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Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy

      Abstract

      Heart failure (HF) affects almost 5 million patients in the United States and is a leading cause of morbidity and mortality. Atrial fibrillation (AF), like HF, affects millions of patients and markedly increases in prevalence with age. As the US population ages, the number of patients afflicted with HF and AF will continue to grow. HF with preserved ejection fraction is particularly common in the elderly population. The prevalence of AF in patients with HF increases from <10% in those with New York Heart Association (NYHA) functional class I HF to approximately 50% in those with NYHA functional class IV HF. The pathophysiologic changes that occur in patients with HF and AF are complex and incompletely understood. Alterations in neurohormonal activation, electrophysiologic parameters, and mechanical factors conspire to create an environment in which HF predisposes to AF and AF exacerbates HF. Mechanisms include atrial remodeling and tachycardia-induced myopathy. The development of AF in HF appears to independently predict death resulting from pump failure and total mortality. Although the currently available therapeutic options for AF in patients with HF are varied, their effect on prognosis remains unknown and is the subject of ongoing clinical trials. It will be critical to define and plan therapies specifically for those patients with AF, HF, and preserved ejection fraction in addition to the population with low ejection fraction that has dominated previous investigations.
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      References

      1. American Heart Association. 2002 Heart and Stroke Statistical Update. Dallas: American Heart Association, 2002

        • Nohria A.
        • Lewis E.
        • Stevenson L.W.
        Medical management of advanced heart failure.
        JAMA. 2002; 287: 628-640
        • Moser D.K.
        • Mann D.L.
        Improving outcomes in heart failure.
        Circulation. 2002; 105: 2810-2812
        • Zile M.
        • Brutsaert D.L.
        New concepts in diastolic dysfunction and diastolic heart failure, part 1.
        Circulation. 2002; 105: 1387-1393
        • Benjamin E.J.
        • Wolf P.A.
        • D’Agostino R.B.
        • Silbershatz H.
        • Kannel W.B.
        • Levy D.
        Impact of atrial fibrillation on the risk of death.
        Circulation. 1998; 98: 946-952
        • Ho K.K.L.
        • Pinsky J.L.
        • Kannel W.B.
        • Levy D.
        The epidemiology of heart failure.
        J Am Coll Cardiol. 1993; 22: 6A-13A
        • Hohnloser S.H.
        • Kuck K.-H.
        • Lilienthal J.
        • PIAF Investigators
        Rhythm or rate control in atrial fibrillation—Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial.
        Lancet. 2000; 356: 1789-1794
        • Vaziri S.M.
        • Larson M.G.
        • Benjamin E.J.
        • Levy D.
        Echocardiographic predictors of nonrheumatic atrial fibrillation.
        Circulation. 1994; 89: 724-730
        • Doval H.C.
        • Nul D.R.
        • Grancelli H.O.
        • Perrone S.V.
        • Bortman G.R.
        • Curiel R.
        • Grupo de Estudio de la Sobrevida en la Insuficiencia Cardiaca en Argentina (GESICA)
        Randomised trial of low-dose amiodarone in severe congestive heart failure.
        Lancet. 1994; 344: 493-498
        • Dries D.L.
        • Exner D.V.
        • Gersh B.J.
        • Domanski M.J.
        • Waclawiw M.A.
        • Stevenson L.W.
        Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction.
        J Am Coll Cardiol. 1998; 32: 695-703
        • SOLVD Investigators
        Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions.
        N Engl J Med. 1992; 327: 685-691
        • SOLVD Investigators
        Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure.
        N Engl J Med. 1991; 325: 293-302
        • Carson P.E.
        • Johnson G.R.
        • Dunkman W.B.
        • Fletcher R.D.
        • Farrell L.
        • Cohn J.N.
        • V-HeFT VA Cooperative Studies Group
