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Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e973 CLINICAL STATEMENTS AND GUIDELINES normal sinus rhythm at 24 months compared with amiodarone and, in addition, had a 45% decrease in hospitalization and decrease in mortality (8% vs. 18%).11 The CASTLE AF (Catheter Ablation for Atrial Fibrillation with Heart Failure) trial randomized 363 patients with paroxysmal or persistent AF, LVEF <35%, NYHA class II to IV HF, and ICD to ablation versus standard medical care.12 The composite endpoint of death or rehospitalization was lower in ablation (28.5%) compared with standard care (44.6%). In addition, there was a lower mortality in the ablation group. In a meta-analysis of 11 RCTs comparing rhythm versus rate control, patients undergoing catheter ablation had improved survival (49% relative risk reduction) and reduced hospitalizations (56% relative risk reduction).13 4. If a rhythm control strategy fails or is undesired, and ventricular rates remain rapid despite medical therapy after all other options are exhausted, atrioventricular nodal ablation with implantation of a CRT device can be considered as a treatment option. Ablate and pace is an old strategy for difficult to rate control AF. Early studies with RV pacing showed benefit.15,16 However, when RV pacing was compared with cardiac resynchronization in more recent trials, especially in those with reduced LVEFs, CRT generally produced more benefit than RV pacing.17–21 The PAVE (Left Ventricular-Based Cardiac Stimulation post AV Nodal Ablation Evaluation) and the BLOCK-HF (Biventricular versus Right Ventricular Pacing in Patients with AV block) trials included patients with LVEF >35%, with mean EF 46%22 in PAVE and 40% in BLOCK-HF (enrolled ≤50%). In both of these trials, patients undergoing CRT had improved outcomes. 5. HF is a hypercoagulable state and serves as an independent risk factor for stroke, systemic embolism, and mortality in the setting of AF.23,24 There are compelling data to support the use of anticoagulation in most patients with HF and concomitant AF, barring contraindications. In patients with HF and a CHA2DS2-VASc score of 1, those with AF had a 3-fold higher risk compared with individuals without concomitant AF.25 In a post hoc analysis of 2 contemporary HF trials, paroxysmal and new onset AF were associated with a greater risk for hospitalization caused by HF or stroke.26 In a recent registry study, the risk of stroke was particularly higher in the initial period after diagnosis of HF among patients with prevalent AF.29 Because HF is a risk factor, additional risk factors may not be required to support the use of anticoagulation in patients with HF, and the decision to anticoagulate can be individualized according to risk versus benefit. 11 SPECIAL POPULATIONS 11.1 Disparities and Vulnerable Populations* Recommendations for Disparities and Vulnerable Populations Referenced studies that support the recommendations are summarized in the Online Data Supplements. COR LOE Recommendations 1 C-LD 1. In vulnerable patient populations at risk for health disparities, HF risk assessments and multidisciplinary management strategies should target both known risks for CVD and social determinants of health, as a means toward elimination of disparate HF outcomes.1–6 1 C-LD 2. Evidence of health disparities should be monitored and addressed at the clinical practice and the health care system levels.7–13 *This section crosslinks to Section 7.1.1, “Stage C Nonpharmacological Interventions and Self-Care Support in HF,” where screening and interventions for social determinants of health are now addressed. Synopsis There are important differences in HF incidence, risk factors, clinical care needs, and outcomes between specific patient populations2,3,14,15 (Table 27). It is essential that HF clinicians be aware of the biological factors, social determinants of health, and implicit biases that impact the burden of disease, clinical decision-making, and effective delivery of GDMT.9,16–18 Women generally present with HF later in life, with more comorbidities and lower patient-reported health status than men.10,19 Survival for women with HF is generally more favorable,20 although access to specialty care may be lower.21–24 The highest incident of HF is consistently observed in self-identified Black patients.25,26 HF hospitalization and mortality rates for Black patients are also higher than for White patients, with the gap increasing over time for young men.2,4,27 These differences are driven mostly by social circumstances; a biological premise or genetic explanation for disease or disease severity should not be inferred by race or ethnicity.28 Older patients with HF are especially vulnerable to polypharmacy, multimorbidity, cognitive decline, and frailty.29,30 Important strategies to remove biases within health care professionals and systems impacting minority and socioeconomically disadvantaged patient populations include implicit bias training, recruiting a diverse workforce, and promoting broad access to HF care.28,31–35 Recommendation-Specific Supportive Text 1. Hypertension is significantly more prevalent in Black patients, compared with White patients, populations in the United States, with a younger age of onset and greater attributable cardiovascular risks.36,37 An estimated 50 000 to 350 000 immigrants to the United States from Mexico and Central America may have asymptomatic Trypanosoma Downloaded from http://ahajournals.org by on October 7, 2026