Combined management of atrial fibrillation and heart failure: case studies

Atrial fibrillation (AF) and heart failure (HF) are omnipresent cardiovascular disorders with a substantial impact on morbidity and mortality. As both share common risk factors, their pathophysiology is highly interrelated and a lot of patients present with both conditions. Surprisingly, despite their high prevalence, there is a paucity of evidence regarding the optimal combined management of AF and HF. The initial treatment for new-onset AF in the context of HF should focus on anticoagulation, rate control and prompt electrical cardioversion in case of hemodynamic instability. Subsequently, attention should focus upon the underlying pathophysiological substrate. This often requires multidisciplinary collaboration, not only between different subspecialties of cardiology, but also among medical and paramedical caregivers, especially when underlying HF is present. AF often contributes to worsening HF symptoms, but options to maintain sinus rhythm are less successful in patients with structural heart disease. Therefore, rhythm control strategies, whether medical or through catheter/surgical ablation, should target specific groups of patients with a high likelihood of perceived benefit. Indeed, morbidity and mortality are similar with rate versus rhythm control in the general population. Carefully performed cardiac imaging is vital to select these cases that might benefit most from rhythm control. A special group of HF patients are the one with cardiac devices, as they can be continuously monitored, even through remote care systems. The latter likely involves dedicated nurse practitioners and general physicians. Again, a collaborative environment with a disease management strategy is needed to ensure an optimally working device and maximized benefits for the patient.