Management of atrial fibrillation in patients with heart failure with preserved ejection fraction

Atrial fibrillation (AF) and heart failure with a preserved ejection fraction (HFpEF) frequently co-exist and are associated with high cardiovascular morbidity and mortality. The management of AF in HFpEF requires a multifaceted and integrated approach that includes the initiation of evidence-based medical therapies for heart failure, control of arrhythmia symptoms and burden with rhythm or rate control, assessment of thromboembolic risk with treatment, and aggressive control of common clinical comorbidities. The optimal management strategy of AF is uncertain though subanalyses of randomized trials and retrospective studies suggest an improvement in cardiovascular outcomes with a catheter ablation-based rhythm control strategy, especially in patients with HFpEF and paroxysmal or early persistent AF. In this review, we summarize this integrated approach to the management of AF in HFpEF, examine the evidence for recommending first-line rhythm versus rate control, and highlight key areas in need of further study.