Atrial fibrillation in heart failure: an innocent bystander?

Heart failure (HF) and atrial fibrillation (AF) frequently coexist and each complicates the course of the other. The purpose of this review is to analyse the prognostic impact of AF in patients with HF and assess whether there is an advantage in targeting therapies towards the maintenance of sinus rhythm (SR) in this cohort of patients. The presence of AF in patients with HF has been reported to be independently associated with an increase in mortality in many studies and this increased risk is observed in those with both preserved and impaired LV systolic function. The optimal strategy for targeting AF in patients with HF is unclear but recent randomised controlled studies indicate no significant prognostic advantage associated with a rhythm control strategy as compared to a rate control strategy. A number of small studies have investigated the role of both cardiac resynchronization therapy (CRT) and AF catheter ablation for the maintenance of / conversion to SR in patients with HF with initial promising results although larger randomised controlled studies will need to be performed to define the role of these modalities in the treatment of this cohort and whether preliminary benefits observed in these studies translate to improvements in longer term prognosis. Finally, there has been a focus on modifying the arrhythmogenic atrial substrate and neurohormonal milieu by pharmacological means in order to prevent AF although it remains to be seen whether this approach proves to be efficacious with improvements in clinically relevant outcomes.