Systematic review of the management of atrial fibrillation in patients with heart failure

Aims To systematically review the management of atrial fibrillation (AF) in patients with heart failure. Methods Studies investigating the management of AF in patients with heart f ailure published between 1967 to 1998 were identified using MEDLINE, the Co chrane register and Embase databases. Reference lists from relevant papers and reviews were hand searched for further papers. Results Eight studies pertaining to acute and twenty-four pertaining to chr onic AF were identified. For patients with acute AF ventricular rate contro l, anticoagulation and treatment of heart failure should be pursued simulta neously before cardioversion is attempted. Digoxin is relatively ineffectiv e at controlling ventricular response and for cardioversion. Intravenous di ltiazem is rapidly effective in controlling ventricular rate and limited ev idence suggests it is safe. Amiodarone controls ventricular rate rapidly an d increases the rate of cardioversion. There are insufficient data to concl ude that immediate anti-coagulation, transoesophageal echocardiography to e xclude atrial thrombi followed by immediate cardioversion is an appropriate strategy. Patients with chronic AF should be anticoagulated unless contra- indications exist. It is not clear whether the preferred strategy should be cardioversion and maintenance of sinus rhythm with amiodarone or ventricul ar rate control of AF combined with anticoagulation to improve outcome incl uding symptoms, morbidity and survival. Electrical cardioversion has a high initial success rate but there is also a high risk of early relapse. Amiod arone currently appears the most effective and safest therapy for maintaini ng sinus rhythm post-cardioversion. Digoxin is fairly ineffective at contro lling ventricular rate during exercise. Addition of a beta-blocker reduces ventricular rate and improves symptoms. Whether digoxin is required in addi tion to beta-blockade for the control of AF in this setting is currently un der investigation. If pharmacological therapy is ineffective or not tolerat ed then atrio-ventricular node ablation and permanent pacemaker implantatio n should be considered. Conclusion There is a paucity of controlled clinical trial data for the man agement of AF among patients with heart failure. The interaction between AF and heart failure means that neither can be treated optimally without trea ting both. Presently treatment should be on a case by case basis. (Eur Hear t J 2000; 21: 614-632) (C) 2000 The European Society of Cardiology.