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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e92

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

9.2 Management of AF in Patients With HF

Recommendations for Management of AF in Patients With HF* Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 B-NR 1 In patients who present with a new diagnosis of

HFrEF and AF, arrhythmia-induced cardiomyopathy should be suspected, and an early and aggressive approach to AF rhythm control is recommended.1,2

1 A 2 In appropriate patients with AF and HFrEF who are

on GDMT, and with reasonable expectation of procedural benefit (Figure 24), catheter ablation is beneficial to improve symptoms, QOL, ventricular function, and cardiovascular outcomes.3–13

2a B-NR 3 In appropriate patients with symptomatic AF and

HFpEF with reasonable expectation of benefit, catheter ablation can be useful to improve symptoms and improve QOL.14,15

2a B-R 4 In patients with AF and HF, digoxin is reasonable for rate

control, in combination with other rate-controlling agents or as monotherapy if other agents are not tolerated.16,17

2a B-NR 5 In patients with AF and HF with rapid ventricular rates

in whom beta blockers or calcium channel blockers are contraindicated or ineffective, intravenous amiodarone is reasonable for acute rate control.†18,19

2a B-R 6 In patients with AF, HFrEF (LVEF <50%), and

refractory rapid ventricular response who are not candidates for or in whom rhythm control has failed, AVNA and biventricular pacing therapy can be useful to improve symptoms, QOL, and EF.20–23

2a B-NR 7 In patients with AF, HF, and implanted biventricular pacing

therapy in whom an effective pacing percentage cannot be achieved with pharmacological therapy, AVNA can be beneficial to improve functional class,24,25 reduce the risk of ICD shock,26 and improve survival.24,25

2a B-NR 8 In patients with AF-induced cardiomyopathy who have

recovered LV function, long-term surveillance can be beneficial to detect recurrent AF in view of the high risk of recurrence of arrhythmia-induced cardiomyopathy.27,28

2b B-NR 9 In patients with suspected AF-induced cardiomyopathy

or refractory HF symptoms undergoing pharmacological rate-control therapy for AF, a stricter rate-control strategy (target heart rate <80 bpm at rest and <110 bpm during moderate exercise) may be reasonable.29–31

2b C-LD 10.	 In patients with AF and HFrEF who undergo AVNA, conduction system pacing of the His bundle or left bundle branch area may be reasonable as an alternative to biventricular pacing to improve symptoms, QOL, and LV function.32–35

3: Harm B-R 11.	 In patients with AF and known LVEF <40%, nondihydropyridine calcium channel–blocking drugs should not be administered because of their potential to exacerbate HF.36

3: Harm B-R 12.	 For patients with AF, dronedarone should not be administered for maintenance of sinus rhythm to those with NYHA class III and IV HF or patients who have had an episode of decompensated HF in the past 4 weeks, due to the risk of increased early mortality associated with worsening HF.37 *Please see other recommendations on anticoagulation in AF (Section 8.4.4, “Anticoagulation Therapy Before and After Catheter Ablation”), rate control in HF (Section 7, “Rate Control”), and agents for pharmacological cardioversion (Section 7.2, “Specific Pharmacological Agents for Rate Control”) and maintenance of sinus rhythm (Section 8.3.1, “Specific Drug Therapy for Long-Term Maintenance of Sinus Rhythm”). †Consider the risk of cardioversion and stroke when using amiodarone as a rate-control agent. Synopsis AF is the most common cause of arrhythmia-induced cardiomyopathy,27,38 a condition where persistent AF, with or without rapid ventricular rates, can lead to LV dysfunction and HF that can be partially or completely reversed with adequate arrhythmia control.39 AF can either be the only reason for cardiomyopathy (AF-induced) or can exacerbate LV dysfunction and HF in a patient with concomitant structural heart disease (AFmediated).38,39 Medical therapies for rate control (Section 7) or rhythm control (Section 8) of AF have special considerations in patients with HF based on differential safety. Routine pharmacological rhythm compared with rate control has not demonstrated benefit on clinical outcomes in patients with HFrEF,29,40 although a recent subgroup analysis of patients with HF (most heart failure with preserved ejection fraction) demonstrated benefit of early rhythm control compared to rate control on clinical outcomes.1 Several trials have compared AF catheter ablation with medical therapy in patients with HFrEF. Although earlier trials were small and focused on endpoints such as improvement in LVEF, QOL, and 6-minute walk, 2 of the largest trials have shown a benefit in reducing mortality rate and HF hospitalization.3–13 Patients with AF and HF may undergo AVNA for rate control refractory to medical therapy.20,21 Similar to findings in patients who undergo pacemaker implantation for conduction system disease, patients with HF appear to be more likely to develop or have worsened cardiomyopathy related to RV pacing dyssynchrony41,42 and have improved outcomes with biventricular or conduction system pacing.23,32,33,35

Recommendation-Specific Supportive Text 1.	 It can be difficult to determine the extent of the

contribution of AF to cardiomyopathy and new onset HFrEF. Allowing AF to persist long term, regardless of reasonable rate control, may result in worsening HF and cardiomyopathy. An early and aggressive approach to rhythm control can reduce AF burden, resulting in favorable ventricular remodeling and halting of any occult arrhythmia-induced cardiomyopathy. In a prespecified subanalysis of 798 HF patients (NYHA class II/ III or LVEF <50%) in EAST-AFNET (HFpEF, 442; midrange, 211; HFrEF [<40%], 132), early rhythm control significantly improved the composite outcome of death, stroke, or hospitalization for worsening of HF or for ACS (early rhythm control, 94/396; 5.7/100 patient-years) versus usual care (130/402; 7.9/100 patient-years; HR, 0.74 [95% CI, 0.56-0.97]; P=0.03), and this was not altered by HF status. Safety outcomes in each group were comparable. However, only 17% of the HF population had LVEF <40%.1 In a post hoc analysis of the CASTLE-AF trial, an AF burden <50% at 6 months

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