascular outcomes than rate control treatment in patients with recently diagnosed atrial fibrillation. This association was not found in patients who had had atrial fibrillation for more than one year.

Atrial fibrillation burden and heart failure: Data from 39,710 individuals with cardiac implanted electronic devices

BACKGROUND

Atrial fibrillation (AF) and heart failure (HF) often accompany one another, and each is independently associated with poor outcomes. However, the association between AF burden and outcomes is poorly understood.

OBJECTIVE

The purpose of this study was to describe the association between device-based AF burden and HF clinical outcomes.

METHODS

We used a nationwide, remote monitoring database of cardiac implantable electronic devices (CIEDs) linked to Medicare claims. We included patients with nonpermanent AF, undergoing new CIED implant, stratified by baseline HF. The outcomes were new-onset HF, HF hospitalization, and all-cause mortality at 1 and 3 years.

RESULTS

We identified 39,710 patients who met inclusion criteria (25,054 with HF; 14,656 without HF). Patients with HF were younger (mean age 76.3 vs 78.5 years; P <.001), more often male (65% vs 54%; P <.001), and had higher mean CHA2DS2-VASc scores (5.4 vs 4.1; P <.001). Among those without HF, increasing device-based AF burden was significantly associated with increased risk of new-onset HF (adjusted hazard ratio [HR] 1.09 per 10% AF burden; 95% confidence interval [CI] 1.06-1.12; P <.001) and all-cause mortality (adjusted HR 1.05 per 10% AF burden; 95% CI 1.01-1.10; P = .012). Among patients with HF, increasing AF burden was significantly associated with increased risk of HF hospitalization (adjusted HR 1.05 per 10% AF burden; 95% CI 1.04-1.06; P <.001) and all-cause mortality (adjusted HR 1.06 per 10% AF burden; 95% CI 1.05-1.08; P <.001).

CONCLUSION

Among older patients with AF receiving a CIED, increasing AF burden is significantly associated with increasing risk of adverse HF outcomes and all-cause mortality.

Sex-Specific Prevalence, Incidence, and Mortality Associated With Atrial Fibrillation in Heart Failure

OBJECTIVES

This study sought to investigate the mortality associated with atrial fibrillation (AF) in men and women with heart failure (HF) according to the sequence of presentation and rhythm versus rate control.

BACKGROUND

The sex-specific epidemiology of AF in HF is sparse.

METHODS

Using the Danish nationwide registries, all first-time cases of HF were identified and followed for all-cause mortality from 1998 to 2018.

RESULTS

Among 252,988 patients with HF (mean age: 74 ± 13 years, 45% women), AF presented before HF in 54,064 (21%) and on the same day in 27,651 (11%) individuals, similar in women and men. Among patients without AF, the cumulative 10-year incidence of AF was 18.7% (95% confidence interval [CI]: 18.2% to 19.1%) in women and 21.3% (95% CI: 21.0% to 21.6%) in men. On follow-up (mean: 6.2 ± 5.8 years), adjusted mortality rate ratios were 3.33 (95% CI: 3.25 to 3.41) in women and 2.84 (95% CI: 2.78 to 2.90) in men if AF antedated HF, 3.45 (95% CI: 3.37 to 3.56) in women versus 2.76 (95% CI: 2.69 to 2.83) in men when AF and HF were diagnosed concomitantly, and 4.85 (95% CI: 4.73 to 4.97) in women versus 3.89 (95% CI: 3.80 to 3.98) in men when AF developed after HF. Compared with rate control for AF, a rhythm-controlling strategy was associated with lowered mortality in inverse probability-weighted models across all strata and in both sexes (hazard ratios: 0.75 to 0.83), except for women who developed AF after HF onset (hazard ratio: 1.03).

CONCLUSIONS

More than half of all men and women with HF will develop AF during their clinical course, with prognosis associated with AF being worse in women than men. Further studies are needed to understand the underlying mechanisms.

The RACE to the EAST. In pursuit of rhythm control therapy for atrial fibrillation-a dedication to Harry Crijns

The RACE trial was one of the first landmark trials to establish whether restoring and maintaining sinus rhythm could reduce morbidity and mortality in patients with atrial fibrillation (AF). Its neutral outcome shaped clinical decision-making for almost 20 years. However, there were two important treatment-related factors associated with mortality of rhythm control therapy at that time: One was safety of antiarrhythmic drug therapy, and the other one withdrawal of anticoagulation after restoration of sinus rhythm. Both concerns have been overcome, and, moreover, important knowledge considering the importance of time for the treatment of AF has been gained. These insights led to the concept of the EAST-AFNET 4 trial, and after more than two decades in the pursuit of ongoing therapeutic improvement, early rhythm control therapy has demonstrated to reduce a composite of cardiovascular death, stroke, and hospitalization for worsening of HF or acute coronary syndrome, by 21% (first primary outcome, absolute reduction 1.1 per 100 patient-years). For this entire period, Harry Crijns characterized the treatment of AF patients, and contributed decisively to realizing the benefit of rhythm control therapy. It is almost easier to list the clinical trials without Harry's involvement than to list those which he co-designed and led.

Catheter Ablation of Atrial Fibrillation in Heart Failure: from Evidences to Guidelines

PURPOSE OF REVIEW

Catheter ablation of atrial fibrillation in heart failure seems to be the way to improve the quality of life, life expectance, and prognosis. In this review, we outline the growing role of this therapy and which patients can benefit from it.

RECENT FINDINGS

While previous studies comparing rate control and rhythm control had not demonstrated the superiority of rhythm control in the prognosis of patients with atrial fibrillation and heart failure, recent findings seem to demonstrate that catheter ablation of atrial fibrillation reduces mortality and hospitalization for heart failure and improves the quality of life, when compared to medical therapy alone. An early rhythm-control strategy in atrial fibrillation may reduce cardiovascular death, stroke, hospitalization for HF, or acute coronary syndrome. Catheter ablation in heart failure is an effective and safe solution to obtain a rhythm control and, therefore, to improve outcomes. A better selection of the patients could help to avoid futile procedures and to identify patients requiring a closer follow-up, to redo procedures, or the addition of antiarrhythmic drugs.

