Atrial arrhythmias and congestive heart failure (CHF) are closely related. While CHF promotes the development of atrial arrhythmias, in particular atrial fibrillation (AF) and atrial flutter (AFL), the presence of these arrhythmias may exacerbate or cause left ventricular (LV) dysfunction and CHF.1,2 In addition, each adversely affects the prognosis of the other.3,4 Cardiomyopathy due to rapid uncontrolled ventricular response has been implicated as the main mechanism by which AF or AFL causes LV dysfunction.5 However, in the absence of a rapid ventricular rate during these arrhythmias LV dysfunction can still occur as a result of impaired atrial contractile function, loss of atrioventricular synchrony or an irregular ventricular rhythm.5–8
Rhythm versus Rate Control in Heart Failure
The most effective strategy to prevent or reverse LV dysfunction associated with AF or AFL is the restoration and maintenance of sinus rhythm. Although antiarrhythmic drugs remain first-line therapy, their use in CHF patients is extremely challenging owing to their limited efficacy and potentially deleterious effects in these patients.9 This led to a renewed interest in rate control, prompted by reports from large randomised studies such as the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) and the Rate Control versus Electrical Cardioversion (RACE) trials suggesting comparable outcomes for strategies involving pharmacological rhythm or rate control.10–12 However, recent evidence from these two studies not only confirmed the adverse prognostic effects of CHF, but also highlighted the potential benefits of sinus rhythm. In a recently reported substudy of the AFFIRM trial, restoration and maintenance of sinus rhythm were associated with a 47% reduction in mortality risk, while the use of antiarrhythmic drugs and the presence of CHF significantly increased the risk of death by 49 and 57%, respectively.13 In a separate substudy, the RACE investigators also demonstrated that pharmacological rate control could prevent deterioration of LV function. Restoration and maintenance of sinus rhythm were associated with an improvement in LV function.14 In patients with LV dysfunction, modest improvements in LV ejection fraction (LVEF) and fractional shortening can be achieved non-pharmacologically using the proven and effective ‘ablate and pace’ strategy.15–17
- Stevenson WG, Stevenson LW, Atrial fibrillation in heart failure, N Engl J Med, 1999;341:910–11.
- Ehrlich JR, Nattel S, Hohnloser SH, Atrial fibrillation and congestive heart failure: specific considerations at the intersection of two common and important cardiac disease sets, J Cardiovasc Electrophysiol, 2002;13:399–405.
- Middlekauff HR, Stevenson WG, Stevenson LW, Prognostic significance of atrial fibrillation in advanced heart failure: a study of 390 patients, Circulation, 1991;84:40–48.
- Wang TJ, Larson MG, Levy D, et al., Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study, Circulation, 2003;107:2920–25.
- Shinbane JS, Wood MA, Jensen DN, et al., Tachycardia-induced cardiomyopathy: a review of animal models and clinical studies, J Am Coll Cardiol, 1997;29:709–15.
- Natale A, Zimerman L, Tomassoni G, et al., Impact on ventricular function and quality of life of transcatheter ablation of the atrioventricular junction in chronic atrial fibrillation with a normal ventricular response, Am J Cardiol, 1996;78:1431–3.
- Clark DM, Plumb VJ, Epstein AE, Kay GN, Haemodynamic effects of an irregular sequence of ventricular cycle lengths during atrial fibrillation, J Am Coll Cardiol, 1997;30:1039–45.
- Daoud EG, Weiss R, Bahu M, et al., Effect of an irregular ventricular rhythm on cardiac output, Am J Cardiol,1996;78: 1433–6.
- Falk RH, Atrial fibrillation, N Engl J Med, 2001;344:1067–78.
- 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;347:1825–33.
- Van Gelder IC, Hagens VE, Bosker HA, et al., A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation, N Engl J Med, 2002;347:1834–40.
- Hohnloser SH, Kuck KH, Lilienthal J, Rhythm or rate control in atrial fibrillation - Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial, Lancet, 2000;356:1789–94.
- Corley SD, Epstein AE, DiMarco JP, et al., Relationships between sinus rhythm, treatment and survival in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Study, Circulation, 2004;109:1509–13.
