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European Heart Journal 2000 21(8):614-632; doi:10.1053/euhj.1999.1767
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Review

Systematic review of the management of atrial fibrillation in patients with heart failure

A.U Khanda, A.C Rankina, G.C Kayeb and J.G.F Clelandb,f1

a Department of Cardiology, Glasgow Royal Infirmary, Glasgow
b Department of Cardiology, Castle Hill Hospital, University of Hull, Kingston-on-Hull, U.K.

Received June 21, 1999; accepted June 23, 1999

Abstract

Aims To systematically review the management of atrial fibrillation (AF) in patients with heart failure.

Methods Studies investigating the management of AF in patients with heart failure published between 1967 to 1998 were identified using MEDLINE, the Cochrane register and Embase databases. Reference lists from relevant papers and reviews were hand searched for further papers.

Results Eight studies pertaining to acute and twenty-four pertaining to chronic AF were identified. For patients with acute AF ventricular rate control, anticoagulation and treatment of heart failure should be pursued simultaneously before cardioversion is attempted. Digoxin is relatively ineffective at controlling ventricular response and for cardioversion. Intravenous diltiazem is rapidly effective in controlling ventricular rate and limited evidence suggests it is safe. Amiodarone controls ventricular rate rapidly and increases the rate of cardioversion. There are insufficient data to conclude that immediate anti-coagulation, trans-oesophageal echocardiography to exclude atrial thrombi followed by immediate cardioversion is an appropriate strategy. Patients with chronic AF should be anti-coagulated unless contra-indications exist. It is not clear whether the preferred strategy should be cardioversion and maintenance of sinus rhythm with amiodarone or ventricular rate control of AF combined with anticoagulation to improve outcome including symptoms, morbidity and survival. Electrical cardioversion has a high initial success rate but there is also a high risk of early relapse. Amiodarone currently appears the most effective and safest therapy for maintaining sinus rhythm post-cardioversion. Digoxin is fairly ineffective at controlling ventricular rate during exercise. Addition of a ß-blocker reduces ventricular rate and improves symptoms. Whether digoxin is required in addition to ß-blockade for the control of AF in this setting is currently under investigation. If pharmacological therapy is ineffective or not tolerated then atrio-ventricular node ablation and permanent pacemaker implantation should be considered.

Conclusion There is a paucity of controlled clinical trial data for the management of AF among patients with heart failure. The interaction between AF and heart failure means that neither can be treated optimally without treating both. Presently treatment should be on a case by case basis.

Key Words: Atrial fibrillation, heart failure, systematic review, evidence-based cardiology

f1 Correspondence: Professor John G. F. Cleland, Department of Cardiology, University of Hull, Castle Hill Hospital, Kingston-upon-Hull, HU16 5JQ, U.K.

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A. U. Khand, A. C. Rankin, J. G.F. Cleland, I. Gemmell, E. Clark, and P. W. Macfarlane
The assessment of autonomic function in chronic atrial fibrillation: description of a non-invasive technique based on circadian rhythm of atrioventricular nodal functional refractory periods.
Europace, November 1, 2006; 8(11): 927 - 934.
[Abstract] [Full Text] [PDF]