A randomized ablation-based atrial fibrillation rhythm control versus rate control trial in patients with heart failure and high burden atrial fibrillation: The RAFT-AF trial rationale and design

Heart failure (HF) and atrial fibrillation (AF) are 2 cardiac conditions that are increasing in prevalence and incidence. The 2 conditions frequently coexist, and are associated with increased morbidity and mortality. Catheter ablation of AF has been successfully performed in patients with HF, with an improvement in HF and AF, when compared to amiodarone, but further data is required to compare this to rate control. OBJECTIVES: The primary objective is to determine whether AF treated by catheter ablation, with or without antiarrhythmic drugs reduces all-cause mortality and hospitalizations for HF as compared with rate control in patients with HF and a high burden AF. METHODS: This is a multi-center prospective randomized open blinded endpoint (PROBE) study. Patients with NYHA class II-III HF (HF with reduced ejection fraction (<35%) or HF with preserved ejection fraction), and high burden AF are included in the trial. Patients are randomized to either rate control or catheter ablation-based AF rhythm control in a 1:1 ratio. Patients in the rate control group receive optimal HF therapy and rate control measures to achieve a resting hazard ratio (HR) < 80 bpm and 6-minute walk HR < 110 bpm. Patients randomized to catheter ablation-based AF rhythm control group receive optimal HF therapy and one or more aggressive catheter ablation, which include PV antral ablation and LA substrate ablation with or without adjunctive antiarrhythmic drug. The primary outcome is a composite of all-cause mortality and hospitalization for heart failure defined as an admission to a health care facility. The sample size is 600. Enrolment has been completed.

Characteristics and Treatment of Atrial Fibrillation with Respect to the Presence or Absence of Heart Failure. Insights from the Multicenter Polish Atrial Fibrillation (POL-AF) Registry

Background: We aimed to assess characteristics and treatment of AF patients with and without heart failure (HF). Methods: The prospective, observational Polish Atrial Fibrillation (POL-AF) Registry included consecutive patients with AF hospitalized in 10 Polish cardiology centers in 2019–2020. Results: Among 3999 AF patients, 2822 (71%) had HF (AF/HF group). Half of AF/HF patients had preserved ejection fraction (HFpEF). Compared to patients without HF (AF/non–HF), AF/HF patients were older, more often male, more often had permanent AF, and had more comorbidities. Of AF/HF patients, 98% had class I indications to oral anticoagulation (OAC). Still, 16% of patients were not treated with OAC at hospital admission, and 9%—at discharge (regardless of the presence of HF and its subtypes). Of patients not receiving OAC upon admission, 61% were prescribed OAC (most often apixaban) at discharge. AF/non–HF patients more often converted from AF at admission to sinus rhythm at discharge compared to AF/HF patients (55% vs. 30%), despite cardioversion performed as often in both groups. Class I antiarrhythmics were more often prescribed in AF/non–HF than in AF/HF group (13% vs. 8%), but still as many as 15% of HFpEF patients received them. Conclusions: Over 70% of hospitalized AF patients have coexisting HF. A significant number of AF patients does not receive the recommended OAC.

The Benefit of Atrioventricular Junction Ablation for Permanent Atrial Fibrillation and Heart Failure Patients Receiving Cardiac Resynchronization Therapy: An Updated Systematic Review and Meta-analysis

BACKGROUND

Atrial fibrillation (AF) is correlated with a poor biventricular pacing and inadequate response to cardiac resynchronization therapy (CRT). Biventricular pacing improvement can be achieved by conducting the atrioventricular junction ablation (AVJA). We aimed to investigate the benefit of AVJA for permanent AF and heart failure with reduced ejection fraction (HFrEF) patients receiving CRT.

METHODS

In August 2020, a systematic review and meta-analysis study comparing CRT plus AVJA versus CRT for permanent AF and HFrEF patients was conducted. Relevant articles were identified through the electronic scientific database such as ClinicalTrials.gov, ProQuest, ScienceDirect, PubMed, and Cochrane. The pooled risk ratio (RR) and pooled mean difference (MD) were estimated.

RESULTS

A total of 3199 patients from 14 cohort studies were involved in this study. Additional AVJA reduced cardiovascular mortality (RR = 0.75, 95% confidence interval [CI] = 0.61 to 0.93, P < 0.01) in permanent AF and HFrEF patients receiving CRT. Biventricular pacing rate was higher in CRT plus AVJA group (MD = 8.65%, 95% CI = 5.62 to 11.67, P < 0.01) than in CRT alone group. The reverse remodeling characterized by the reduction of left ventricular end-diastolic diameter (LVEDD) was greater in the CRT plus AVJA group (MD = -2.11 mm, 95% CI = -3.79 to -0.42, P = 0.01).

CONCLUSION

In permanent AF and HFrEF patients receiving CRT, AVJA effectively increased the biventricular pacing rate. Adequate biventricular pacing rate provided a better response to the CRT marked by the greater ventricular reverse remodeling and survival from cardiovascular mortality.

Atrial Fibrillation (Part 2) - Catheter Ablation

More than 20 years since its initial use, catheter ablation has become a routinely performed procedure for the treatment of patients with atrial fibrillation (AF). Initially based on the electrical isolation of pulmonary veins in patients with paroxysmal AF, subsequent advances in the understanding of pathophysiology led to additional techniques not only to achieve better results, but also to treat patients with persistent forms of arrhythmia, as well as patients with structural heart disease and heart failure.

