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Withdrawal of heart failure therapy after atrial fibrillation rhythm control with ejection fraction normalization:

Louise Segan1,2,3,4,5, Peter M Kistler1,2,3,4,5,6, Shane Nanayakkara1,2,4,5

  • 1Department of Cardiometabolics, The Baker Heart and Diabetes Institute, 99 Commercial Rd, Melbourne, VIC 3004, Australia.

European Heart Journal
|August 19, 2025
PubMed

Insights

Discontinuing heart failure (HF) therapy after restoring normal heart function in atrial fibrillation-mediated cardiomyopathy (AFCM) is safe for most patients. Rhythm control and normal ejection fraction (LVEF) allow for successful HF medication withdrawal.

Area of Science:

  • Cardiology
  • Electrophysiology
  • Heart Failure Research

Background:

  • Atrial fibrillation-mediated cardiomyopathy (AFCM) causes reversible left ventricular systolic dysfunction.
  • Current guidelines recommend indefinite heart failure (HF) pharmacotherapy post-normalization of left ventricular ejection fraction (LVEF).
  • The necessity of continued HF therapy for maintaining LVEF after AF rhythm control is uncertain.

Purpose of the Study:

  • To evaluate the impact of staged withdrawal of HF therapy after AF rhythm control and LVEF normalization in AFCM.
  • To determine if HF pharmacotherapy is necessary to maintain normal LVEF in these patients.

Main Methods:

  • A multi-center, randomized trial involving 60 patients with AFCM.
  • Participants underwent AF rhythm control and achieved LVEF normalization before randomization.
  • Randomization was 1:1 to early (Group A) or delayed (Group B) withdrawal of HF therapy, with a crossover design.

Main Results:

  • LVEF was maintained at ≥50% at 6 months in 90% of patients withdrawing HF therapy (Group A) versus 100% continuing therapy (Group B).
  • Cardiac magnetic resonance (CMR) LVEF and other clinical parameters were similar between groups post-randomization and throughout follow-up.
  • No significant decline in LVEF or worsening of other outcomes was observed after HF therapy withdrawal.

Conclusions:

  • Withdrawal of HF therapy following AF rhythm control and LVEF recovery in AFCM is not associated with LVEF decline in the majority of patients.
  • This suggests that HF pharmacotherapy may be safely discontinued in select AFCM patients after successful rhythm control and LVEF normalization.
Abstract

Keywords:
AF-mediated cardiomyopathyArrhythmia-induced cardiomyopathyAtrial fibrillationCatheter ablationClinical trialHeart failure therapyNormalized left ventricular ejection fraction

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