        The influence of atrial fibrillation on prognosis in mild to moderate heart failure.
        Circulation. 1993; 87: VI-102-VI-110
        • Deedwania P.C.
        • Singh B.N.
        • Ellenbogen K.
        • Fisher S.
        • Fletcher R.
        • Singh S.N.
        Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation.
        Circulation. 1998; 98: 2574-2579
        • Torp-Pedersen C.
        • Møller M.
        • Bloch-Thomsen P.E.
        • Køber L.
        • Sandøe E.
        • Egstrup K.
        • Agner E.
        • Carlsen J.
        • Videbalk J.
        • Marchant B.
        • Camm A.J.
        • Danish Investigations of Arrhythmia and Mortality on Dofetilide Study Group
        Dofetilide in patients with congestive heart failure and left ventricular dysfunction.
        N Engl J Med. 1999; 341: 857-865
        • CONSENSUS Trial Study Group
        Effects of enalapril on mortality in severe congestive heart failure.
        N Engl J Med. 1987; 316: 1429-1435
        • Aronow W.S.
        • Ahn C.
        • Kronzon I.
        Prognosis of congestive heart failure after prior myocardial infarction in older persons with atrial fibrillation versus sinus rhythm.
        Am J Cardiol. 2001; 87: 224-225
        • Stevenson W.G.
        • Stevenson L.W.
        Atrial fibrillation in heart failure.
        N Engl J Med. 1999; 341: 910-911
        • Mathew J.
        • Hunsberger S.
        • Fleg J.
        • McSherry F.
        • Williford W.
        • Yusuf S.
        • Digitalis Investigation Group
        Incidence, predictive factors, and prognostic significance of supraventricular tachyarrhythmias in congestive heart failure.
        Chest. 2000; 118: 914-922
        • Crijns H.J.G.M.
        • Tjeerdsma G.
        • de Kam P.J.
        • Boomsma F.
        • van Gelder I.C.
        • van den Berg M.P.
        • van Veldhuisen D.J.
        Prognostic value of the presence of atrial fibrillation in patients with advanced chronic heart failure.
        Eur Heart J. 2000; 21: 1238-1245
        • Nattel S.
        Ionic determinants of atrial fibrillation and Ca2+ channel abnormalities.
        Circ Res. 1999; 85: 473-476
        • Wijffels M.C.E.F.
        • Kirchof C.J.H.J.
        • Dorland R.
        • Allessie M.A.
        Atrial fibrillation begets atrial fibrillation.
        Circulation. 1995; 92: 1954-1968
        • Van Den Berg M.P.
        • Tuinenburg A.E.
        • Crijns H.J.G.M.
        • Van Gelder I.C.
        • Gosselink A.T.M.
        • Lie K.I.
        Heart failure and atrial fibrillation.
        Heart. 1997; 77: 309-313
        • Solti F.
        • Vecsey T.
        • Kékesi V.
        • Juhász-Nagy A.
        The effect of atrial dilatation on the genesis of atrial arrhythmias.
        Cardiovasc Res. 1989; 23: 882-886
        • Tomaselli G.F.
        • Marbán E.
        Electrophysiological remodeling in hypertrophy and heart failure.
        Cardiovasc Res. 1999; 42: 270-283
        • Zile M.R.
        • Brutsaert D.L.
        New concepts in diastolic dysfunction and diastolic heart failure, part 2.
        Circulation. 2002; 105: 1503-1508
        • Li D.
        • Shinagawa K.
        • Pang L.
        • Leung T.K.
        • Cardin S.
        • Wang Z.
        • Nattel S.
        Effects of angiotensin-converting enzyme inhibition on the development of the atrial fibrillation substrate in dogs with ventricular tachypacing-induced congestive heart failure.
        Circulation. 2001; 104: 2608-2614
        • Li D.
        • Fareh S.
        • Leung T.K.
        • Nattel S.
        Promotion of atrial fibrillation by heart failure in dogs.
        Circulation. 1999; 100: 87-95
        • Shinagawa K.
        • Shi Y.-F.
        • Tardif J.-C.
        • Leung T.-K.
        • Nattel S.
        Dynamic nature of atrial fibrillation substrate during development and reversal of heart failure in dogs.
        Circulation. 2002; 105: 2672-2678
        • Li D.
        • Melnyk P.
        • Feng J.
        • Wang Z.
        • Petrecca K.
        • Shrier A.
        • Nattel S.