Atrial Fibrillation and Heart Failure: Epidemiology, Pathophysiology, Prognosis, and Management

Atrial fibrillation (AF) and heart failure (HF) have similar risk factors, frequently coexist, and potentiate each other in a vicious cycle. Evidence suggests the presence of AF in both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) increases the risk of all-cause mortality and stroke, particularly when AF is incident. Catheter ablation may be an effective strategy in controlling symptoms and improving quality of life in AF-HFrEF. Strong data guiding management of AF-HFpEF are lacking largely due to its challenging diagnosis. Improving outcomes associated with these coexistent conditions requires further careful investigation.

A Comparison of Rate Control Agents for the Treatment of Atrial Fibrillation: Follow-Up Investigation of the AFFIRM Study

There are limited data from randomized controlled trials comparing rate control agents in atrial fibrillation. Patient-level data from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial was used to compare outcomes in patients randomized to the rate control arm who were treated with a single rate control agent at baseline. The rate control agents used were beta-blockers, non-dihydropyridine calcium channel blockers, and digoxin. The independent variable for this analysis was the initial study drug used and the dependent variables were time to first hospitalization and time to death from any cause. We analyzed 1,144 out of 2,027 participants assigned to the rate control group who were on a single rate control agent at the start of the trial. There were 485 (42.5%) participants in the beta-blocker group, 344 (30%) in the calcium channel blocker group, and 315 (27.5%) in the digoxin group. All hospitalization and all-cause mortality occurred in 55.9% and 12.5% of those in the beta-blocker group, 58.4% and 16.7% in the calcium channel blocker group, and 55.2% and 21.1% in the digoxin group, respectively. After adjustment for differences in baseline characteristics, there were no significant differences in time to hospitalization or death for any group. In the AFFIRM trial, the initial rate control drug used was not associated with statistically significant differences in time to hospitalization or death after controlling for differences in baseline characteristics. There is limited data at present to guide the selection of rate control agents in patients with atrial fibrillation.

The crosstalk between cardiomyocyte calcium and inflammasome signaling pathways in atrial fibrillation

Atrial fibrillation (AF) is the most frequent arrhythmia in adults. The prevalence and incidence of AF is going to increase substantially over the next few decades. Because AF increases the risk of stroke, heart failure, dementia, and others, it severely impacts the quality of life, morbidity, and mortality. Although the pathogenesis of AF is multifaceted and complex, focal ectopic activity and reentry are considered as the fundamental proarrhythmic mechanisms underlying AF development. Over the past 2 decades, large amount of evidence points to the key role of intracellular Ca²⁺ dysregulation in both initiation and maintenance of AF. More recently, emerging evidence reveal that NLRP3 (NACHT, LRR, PYD domain-containing 3) inflammasome pathway contributes to the substrate of both triggered activity and reentry, ultimately promoting AF. In this article, we review the current state of knowledge on Ca²⁺ signaling and NLRP3 inflammasome activity in AF. We also discuss the potential crosstalk between these two quintessential contributors to AF promotion.

Catheter Ablation Compared with Medical Therapy for Atrial Fibrillation with Heart Failure: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background: The optimal strategy for patients with coexisting atrial fibrillation (AF) and heart failure (HF) was not settled. Our purpose was to conduct a systematic review and meta-analysis of randomized controlled trials to evaluate the effect of catheter ablation compared with medical therapy for AF on mortality, HF hospitalization, left ventricular (LV) function, and quality of life among patients with HF and AF. Materials and Methods: We searched Pubmed (1966 to September 20, 2019), EMBASE (1966 to September 20, 2019), the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov for randomized controlled trials with a comparison of catheter ablation for AF with medical therapy among patients with coexisting AF and HF. Risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI) was used as a measure of the effect of catheter ablation versus medical therapy on endpoints. Our final analysis included 6 randomized control trials with 775 patients. Results: Pooled results from the random-effects model showed that compared with medical therapy for AF, catheter ablation was associated with reduced all-cause mortality (RR 0.52, 95%Cl, 0.35 to 0.76) and HF hospitalization (RR 0.56, 95%Cl, 0.44 to 0.71), as well as increased LV ejection fraction (LVEF), distance walked in six minutes, and improvements in quality of life. Conclusions: This updated meta-analysis showed that compared to medical therapy, catheter ablation for AF was associated with significant benefits in several key clinical and biomarker endpoints, including reductions in all-cause mortality and HF hospitalization.

Chronic Amiodarone Use and the Risk of Cancer: A Systematic Review and Meta-analysis

Background

Observational studies have identified inconsistent associations between chronic use of amiodarone and cancer-related outcomes. We performed a systematic review and meta-analysis to evaluate cancer risk among patients receiving amiodarone.

Methods

We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) to May 1, 2020. We included randomized controlled trials (RCTs) with follow-up ≥2 years that compared amiodarone (any dose) to any comparator (placebo, active pharmacologic or interventional comparator, or usual care), and reported ≥1 outcome of interest. We contacted authors of published chronic amiodarone trials for potentially unreported cancer outcomes. The primary outcome was cancer incidence. Secondary outcomes were cancer-related death and site-specific cancers. We determined risk ratios and 95% confidence intervals using a fixed-effect model, and statistical heterogeneity using I². We conducted prespecified subgroup and sensitivity analyses for amiodarone indication, amiodarone dose, duration of therapy, and trial-level risk of bias.

Results

From 1439 articles, we included 5 RCTs (n = 4357). Mean follow-up duration ranged from 21 to 37 months. We included previously unpublished cancer outcome data from 1 RCT. Our primary outcome was not reported in any RCT. There was no significant difference in cancer-related death between amiodarone (1.69%) and the comparator (1.75%) (risk ratio 0.96, 95% confidence interval 0.57-1.63; I² = 0%). There were no significant interactions from our subgroup or sensitivity analyses.