- Hagens VE, Van Veldhuisen DJ, Kamp O, et al., Effect of rate and rhythm control on left ventricular function and cardiac dimensions in patients with persistent atrial fibrillation: results from the Rate Control versus Electrical Cardioversion for persistent atrial fibrillation (RACE) study, Heart Rhythm, 2005;2:19–24.
- Wood MA, Brown-Mahoney C, Kay GN, Ellenbogen KA, Clinical outcomes after ablation and pacing therapy for atrial fibrillation: a meta-analysis, Circulation, 2000;101:1138–44.
- Brignole M, Menozzi C, Gianfranchi L, et al., Assessment of atrioventricular junction ablation and VVIR pacemaker versus pharmacological treatment in patients with heart failure and chronic atrial fibrillation: a randomised controlled study, Circulation, 1998:98:953–60.
- Ozcan C, Jahangir A, Friedman PA, et al., Significant effects of atrioventricular node ablation and pacemaker implantation on left ventricular function and long-term survival in patients with atrial fibrillation and left ventricular dysfunction, Am J Cardiol, 2003;92:33–7.
- Doshi R, Daoud E, Fellows C, et al., PAVE: The first prospective randomised study evaluating biventricular pacing after ablate and pace therapy. Presented at the American College of Cardiology Annual Scientific Session, 2004.
- Brignole M, Gammage M, Puggioni E, et al., on behalf of the Optimal Pacing Site (Opsite) Study Investigators. Comparative assessment of right, left and biventricular pacing in patients with permanent atrial fibrillation, Eur Heart J, 2005:26:712–22.
- Cappato R, Calkins H, Chen SA, et al., Worldwide survey on the methods, efficacy and safety of catheter ablation for human atrial fibrillation, Circulation, 2005;111:1100–15.
- Chen MS, Marrouche NF, Khaykin Y, et al., Pulmonary vein isolation for the treatment of atrial fibrillation in patients with impaired systolic function, J Am Coll Cardiol, 2004;43:1004–9.
- Hsu LF, Jais P, Sanders P, et al., Catheter ablation for atrial fibrillation in congestive heart failure, N Engl J Med, 2004;351: 2373–83.
- Gentlesk P, Sauer WH, Gerstenfeld EP, et al., Reversal of left ventricular dysfunction following ablation of atrial fibrillation, J Cardiovasc Electrophysiol, 2007;18:9–14.
- Tondo C, Mantica M, Russo G, et al., Pulmonary vein vestibule ablation for the control of atrial fibrillation in patients with impaired left ventricular function, Pacing Clin Electrophysiol, 2006;29:962–70.
- Pappone C, Augello G, Vicedomini G, et al., Circumferential pulmonary vein ablation in patients with atrial fibrillation and associated systolic or diastolic heart failure, Eur Heart J, 2003;24:494.
- Cha YM, Asirvatham SJ, Friedman PA, et al., Improvement in left ventricular function following radiofrequency catheter ablation of atrial fibrillation in patients with congestive heart failure, J Cardiovasc Electrophysiol, 2007;18:9–14.
- Pappone C, Rosanio S, Augello G, et al., Mortality, morbidity and quality of life after circumferential pulmonary vein ablation for atrial fibrillation, J Am Coll Cardiol, 2003;42:185–97.
- Hsu LF, Tan I, Kam R, et al., Clinical benefits of curative ablation of atrial flutter in patients with severe left ventricular dysfunction, Heart Rhythm, 2007;4:S114.
- De Ferrari GM, Petracci B, Frattini F, et al., Long-term effects of an aggressive rhythm control strategy in patients with permanent atrial fibrillation and advanced heart failure, Heart Rhythm, 2005;2(Suppl. 1):S116.
- AF-CHF Study Group, Rationale and design of a study assessing treatment strategies of atrial fibrillation in patients with heart failure: the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial, Am Heart J, 2002;144:597–607.
- Stevenson WG, Stevenson LW, Atrial fibrillation and heart failure – five more years, N Engl J Med, 2004;351:2437–40.