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May 3, 2022 Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 e972 CLINICAL STATEMENTS AND GUIDELINES death (14%), hospitalization for HF (26%), and renal outcomes (38%) with SGLT2i treatment.14–17 Benefits were consistent across age, sex, and in patients with or without diabetes. Whether dapagliflozin or empagliflozin improves outcomes specifically in patients with HFpEF is being studied.46,47 The SOLOIST-WHF trial extends the benefits of SGLT2i to patients with diabetes and acutely decompensated HF.48 Patients on SGLT2i should be closely monitored for potential risks, including severe genitourinary infections and, less commonly, diabetic ketoacidosis.49 10.2 Management of AF in HF Recommendations for Management of AF in HF Referenced studies that support the recommendations are summarized in the Online Data Supplements. COR LOE Recommendations 1 A 1. Patients with chronic HF with permanent-persistent-paroxysmal AF and a CHA2DS2-VASc score of ≥2 (for men) and ≥3 (for women) should receive chronic anticoagulant therapy.1–5 1 A 2. For patients with chronic HF with permanentpersistent-paroxysmal AF, DOAC is recommended over warfarin in eligible patients.2–10 2a B-R 3. For patients with HF and symptoms caused by AF, AF ablation is reasonable to improve symptoms and QOL.11–14 2a B-R 4. For patients with AF and LVEF ≤50%, if a rhythm control strategy fails or is not desired, and ventricular rates remain rapid despite medical therapy, atrioventricular nodal ablation with implantation of a CRT device is reasonable.15–22 2a B-NR 5. For patients with chronic HF and permanentpersistent-paroxysmal AF, chronic anticoagulant therapy is reasonable for men and women without additional risk factors.23–26 Synopsis The interplay between AF and HF is complex. It is clear that AF may worsen HF but also that HF increases the risk of AF. Data from randomized trials support the use of anticoagulation among those with HF and AF but not in patients with HF without AF. Anticoagulation may be accomplished with DOAC or with warfarin when favored because of other indications, cost or drug-drug interactions (the DOAC are generally preferred). The choice between rate or rhythm control strategy reflects both patient symptoms and the likelihood of better ventricular function with sinus rhythm. RCTs of rhythm control with antiarrhythmic agents versus rate control have not shown a benefit of rhythm control. More recent RCTs with ablation show that ablation may be preferable to antiarrhythmic drugs for a rhythm control strategy. Patients thought to have a cardiomyopathy resulting from rapid AF despite attempts at rate control should be aggressively treated to maintain sinus rhythm and, if that is not successful, atrioventricular nodal ablation with placement of a CRT device can be considered. Patients with HF, and difficult to control rates, may benefit from atrioventricular node ablation and implantation of a permanent pacemaker if other rate and rhythm control measures fail. If their LVEF is >50%, there is no current evidence that CRT is beneficial compared with RV pacing.15,21 Recommendation-Specific Supportive Text 1. The efficacy of long-term warfarin for the prevention of stroke in patients with AF is well established; randomized trials have shown reduced embolic rates and mortality. The AHA/ACC/Heart Rhythm Society guidelines for AF recommend use of the CHA2DS2-VASc score (history of hypertension, age ≥75 [doubled weight], diabetes mellitus, previous stroke or transient ischemic attack or thromboembolism [doubled weight], vascular disease, age 65 to 74 years, sex category) to assess patient risk for adverse outcomes before initiating anticoagulation therapy.1,27,28 Regardless of whether patients receive rhythm or rate control, anticoagulation is recommended for patients with HF and AF for stroke prevention with a CHA2DS2-VASc score of ≥2 (for men) and ≥3 (for women).2–5 2. Trials of DOAC have compared the efficacy and safety with warfarin therapy rather than placebo. Several DOAC are available, including the factor Xa inhibitors apixaban, rivaroxaban, edoxaban, and the direct thrombin inhibitor dabigatran.2–5 These drugs do not need routine anticoagulation monitoring or dose adjustment. The fixed dosing together with fewer interactions may simplify patient management, particularly with the polypharmacy commonly seen in HF, but cost for some patients can be prohibitive when not covered by insurance. These drugs have a potential for an improved benefit–risk profile compared with warfarin, which may increase their use in practice, especially in those at increased bleeding risk.6–9 In a meta-analysis of 4 trials examining efficacy and safety of DOAC in patients with and without HF, DOAC more effectively reduced the rate of stroke or systemic embolism, major bleeding, and intracranial bleeding compared with warfarin, with no treatment heterogeneity by HF status.10 3. The 2 largest RCTs of AF ablation in HF showed a benefit in hospitalizations and mortality with ablation.11,12although other smaller trials did not. In the AATAC (Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients with Congestive Heart Failure and an Implanted Device) trial, 203 patients with persistent AF, LVEF <40%, and NYHA class II to III HF, ablation improved the likelihood of maintaining Downloaded from http://ahajournals.org by on October 7, 2026