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 Eur Heart JHome page
R. J. Shelton, A. L. Clark, K. Goode, A. S. Rigby, and J. G.F. Cleland
The diagnostic utility of N-terminal pro-B-type natriuretic peptide for the detection of major structural heart disease in patients with atrial fibrillation
Eur. Heart J., October 1, 2006; 27(19): 2353 - 2361.
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 J Am Coll CardiolHome page
Developed in Collaboration With the European Heart, D. P. Zipes, A. J. Camm, M. Borggrefe, A. E. Buxton, B. Chaitman, M. Fromer, G. Gregoratos, G. Klein, A. J. Moss, et al.
ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death)
J. Am. Coll. Cardiol., September 5, 2006; 48(5): e247 - e346.
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 EuropaceHome page
Writing Committee Members, D. P. Zipes, A. J. Camm, M. Borggrefe, A. E. Buxton, B. Chaitman, M. Fromer, G. Gregoratos, G. Klein, A. J. Moss, et al.
ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: A report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society
Europace, September 1, 2006; 8(9): 746 - 837.
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 CirculationHome page
U. C. Hoppe, J. M. Casares, H. Eiskjaer, A. Hagemann, J. G.F. Cleland, N. Freemantle, and E. Erdmann
Effect of Cardiac Resynchronization on the Incidence of Atrial Fibrillation in Patients With Severe Heart Failure
Circulation, July 4, 2006; 114(1): 18 - 25.
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 BMJHome page
M. Coceani and R. Mariotti
Is amiodarone safe in heart failure?
BMJ, February 11, 2006; 332(7537): 317 - 318.
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 Eur Heart JHome page
Authors/Task Force Members, K. Swedberg, Writing Committee:, J. Cleland, H. Dargie, H. Drexler, F. Follath, M. Komajda, L. Tavazzi, O. A. Smiseth, et al.
Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology
Eur. Heart J., June 1, 2005; 26(11): 1115 - 1140.
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 Asian Cardiovasc. Thorac. Ann.Home page
D. Mikroulis, V. Didilis, F. Konstantinou, K. Tsakiridis, G. Vretzakis, and G. Bougioukas
Diltiazem versus Amiodarone to Prevent Atrial Fibrillation in Coronary Surgery
Asian Cardiovasc Thorac Ann, March 1, 2005; 13(1): 47 - 52.
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 Eur Heart JHome page
Endorsed by the European Society of Intensive Care, Authors/Task Force Members, M. S. Nieminen, M. Bohm, M. R. Cowie, H. Drexler, G. S. Filippatos, G. Jondeau, Y. Hasin, J. Lopez-Sendon, et al.
Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: The Task Force on Acute Heart Failure of the European Society of Cardiology
Eur. Heart J., February 2, 2005; 26(4): 384 - 416.
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 J Am Coll CardiolHome page
A. U. Khand, A. C. Rankin, W. Martin, J. Taylor, I. Gemmell, and J. G. F. Cleland
Carvedilol alone or in combination with digoxin for the management of atrial fibrillation in patients with heart failure?
J. Am. Coll. Cardiol., December 3, 2003; 42(11): 1944 - 1951.
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 Eur Heart JHome page
S. D.R. Thackray, K. K.A. Witte, N. P. Nikitin, A. L. Clark, G. C. Kaye, and J. G.F. Cleland
The prevalence of heart failure and asymptomatic left ventricular systolic dysfunction in a typical regional pacemaker population
Eur. Heart J., June 2, 2003; 24(12): 1143 - 1152.
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 J CARDIOVASC PHARMACOL THERHome page
G. C. Gronefeld and S. H. Hohnloser
Heart Failure Complicated by Atrial Fibrillation: Mechanistic, Prognostic, and Therapeutic Implications
Journal of Cardiovascular Pharmacology and Therapeutics, June 1, 2003; 8(2): 107 - 113.
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 Eur Heart JHome page
J.G.F Cleland, K Swedberg, F Follath, M Komajda, A Cohen-Solal, J.C Aguilar, R Dietz, A Gavazzi, R Hobbs, J Korewicki, et al.
The EuroHeart Failure survey programme--a survey on the quality of care among patients with heart failure in Europe: Part 1: patient characteristics and diagnosis
Eur. Heart J., March 1, 2003; 24(5): 442 - 463.
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 Canadian J. AnesthesiaHome page
C.-H. Tsou, C.-E. Chiang, J.-T. Liou, S.-T. Hsin, and H.-N. Luk
Successful use of iv diltiazem to control perioperative refractory complex atrial tachyarrhythmias in a patient with pneumoconiosis: [L'utilisation reussie du diltiazem iv dans le controle de tachyarythmies perioperatoires, auriculaires, refractaires, complexes, chez un malade souffrant de pneumoconiose]
Can J Anesth, January 1, 2003; 50(1): 36 - 41.
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 Eur Heart J SupplHome page
F Zannad
Evidence-based drug therapy for chronic heart failure
Eur. Heart J. Suppl., April 1, 2002; 4(suppl_D): D66 - D72.
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 Br Med BullHome page
J. G F Cleland, J. John, J. Dhawan, and A. Clark
What is the optimal medical management of ischaemic heart failure?
Br. Med. Bull., October 1, 2001; 59(1): 135 - 158.
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 Eur Heart JHome page
Task Force for the Diagnosis and Treatment of Chro, W. J. Remme, and K. Swedberg
Guidelines for the diagnosis and treatment of chronic heart failure
Eur. Heart J., September 1, 2001; 22(17): 1527 - 1560.
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 Eur Heart JHome page
J.G.F. Cleland, K. Thygesen, B.F. Uretsky, P. Armstrong, J.D. Horowitz, B. Massie, M. Packer, P.A. Poole-Wilson, L. Ryden, and on behalf of the ATLAS investigators
Cardiovascular critical event pathways for the progression of heart failure; a report from the ATLAS study
Eur. Heart J., September 1, 2001; 22(17): 1601 - 1612.
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 CirculationHome page
O. D. Pedersen, H. Bagger, N. Keller, B. Marchant, L. Kober, and C. Torp-Pedersen
Efficacy of Dofetilide in the Treatment of Atrial Fibrillation-Flutter in Patients With Reduced Left Ventricular Function: A Danish Investigations of Arrhythmia and Mortality ON Dofetilide (DIAMOND) Substudy
Circulation, July 17, 2001; 104(3): 292 - 296.
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 Eur Heart JHome page
A.U Khand, I Gemmell, A.C Rankin, and J.G.F Cleland
Clinical events leading to the progression of heart failure: insights from a national database of hospital discharges
Eur. Heart J., January 2, 2001; 22(2): 153 - 164.
[Abstract] [PDF]

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