Developments in the Management of Atrial Arrhythmias in Congestive Heart Failure

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Citation
Asia Pacific Cardiology - Volume 1 Issue 1;2007:1(1):46-48

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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

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