Conclusions

Chronic amiodarone use did not increase cancer-related deaths. Data from RCTs do not support an increased risk of cancer-related harms with amiodarone use, and these concerns should not deter use of amiodarone when indicated.

Randomized Trials Versus Common Sense and Clinical Observation: JACC Review Topic of the Week

Concerns about the external validity of traditional randomized clinical trials (RCTs), together with the widespread availability of real-world data and advanced data analytic tools, have led to claims that common sense and clinical observation, rather than RCTs, should be the preferred method to generate evidence to support clinical decision-making. However, over the past 4 decades, results from well-done RCTs have repeatedly contradicted practices supported by common sense and clinical observation. Common sense and clinical observation fail for several reasons: incomplete understanding of pathophysiology, biases and unmeasured confounding in observational research, and failure to understand risks and benefits of treatments within complex systems. Concerns about traditional RCT models are legitimate, but randomization remains a critical tool to understand the causal relationship between treatments and outcomes. Instead, development and promulgation of tools to apply randomization to real-world data are needed to build the best evidence base in cardiovascular medicine.

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Well-conducted RCTs have repeatedly contradicted practices supported by common sense and clinical observation.

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Common sense and clinical observation fail because of the inability to fully understand complex biopsychosocial systems.

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RCTs must be integrated into clinical practice to improve the evidence base in cardiology.

Rhythm Control of Persistent Atrial Fibrillation in Systolic Heart Failure: A Bayesian Network Meta-Analysis of Randomized Controlled Trials

Background and Objectives

Methods

Results

Conclusions

Association between use of amiodarone for non-valvular atrial fibrillation and patient survival: from the prospective China Atrial Fibrillation Registry

Background

Post hoc analysis of the landmark atrial fibrillation follow-up investigation of rhythm management trial revealed that amiodarone was associated with higher risks of mortality, intensive care unit admission, and non-cardiovascular death. We aim to evaluate the association between amiodarone use and patient survival under updated medical mode and level using data from the China Atrial Fibrillation (China-AF) Registry study.

Methods

Clinical data of 8161 non-valvular atrial fibrillation (NVAF) patients who were antiarrhythmic drug (AAD)-naive before enrollment into the China-AF Registry, recruited between August 2011 and February 2017, were collected. The primary outcome was all-cause mortality. A Cox proportional hazard regression model was used to evaluate the association between amiodarone use and the outcome. We also calculated the rate of sinus rhythm maintenance at the penultimate follow-up.

Results

Compared with 6167 patients of non-AAD group, 689 patients of the amiodarone group were younger (mean age 65.6 vs. 68.6 years), more frequently completed high school education, had fewer comorbidities such as chronic heart failure, prior bleeding, and stroke, and were more likely to be treated in tertiary hospitals while less hospitalization. The proportion of persistent AF was much lower among users of amiodarone, who were also less likely to be taking oral anticoagulants. The patients in the amiodarone group had a statistically insignificant lower incidence of all-cause mortality (2.44 vs. 3.91 per 100 person-years) over a mean follow-up duration of 300.6 ± 77.5 days. After adjusting for potential confounders, amiodarone use was not significantly associated with a lower risk of all-cause mortality (adjusted hazard ratio, 0.79; 95% confidence interval, 0.42–1.49). Sub-group analysis revealed the consistent results. The rate of sinus rhythm maintenance at the penultimate follow-up in the amiodarone group was significantly higher than in the non-AAD group.

Conclusions

Our study indicated that amiodarone use was not significantly associated with a lower risk of 1-year all-cause mortality compared with a non-AAD strategy in “real-world” patients with NVAF.

Management of tachyarrhythmias in pregnancy - A review

The most common arrhythmias detected during pregnancy include sinus tachycardia, sinus bradycardia, and sinus arrhythmia, identified in 0.1% of pregnancies. Isolated premature atrial or ventricular arrhythmias are observed in 0.03% of pregnancies. Arrhythmias may become more frequent during pregnancy or may manifest for the first time.

Herzinsuffizienz und Vorhofflimmern – Stellenwert der Katheterablation

Herzinsuffizienz und Vorhofflimmern koexistieren häufig, was zu einer weiteren Erhöhung von Letalität und Morbidität führt. Aufgrund einer zunehmenden Alterung unserer Gesellschaft ist von einer steigenden Prävalenz beider Erkrankungen auszugehen. Infolgedessen wird sich die Anzahl an Patienten mit einem kombinierten Vorliegen von Herzinsuffizienz und Vorhofflimmern ebenfalls erhöhen. Ein Vorteil einer medikamentösen antiarrhythmischen Therapie gegenüber einer medikamentösen Frequenzkontrolle konnte bei Patienten mit Vorhofflimmern und systolischer Dysfunktion bisher nicht gezeigt werden. Für die Katheterablation hingegen wurde in randomisierten prospektiven Studien mehrfach eine Überlegenheit gegenüber einer medikamentösen Therapie nachgewiesen, einschließlich einer Reduktion der Gesamtletalität. Deshalb ist die Katheterablation bei derartigen Patienten schon heute ein wichtiger Bestandteil der multimodalen Therapie.

Advances in the management of atrial fibrillation with a special focus on non-pharmacological approaches to prevent thromboembolism: a review of current recommendations

Atrial fibrillation (AFIB) is the most common heart rhythm abnormality and is associated with significant morbidity and mortality. While the treatment of AFIB involves strategies of rate with or without rhythm control, it is also essential to strategize appropriate therapies to prevent thromboembolic complications arising from AFIB. Previously, anticoagulation was the main treatment option which exposed patients to higher than usual risk of bleeding. However, with the advent of new technology, novel therapeutic options aimed at surgical or percutaneous exclusion or occlusion of the left atrial appendage in preventing thromboembolic complications from AFIB have evolved. This review evaluates recent advances and therapeutic options in treating AFIB with a special focus on both surgical and percutaneous interventions which can reduce and/or eliminate thromboembolic complications of AFIB.

