Heart failure with preserved ejection fraction and atrial fibrillation

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are common diseases, inducing increased morbidity and mortality when associated. In this narrative review, we report available evidence in the literature regarding the pathophysiology behind this association, its impact on prognosis, and the therapeutic management of both entities. AF and HFpEF share several pathophysiological mechanisms, most notably inflammation, electrical and structural remodeling of the left atrium with fibrosis and involvement of epicardial adipose tissue, all concurring to left atrial myopathy. AF and HFpEF furthermore favor one another, showing their intricated pathophysiology. The presence of AF in HFpEF worsens patients' prognosis, as does the presence of HFpEF in AF patients. Data on the specific management of this subgroup of patients is scarce. SGLT2 inhibitors appear as the cornerstone of HFpEF treatment, with the same benefit in AF patients. AF management however is less clear, apart for the need for anticoagulation based on the CHA2DS2-VA score. Rate control therapy and rhythm control therapy are in balance for symptom control. Overall, holistic approaches offer the most promises in these comorbid patients. AF and HFpEF partner in comorbid patients and worsen general prognosis. Their management is complex, as is their pathophysiology, and holistic strategies may be the most appropriate way to provide efficient care in these patients.