Editorials
Significance of Atrial Fibrillation Management Based on the Sequence of Atrial Fibrillation and Heart Failure Onset
2020 Volume 84 Issue 9 Pages 1454-1455
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2020 Volume 84 Issue 9 Pages 1454-1455
Atrial fibrillation (AF) and heart failure (HF) share common risk factors, including aging, hypertension, diabetes, obesity, smoking, coronary diseases, and valvular diseases. Therefore, it is not rare that the same patient has both AF and HF.
Article p 1467
AF Begets HF and Vice VersaPatients with AF develop HF,1,2 and conversely, AF occurs in those with HF.3,4 A meta-analysis reported that patients with AF had a high risk of developing HF (relative risk 4.99).1 Meanwhile, a recent Framingham Heart Study (FHS) reported that preceding HF was associated with a 2-fold increased hazard of incident AF.4
Several studies have examined by how much AF preceded the development of HF in patients with AF and HF or vice versa.4–7 The FHS reported that AF occurred in more than half of patients with HF, and HF occurred in more than one-third of individuals with AF.4 According to the Olmsted County study (OCS), among patients with preceding AF and incident HF, 61% had HF with preserved ejection fraction (HFpEF) and 39% had HF with reduced ejection fraction (HFrEF).5 Thus, patients with AF tend to develop HFpEF rather than HFrEF, which is consistent with the previous studies, including the Japanese Heart Failure Syndrome with Preserved Ejection Fraction (JASPER) registry.7,8 A higher prevalence of AF (61.5%) was reported in Japanese HFpEF patients, in whom 91% had preceding AF.8 Meanwhile, in patients with HFrEF, the prevalence of AF increases depending on NYHA class, from 4.2% in Class I to 49.8%in Class IV.9
Impact of Sequence of HF and AF on Clinical OutcomeThe timing of the onset of AF affects the mortality rate in patients with HF, which is greater when new-onset AF occurs in patients with preceding HF.4,6,7,10 (Figure). In the OCS, patients with preceding AF and new-onset HF had approximately 30% increase in mortality (hazard ratio [HR] 1.29) compared with HF patients without AF.10 Patients with preceding HF and new-onset AF had more than 2-fold mortality compared with HF patients without AF (HR 2.22). Besides, the FHS revealed that this risk was more significant in HFrEF than in HFpEF (HFrEF: HR 2.72; HFpEF: HR 1.83).4 In patients with preceding AF, adaptation occurs over the time prior to HF incidence, whereas HF patients with new-onset AF have less time for adaptation.11
Comparisons of mortality and benefit and challenge of catheter ablation between preceding atrial fibrillation (AF) with new-onset heart failure (HF) and preceding HF with new-onset AF. HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction.
Recently, the evidence of the benefits of catheter ablation (CA) for HFrEF has accumulated.12,13 The AATAC trial showed the superiority of CA for AF recurrence, improvement of EF, and clinical outcomes in HFrEF with persistent AF, compared with amiodarone treatment.12 The CASTLE-AF trial also provided evidence that CA reduced rates of all-cause death and hospitalization for HF, together with reducing the burden of AF.13 Therefore, in the CA era, rhythm control may be recommended aggressively for patients with HF and AF.
Impact of Sequence of HF and AF Onset on the Efficiency of CAA clinical question is raised about whether there are differences in the efficiency of CA according to the sequence of HF and AF onset based on evidence from epidemiological studies.4,6,7,10 Namely, conversion to sinus rhythm by CA early after AF onset in patients with HF may be more efficient than in patients with preceding AF and incident HF.11 However, preceding persistent AF-induced or tachycardia-induced cardiomyopathy may be the crucial substrate of rhythm control, as 2 trials have revealed benefits in persistent AF, even though persistent AF might have been caused after HF onset in some patients.12,13 Thus, the effect of the temporal sequence of AF and HF onset on the efficiency of CA has not been studied.
In this issue of the Journal, Tsuji and colleagues14 address this unsolved issue. They hypothesized that CA might improve clinical outcomes in patients in whom AF causes HF, such as in tachycardia-induced cardiomyopathy, as compared with patients with incident AF and preceding HF. This prospective study showed that the clinical outcome determined by the combined endpoint of death and HF hospitalization in patients with preceding AF and incident HF was better than in patients with incident AF and preceding or concurrent HF. Unfortunately, the clinical outcome did not differ between patients with and without AF recurrent among patients with preceding AF. It may be because many patients with preceding AF had preserved EF, as the efficiency of CA for HFpEF has not been established. Further large-scale studies are needed to confirm their hypothesis that CA may be more efficient for AF-induced HF, including tachycardia-induced cardiomyopathy. In contrast, CA dramatically improved the clinical outcome by maintaining sinus rhythm in patients with incident AF and preceding or concurrent HF. The results support rhythm control having a crucial role in patients with preceding HF early after AF onset, as suggested from the evidence in previous epidemiological studies.4,6,7,10 However, there is a dilemma that AF recurrence is more frequent (45%) in patients with preceding HF than in those with preceding AF (23%) and contributes to poor clinical outcome, as Tsuji and colleagues emphasize.14 In the CASTLE-AF trial, the rate of sinus rhythm was ≈60% at each follow-up point in patients with CA, which shows the difficulty of rhythm control in advanced HF. The tissue damage in the left atrium and concomitant diastolic dysfunction and mitral valve deficiency make it challenging to maintain sinus rhythm. Further innovations in catheter interventions, imaging, and upstream medications are needed to treat such malignant substrates.
N.O. is a member of Circulation Journal’ Editorial Team.