Catheter ablation and mortality, stroke and heart failure readmission with atrial fibrillation

BACKGROUND

Recent randomised clinical trials have suggested prognostic benefits of catheter ablation in highly selected patients with atrial fibrillation (AF) and heart failure (HF).

OBJECTIVES

This study sought to identify the treatment effect associated with catheter ablation in a broad population of patients with AF and HF.

METHODS

Through nationwide administrative registers in Denmark, we estimated the 2-year average treatment effect (ATE) of catheter ablation for AF on a composite endpoint of HF readmission, stroke and all-cause mortality at 1-year and 5-year landmark analyses. The primary cohort was patients with AF before HF, and the second cohort of patients with HF before AF.

RESULTS

A total of 13 756 patients were included with 9904 patients in the primary cohort, and 3852 in the secondary. An ATE (95% CI) reduction of the composite endpoint of 7.0% (4.5% to 9.5%) was observed in the primary cohort and 11.8% (6.0% to 17.6%) in the secondary in the 1-year landmark analysis with a reduction in all-cause mortality of 5.8% (3.7%-7.8%) and 6.3% (0.9%-11.7%), respectively. At the 5-year landmark, catheter ablation was associated with reductions in the composite endpoint and all-cause mortality in the primary (4.7% (2.3% to 7.2%), and 3.6% (1.0% to 6.3%), respectively), but not in the secondary cohort.

CONCLUSIONS

Ablation was associated with decreased risk of HF readmission, stroke and all-cause mortality in patients with AF and HF. The effect is most substantial in patients with AF before HF and with catheter ablation after 1 year from the diagnosis of both conditions.

Obesity Paradox and 12 Month Outcome in Patients with Atrial Fibrillation

BACKGROUND AND AIM

Obesity increases the risk of atrial fibrillation (AF) while it may impact the outcome of patients with AF. The clinical implications of this relationship are not completely clear. We aimed to analyze the association of traditional anthropometric measures of excessive adiposity with 12 month case fatality rate (CFR) in patients with AF.

METHODS

This was a multicenter, longitudinal, observational study on adults with documented AF, excluding records of AF secondary to reversible causes. Anthropometric variables were registered at baseline, and a central committee validated the 12 month outcomes.

RESULTS

We studied 1193 patients (median age: 69.14 years, 55.2% women). At baseline, rhythm control was established for 476 (39.9%) subjects, while frequency control was offered to 717 (60.1%) participants. The 12 month all-cause CFR was 8.9%. A high basal body mass index (BMI), waist-to-height ratio (WHtR) and waist circumference (WC) were associated with lower CFR in bivariate analyses. In a Cox-proportional hazards model, variables associated with 12 month all-cause CFR were BMI categories (HR: 0.736, 95% CI: 0.584-0.928), chronic heart failure (HR: 1.738, 95% CI: 1.127-2.680), chronic kidney disease (HR: 2.269, 95% CI: 1.162-4.429) and carotid stenosis >50% (HR: 5.342, 95% CI: 1.661-17.181).

CONCLUSION

The risk of death at one year in patients with AF is inversely associated with a high BMI and directly associated with the presence of chronic kidney disease, carotid stenosis, and chronic heart failure in this cohort of patients with AF. The causes and implications of this apparent obesity paradox should be addressed in the future.

Current challenges in sudden cardiac death prevention

Ischemic heart disease and non-ischemic dilated cardiomyopathy are the most common causes of arrhythmic sudden cardiac death (SCD). Implantable cardioverter defibrillator (ICD) therapy is the only strategy that proved to be effective in preventing SCD in high-risk individuals while the role of antiarrhythmic drugs is limited to symptoms relief. Current guidelines recommend selecting candidates to ICD implantation based on etiology, symptoms of heart failure (NYHA class), and severely depressed left ventricular ejection fraction, but these parameters are neither sensitive nor specific. The review addresses the mechanisms of SCD in patients with heart failure of either ischemic or non-ischemic etiology, risk stratification, and strategies for prevention of SCD in the clinical practice (including optimization of heart failure therapy, avoidance of triggering factors, antiarrhythmic drugs, ICD therapy, early resuscitation, and public access defibrillators).

Current Management Strategies in Patients with Heart Failure and Atrial Fibrillation: A Review of the Literature

Heart Failure (HF) and Atrial Fibrillation (AF) are common diseases which lead to significant morbidity and mortality. Each disease can be a challenge to treat clinically, especially when they present together. We performed a review of the literature including clinical trials, metanalyses, and guidelines regarding the management of patients with HF and AF. This review describes the pathophysiologic mechanisms behind each disease state, their associated prognosis, and epidemiologic features. Strategies for prevention of stroke in patients with AF, including use of novel oral anticoagulants as well as prevention of the development of AF are discussed. We review the medical and catheter-based therapies for AF and present an original algorithm for the management of AF in patients with HF.

Rhythm Control in Heart Failure Patients with Atrial Fibrillation

AF and heart failure (HF) commonly coexist. Left atrial ablation is an effective treatment to maintain sinus rhythm (SR) in patients with AF. Recent evidence suggests that the use of ablation for AF in patients with HF is associated with an improved left ventricular ejection fraction and lower death and HF hospitalisation rates. We performed a systematic search of world literature to analyse the association in more detail and to assess the utility of AF ablation as a non-pharmacological tool in the treatment of patients with concomitant HF.

The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation

The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.