        Effects of experimental heart failure on atrial cellular and ionic electrophysiology.
        Circulation. 2000; 101: 2631-2638
        • Nattel S.
        • Li D.
        Ionic remodeling in the heart.
        Circ Res. 2000; 87: 440-447
        • Pardaens K.
        • Van Cleemput J.
        • Vanhaecke J.
        • Fagard R.H.
        Atrial fibrillation is associated with a lower exercise capacity in male chronic heart failure patients.
        Heart. 1997; 78: 564-568
        • Naito M.
        • David D.
        • Michelson E.L.
        • Schaffenburg M.
        • Dreifus L.S.
        The hemodynamic consequences of cardiac arrhythmias.
        Am Heart J. 1983; 106: 284-291
        • Shinbane J.S.
        • Wood M.A.
        • Jensen D.N.
        • Ellenbogen K.A.
        • Fitzpatrick A.P.
        • Scheinman M.M.
        Tachycardia-induced cardiomyopathy.
        J Am Coll Cardiol. 1997; 29: 709-715
        • Clark D.M.
        • Plumb V.J.
        • Epstein A.E.
        • Kay G.N.
        Hemodynamic effects of an irregular sequence of ventricular cycle lengths during atrial fibrillation.
        J Am Coll Cardiol. 1997; 30: 1039-1045
        • Tuinenburg A.
        • Van Veldhuisen D.J.
        • Boomsma F.
        • Van Den Berg M.P.
        • De Kam P.J.
        • Crijns H.J.G.M.
        Comparison of plasma neurohormones in congestive heart failure patients with atrial fibrillation versus patients with sinus rhythm.
        Am J Cardiol. 1998; 81: 1207-1210
        • Fenelon G.
        • Wijns W.
        • Andries E.
        • Brugada P.
        Tachycardiomyopathy.
        Pacing Clin Electrophysiol. 1996; 19: 95-106
        • Peters K.G.
        • Kienzle M.G.
        Severe cardiomyopathy due to chronic rapidly conducted atrial fibrillation.
        Am J Med. 1988; 85: 242-244
        • Van Gelder I.C.
        • Crijns H.J.G.M.
        • Blanksma P.K.
        • Landsman M.L.J.
        • Posma J.L.
        • Van Den Berg M.P.
        • Meijler F.L.
        • Lie K.I.
        Time course of hemodynamic changes and improvement of exercise tolerance after cardioversion of chronic atrial fibrillation unassociated with cardiac valve disease.
        Am J Cardiol. 1993; 72: 560-566
        • Ehrlich J.R.
        • Nattel S.
        • Hohnloser S.H.
        Atrial fibrillation and congestive heart failure.
        J Cardiovasc Electrophysiol. 2002; 13: 399-405
        • Middlekauf H.R.
        • Stevenson W.G.
        • Stevenson L.W.
        Prognostic significance of atrial fibrillation in advanced heart failure.
        Circulation. 1991; 84: 40-48
        • Mahoney P.
        • Kimmel S.
        • DeNofrio D.
        • Wahl P.
        • Loh E.
        Prognostic significance of atrial fibrillation in patients at a tertiary medical center referred for heart transplantation because of severe heart failure.
        Am J Cardiol. 1999; 83: 1544-1547
        • Likoff M.J.
        • Chandler S.L.
        • Kay H.R.
        Clinical determinants of mortality in chronic congestive heart failure secondary to idiopathic dilated or to ischemic cardiomyopathy.
        Am J Cardiol. 1987; 59: 634-638
        • Keogh A.M.
        • Baron D.W.
        • Hickie J.B.
        Prognostic guides in patients with idiopathic or ischemic dilated cardiomyopathy assessed for cardiac transplantation.
        Am J Cardiol. 1990; 65: 903-908
        • Pedersen O.D.
        • Bagger H.
        • Keller N.
        • Marchant B.
        • Køber L.
        • Torp-Pedersen C.
        • Danish Investigations of Arrhythmia and Mortality ON Dofetilide Study Group
        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 Dotetilide (DIAMOND) substudy.
        Circulation. 2001; 104: 292-296
        • Gaasch W.H.
        Diagnosis and treatment of heart failure based on left ventricular systolic or diastolic dysfunction.
        JAMA. 1994; 271: 1276-1280
      2. Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD, for the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002;347:1825–1833

        • Scheinman M.M.
        Atrial fibrillation and congestive heart failure.
        Circulation. 1998; 98: 941-942