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catheter ablation vs. MT showed a consistent improvement in symptoms whereas the results on mortality and hospitalization were obtained with a relatively small number of events not permitting to draw definitive conclusions.152,548550,552554,557

12.1.2 Ventricular arrhythmias Ventricular arrhythmias may be a complication, and in some instances, a cause of HF. Frequent ventricular premature beats (VPBs) may lead to reversible systolic dysfunction. Possible factors may include dyssynchrony and abnormal calcium handling.560

Initial management of ventricular arrhythmias in HF should include correction of potential precipitants (including electrolyte abnormalities, particularly hypo/hyperkalaemia, and pro-arrhythmic drugs) as well as the optimization of HF drug therapy. Although ischaemia may be a triggering factor, revascularization has not been shown to reduce risk of ventricular arrhythmias.561 Amiodarone is effective also for suppression of ventricular arrhythmias. However, it does not reduce the incidence of sudden cardiac death or overall mortality.161 For patients with premature ventricular contraction (PVC)-induced CMP, amiodarone administration may be considered to reduce recurrent arrhythmias and improve symptoms and LV function, although its side effects should be taken into consideration. Other drugs are discussed in Supplementary text 12.1. Radiofrequency ablation of VPBs may improve LV function and, possibly, outcomes in patients with tachycardiomyopathy when VPBs contribute to LV dysfunction.562 A sustained reduction in the baseline PVC burden has been associated with a lower risk of cardiac mortality, cardiac transplantation, or hospitalization for HF during followup.563,564

12.1.3 Symptomatic bradycardia, pauses and atrioventricular block Indications for pacemaker therapy do not differ in patients with HF from those with other CV disease. There is ample evidence that RV pacing may have an adverse effect on LV systolic function leading, in the long term, to HF.565 Patients with HFrEF requiring frequent ventricular pacing, e.g. with AV block or slow AF, and who have systolic dysfunction, should be implanted with CRT rather than a standard pacemaker to avoid adverse outcomes, as shown in the BLOCK-HF (Biventricular versus Right Ventricular Pacing in Heart Failure Patients with Atrioventricular Block) trial.216 In the quest for a more physiological alternative to RV pacing, physiological pacing is being increasingly adopted.566 In a non-randomized comparison of 304 consecutive patients with His bundle pacing and 433 consecutive patients with RV pacing, the former group had less HF hospitalization and a trend in reduced mortality.567 Although the technique is promising, more data are needed to confirm its role.

12.2 Chronic coronary syndromes

CAD is the most common cause of HF in industrialized, middleincome, and increasingly in low-income, countries. It should be considered as possible cause of HF in all patients presenting with new onset HF. The diagnostic workup of patients with HF and chronic coronary syndromes (CCS) is reported in the recent 2019 ESC Guidelines on CCS.5 Patients with HF should be carefully evaluated to assess signs and/or symptoms of CCS. Clinical and family histories, physical examination, ECG and imaging tests are recommended.5 Documentation of ischaemia using non-invasive and invasive tests can be difficult in patients with HF because of the possible exercise intolerance and the effects of increased end-diastolic LV pressures. Coronary angiography or CTCA can be performed to establish the

Recommendations for the treatment of atrial fibrillation in patients with heart failure

Recommendations Classa Levelb

Anticoagulation Long-term treatment with an oral anticoagulant is recommended in all patients with AF, HF, and CHA2DS2-VASc score >_2 in men or >_3 in women.7 I A DOACs are recommended in preference to VKAs in patients with HF, except in those with moderate or severe mitral stenosis or mechanical prosthetic heart valves.528,558 I A Long-term treatment with an oral anticoagulant should be considered for stroke prevention in AF patients with a CHA2DS2-VASc score of 1 in men or 2 in women.7,559 IIa B Rate control Beta-blockers should be considered for shortand long-term rate control in patients with HF and AF.535 IIa B Digoxin should be considered when the ventricular rate remains high, despite beta-blockers, or when beta-blockers are contraindicated or not tolerated.536 IIa C Cardioversion Urgent ECV is recommended in the setting of acute worsening of HF in patients presenting with rapid ventricular rates and haemodynamic instability. I C Cardioversion may be considered in patients in whom there is an association between AF and worsening of HF symptoms despite optimal medical treatment.7,541 IIb B AF catheter ablation In cases of a clear association between paroxysmal or persistent AF and worsening of HF symptoms, which persist despite MT, catheter ablation should be considered for the prevention or treatment of AF.552554,557 IIa B

AF = atrial fibrillation; CHA2DS2-VASc = congestive heart failure or left ventricular dysfunction, Hypertension, Age >_75 (doubled), Diabetes, Stroke (doubled)- Vascular disease, Age 6574, Sex category (female) (score); DOAC = directacting oral anticoagulant; ECV = electrical cardioversion; HF = heart failure; MT = medical therapy; VKA = vitamin K antagonist. aClass of recommendation. bLevel of evidence. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026