Heart Failure and Atrial Fibrillation, Like Fire and Fury

Heart failure and atrial fibrillation are 2 common cardiovascular disorders that frequently complicate one another and exert a significant detrimental effect on cardiovascular health and well-being. Both heart failure and atrial fibrillation continue to increase in prevalence as the risk factors underlying each condition become more common. This review encompasses what is currently known about the epidemiology and pathophysiology of these comorbidities along with incorporation of landmark trials that have contributed to current guidelines. The focus is on clinically relevant considerations, including the contribution of inflammation in the pathophysiology of atrial fibrillation and heart failure. We explore the emerging role of catheter ablation relative to medical therapy in the management of heart failure with reduced ejection fraction, along with indications for biventricular pacing modalities in cardiac resynchronization therapy. We discuss current guideline-directed therapies and how practice models and national recommendations will likely change based on the most recent randomized controlled trials.

Early Rhythm-Control Therapy in Patients with Atrial Fibrillation

BACKGROUND

Despite improvements in the management of atrial fibrillation, patients with this condition remain at increased risk for cardiovascular complications. It is unclear whether early rhythm-control therapy can reduce this risk.

METHODS

In this international, investigator-initiated, parallel-group, open, blinded-outcome-assessment trial, we randomly assigned patients who had early atrial fibrillation (diagnosed ≤1 year before enrollment) and cardiovascular conditions to receive either early rhythm control or usual care. Early rhythm control included treatment with antiarrhythmic drugs or atrial fibrillation ablation after randomization. Usual care limited rhythm control to the management of atrial fibrillation-related symptoms. The first primary outcome was a composite of death from cardiovascular causes, stroke, or hospitalization with worsening of heart failure or acute coronary syndrome; the second primary outcome was the number of nights spent in the hospital per year. The primary safety outcome was a composite of death, stroke, or serious adverse events related to rhythm-control therapy. Secondary outcomes, including symptoms and left ventricular function, were also evaluated.

RESULTS

In 135 centers, 2789 patients with early atrial fibrillation (median time since diagnosis, 36 days) underwent randomization. The trial was stopped for efficacy at the third interim analysis after a median of 5.1 years of follow-up per patient. A first-primary-outcome event occurred in 249 of the patients assigned to early rhythm control (3.9 per 100 person-years) and in 316 patients assigned to usual care (5.0 per 100 person-years) (hazard ratio, 0.79; 96% confidence interval, 0.66 to 0.94; P = 0.005). The mean (±SD) number of nights spent in the hospital did not differ significantly between the groups (5.8±21.9 and 5.1±15.5 days per year, respectively; P = 0.23). The percentage of patients with a primary safety outcome event did not differ significantly between the groups; serious adverse events related to rhythm-control therapy occurred in 4.9% of the patients assigned to early rhythm control and 1.4% of the patients assigned to usual care. Symptoms and left ventricular function at 2 years did not differ significantly between the groups.

CONCLUSIONS

Early rhythm-control therapy was associated with a lower risk of adverse cardiovascular outcomes than usual care among patients with early atrial fibrillation and cardiovascular conditions. (Funded by the German Ministry of Education and Research and others; EAST-AFNET 4 ISRCTN number, ISRCTN04708680; ClinicalTrials.gov number, NCT01288352; EudraCT number, 2010-021258-20.).

Cancer Mortality in Trials of Heart Failure With Reduced Ejection Fraction: A Systematic Review and Meta-Analysis

Background The burden of cancer in heart failure with reduced ejection fraction is apparently growing. Randomized controlled trials (RCTs) may help understanding this observation, since they span decades of heart failure treatment. Methods and Results We assessed cancer, cardiovascular, and total mortality in phase 3 heart failure RCTs involving ≥90% individuals with left ventricular ejection fraction <45%, who were not acutely decompensated and did not represent specific patient subsets. The pooled odds ratios (ORs) of each type of death for the control and treatment arms were calculated using a random-effects model. Temporal trends and the impact of patient and RCT characteristics on mortality outcomes were evaluated by meta-regression analysis. Cancer mortality was reported for 15 (25%) of 61 RCTs, including 33 709 subjects, and accounted for 6% to 14% of all deaths and 17% to 67% of noncardiovascular deaths. Cancer mortality rate was 0.58 (95% CI, 0.46-0.71) per 100 patient-years without temporal trend (P=0.35). Cardiovascular (P=0.001) and total (P=0.001) mortality rates instead decreased over time. Moreover, cancer mortality was not influenced by treatment (OR, 1.08; 95% CI, 0.92-1.28), unlike cardiovascular (OR, 0.88; 95% CI, 0.79-0.98) and all-cause (OR, 0.91; 95% CI, 0.84-0.99) mortality. Meta-regression did not reveal significant sources of heterogeneity. Possible reasons for excluding patients with malignancy overlapped among RCTs with and without published cancer mortality, and malignancy was an exclusion criterion only for 4 (8.7%) of the RCTs not reporting cancer mortality. Conclusions Cancer is a major, yet overlooked cause of noncardiovascular death in heart failure with reduced ejection fraction, which has become more prominent with cardiovascular mortality decline.

Outcomes of incident atrial fibrillation in heart failure with preserved or reduced ejection fraction: A community-based study

INTRODUCTION

The best management strategy for patients with atrial fibrillation (AF) with heart failure (HF) and preserved left ventricular ejection fraction (LVEF) is unknown.

METHODS AND RESULTS

This cohort study was conducted in Olmsted County, Minnesota, with resources of the Rochester Epidemiology Project. Patients with incident AF occurring between 2000 and 2014 with a prior or concurrent HF were included. Patients with LVEF ≥ 50% were designated as HF and preserved ejection fraction (HFpEF) and those with LVEF < 50% were designated as HF and reduced ejection fraction (HFrEF). Rhythm control in the first year after AF diagnosis was defined as prescriptions for an antiarrhythmic drug, catheter ablation, or maze procedure. The primary endpoint was all-cause mortality. The secondary endpoints were cardiovascular death, cardiovascular hospitalization, and stroke or transient ischemic attack. Of 859 patients (age, 77.2 ± 12.1 years; 49.2%, female), 447 had HFpEF-AF, and 412 had HFrEF-AF. There was no difference in all-cause mortality (10-year mortality, 83% vs 79%; p = .54) or secondary endpoints between the HFpEF-AF and HFrEF-AF, respectively. Compared with the rate control strategy, rhythm control in HFpEF-AF patients (n = 40, 15.9%) offered no survival benefits (adjusted HR, 0.70; 95% CI, 0.42-1.16; p = .16), whereas rhythm control in HFrEF-AF patients (n = 52, 22.5%) decrease cardiovascular mortality (HR, 0.38; 95% CI, 0.17-0.86; p = .02).

CONCLUSIONS

Patients with HFpEF-AF and HFrEF-AF had similar poor prognoses. Rhythm control strategy was seldom adopted in community care in patients with HF and AF. A rhythm control strategy may provide survival benefit for patients with HFrEF-AF and the benefit of rhythm control in patients with HFpEF-AF warrants further study.

Atrial fibrillation in dilated cardiomyopathy: Outcome prediction from an observational registry

BACKGROUND

Little is known about the role of different types of atrial fibrillation (AF) in dilated cardiomyopathy (DCM). We investigated the epidemiological and prognostic impact of different types of AF in DCM during long-term follow-up.

METHOD

We evaluated consecutive DCM patients enrolled in the Trieste Muscle Heart Disease Registry. Uni- and multivariable, extended Kaplan-Meier and propensity score-matching analyses were performed for a composite outcome including death/heart transplantation/ventricular-assist device implantation.

RESULTS

Out of 1181 DCM patients (71% males, age 49 ± 15 years, left ventricular ejection fraction 33 ± 11%), 46 (3.9%) had baseline permanent AF (permAF), while 66 (5.6%) had a history of paroxysmal/persistent AF. Compared with sinus rhythm (SR) patients, permAF patients were older (48 ± 15 vs. 61 ± 11 respectively, p = 0.001), were more frequently in NYHA class III-IV (18% vs. 30%, p = 0.002) and had larger left atrium diameter (40 ± 8 vs. 50 ± 10 mm, respectively). Paroxysmal/persistent AF patients had intermediate characteristics between permAF and SR. During a median follow-up of 135 (75-210) months, 63 patients developed permAF (0.45 new cases/100patients/year). At multivariable analysis, permAF as a time-dependent variable was an independent outcome predictor (HR 2.45; 95% C.I. 2.61-3.63, p < 0.001), together with creatinine, NYHA class, restrictive filling pattern and moderate-severe mitral regurgitation, while paroxysmal/persistent AF was neutral. Propensity score-matching analysis confirmed the higher rate of primary outcome events in patients with baseline or incident permAF versus patients without permAF during a very long-term follow-up (70% vs. 20%, p < 0.001).

CONCLUSIONS

PermAF in a large DCM cohort had low prevalence and incidence but had a relevant. prognostic role on hard outcomes.

Impact of the Temporal Relationship Between Atrial Fibrillation and Heart Failure on Prognosis After Ablation

BACKGROUND

The purpose of this study was to elucidate the effect of the temporal relationship between atrial fibrillation (AF) and heart failure (HF) on clinical outcomes after catheter ablation.

METHODS AND RESULTS

We included 129 consecutive patients with AF and HF who underwent catheter ablation in hospital from December 2014 to September 2017. The patients were divided into 2 groups based on the temporal relationship between AF and HF. Group 1 consisted of 42 patients with AF following HF while Group 2 consisted of 87 patients with AF preceding HF or those who developed both of them simultaneously at the timing of first visit to a doctor. The primary endpoint was a composite of death and hospitalization due to HF during a 2-year follow-up. AF recurrence was more common in Group 1 (45% vs. 23%; hazard ratio [HR], 2.49; 95% confidence interval [CI], 1.25-4.94; P=0.009). Death and HF hospitalization were more frequent in Group 1 (19 [45%], 6 [7%] patients, respectively, P<0.0001). After adjustment for several covariates, patients in Group 1 were independently associated with poorer outcomes after AF ablation (HR, 8.66; 95% CI, 2.942-5.5; P<0.0001).

CONCLUSIONS

Adverse clinical outcomes of death, HF hospitalization and AF recurrence were more frequent in patients with AF following HF than in those with AF preceding HF.

Left atrial fibrosis predicts left ventricular ejection fraction response after atrial fibrillation ablation in heart failure patients: the Fibrosis-HF Study

Aims

Atrial fibrillation (AF) and heart failure (HF) often coexist. Catheter ablation has been reported to restore left ventricular (LV) function but patients benefit differently. This study investigated the correlation between left atrial (LA) fibrosis extent and LV ejection fraction (LVEF) recovery after AF ablation.

Methods and results

In this study, 103 patients [64 years, 69% men, 79% persistent AF, LVEF 33% interquartile range (IQR) (25–38)] undergoing first time AF ablation were investigated. Identification of LA fibrosis and selection of ablation strategy were based on sinus rhythm voltage mapping. Continuous rhythm monitoring was used to assess ablation success. Improvement in post-ablation LVEF was measured as primary study endpoint. An absolute increase in post-ablation LVEF ≥10% was defined as ‘Super Response’. Left atrial fibrosis was present in 38% of patients. After ablation LVEF increased by absolute 15% (IQR 6–25) (P &lt; 0.001). Left ventricular ejection fraction improvement was higher in patients without LA fibrosis [15% (IQR 10–25) vs. 10% (IQR 0–20), P &lt; 0.001]. An inverse correlation between LVEF improvement and the extent of LA fibrosis was found (R2 = 0.931). In multivariate analysis, the presence of LA fibrosis was the only independent predictor for failing LVEF improvement [odds ratio 7.2 (95% confidence interval 2.2–23.4), P &lt; 0.001]. Echocardiographic ‘Super Response’ was observed in 55/64 (86%) patients without and 21/39 (54%) patients with LA fibrosis, respectively (P &lt; 0.001).

Conclusion

Presence and extent of LA fibrosis predict LVEF response in HF patients undergoing AF ablation. The assessment of LA fibrosis may impact prognostic stratification and clinical management in HF patients with AF.

Digoxin, mortality, and cardiac hospitalizations in patients with atrial fibrillation and heart failure with reduced ejection fraction and atrial fibrillation: An AF-CHF analysis

BACKGROUND

Recent publications have raised serious concerns regarding the safety of digoxin for atrial fibrillation (AF). However, the subgroup of patients with reduced ejection fraction and AF have been speculated to derive clinical benefit from digoxin. We aimed to assess the impact of digoxin on mortality and cardiovascular hospitalizations in the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial since all AF-CHF patients had an ejection fraction ≤35% and AF.

METHODS AND RESULTS

Using marginal structural modeling, a contemporary statistical method that overcomes limitations of traditional modeling techniques and reduces bias, we assessed the impact of digoxin on the pre-specified primary and secondary outcomes of the AF-CHF trial, i.e., all-cause, cardiac and arrhythmic death as well as cardiovascular hospitalization. Among 1376 patients, 869 (65%) were on digoxin at one-year follow-up. Over a mean (SD) follow-up of 37 (19) months (maximum 74 months), 445 (32%) patients died, 357 (26%) from cardiovascular causes and 159 (12%) from arrhythmic death. Digoxin was significantly associated with all-cause, cardiac, and arrhythmic death, with estimated hazard ratios (HR) of 1.39 (95% confidence interval [CI] 1.11-1.73, P = 0.004), 1.44 (95% CI 1.13-1.82, P = 0.003), and 2.03 (95% CI 1.63-2.54, P < 0.0001), respectively. Digoxin was not associated with cardiovascular hospitalizations [HR 1.12 (95% CI 0.91-1.37), P = 0.29].

CONCLUSION

Digoxin is associated with increased all-cause mortality among patients with combined heart failure with reduced ejection fraction and AF, which is predominantly driven by arrhythmic deaths. In contrast, cardiovascular hospitalizations were not impacted by digoxin.

Catheter Ablation vs. Medical Treatment in Patients With Atrial Fibrillation

Atrial fibrillation has become the most commonly seen cardiac arrhythmia in clinical practice affecting almost 5.6 million Americans with that number expected to rise in the near future. The current literature review is aimed to assess the efficacy of catheter ablation in the treatment of patients with atrial fibrillation when compared to standard medical therapy. A PubMed search for studies of "Atrial Fibrillation" found 83,251 articles. Following the application of inclusion/exclusion criteria, we identified 44 articles of relevance that compared catheter ablation and medical therapy in the treatment of atrial fibrillation. These 44 articles included 20 Observational studies, eight randomized clinical trials, three clinical trials, five cohort studies, and eight review articles. Our review determined that catheter ablation was associated with a much lower rate of reoccurrence of atrial fibrillation when compared to medical therapy, as well as decreased cardiovascular outpatient visits and thromboembolic complications. The effect of quality on life when compared to medical treatment, however, was found to be inconclusive.

With our powers combined: Does the pooled analysis of existing randomized data regarding treatment of atrial fibrillation in heart failure settle the case for catheter ablation?

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Rhythm control for patients with atrial fibrillation complicated with heart failure in the contemporary era of catheter ablation: a stratified pooled analysis of randomized data

AIMS

The optimal treatment for patients with atrial fibrillation (AF) and heart failure (HF) has been a subject of debate for years. We aimed to evaluate the efficacy and safety of rhythm control strategy in patients with AF complicated with HF regarding hard clinical endpoints.

METHODS AND RESULTS

Up-to-date randomized data comparing rhythm control using antiarrhythmic drugs (AADs) vs. rate control (Subset A) or rhythm control using catheter ablation vs. medical therapy (Subset B) in AF and HF patients were pooled. The primary outcomes were all-cause mortality, re-hospitalization, stroke, and thromboembolic events. A total of 11 studies involving 3598 patients were enrolled (Subset A: 2486; Subset B: 1112). As compared with medical rate control, the AADs rhythm control was associated with similar all-cause mortality [odds ratio (OR): 0.96, P = 0.65], significantly higher rate of re-hospitalization (OR: 1.25, P = 0.01), and similar rate of stroke and thromboembolic events (OR: 0.91, P = 0.76,); however, as compared with medical therapy, catheter ablation rhythm control was associated with significantly lower all-cause mortality (OR: 0.51, P = 0.0003), reduced re-hospitalization rate (OR: 0.44, P = 0.003), similar rate of stroke events (OR: 0.59, P = 0.27), greater improvement in left ventricular ejection fraction [weighted mean difference (WMD): 6.8%, P = 0.0004], lower arrhythmia recurrence (29.6% vs. 80.1%, OR: 0.04, P < 0.00001), and greater improvement in quality of life (Minnesota Living with Heart Failure Questionnaire score) (WMD: -9.1, P = 0.007).

CONCLUSION

Catheter ablation as rhythm control strategy substantially improves survival rate, reduces re-hospitalization, increases the maintenance rate of sinus rhythm, contributes to preserve cardiac function, and improves quality of life for AF patients complicated with HF.

Addressing Comorbidities in Heart Failure: Hypertension, Atrial Fibrillation, and Diabetes

Heart failure (HF) is a growing global epidemic and an increasingly cumbersome burden on health care systems worldwide. As such, optimal management of existing comorbidities in the setting of HF is particularly important to prevent disease progression, reduce HF hospitalizations, and improve quality of life. In this review, the authors address 3 key comorbidities commonly associated with HF: hypertension, atrial fibrillation, and diabetes mellitus. They comprehensively describe the epidemiology, management, and emerging therapies in these 3 disease states as they relate to the overall HF syndrome.