Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy

Maisel, William H.; Stevenson, Lynne Warner

doi:10.1016/s0002-9149(02)03373-8

Cited by 841 publications

(551 citation statements)

References 46 publications

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“…2 Patients with heart failure have a five to ten-fold greater probability of developing this arrhythmia than those without heart failure. [3][4][5] To what extent the presence and development of this arrhythmia retains a prognostic role in patients with heart failure remains debatable.…”

Section: Linkedmentioning

confidence: 99%

Impact of Atrial Fibrillation on Outcome of Patients with Idiopathic Dilated Cardiomyopathy: Data from the Heart Muscle Disease Registry of Trieste

Aleksova¹,

Merlo²,

Zecchin³

et al. 2010

Clinical Medicine & Research

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Objective: There is a paucity and inconsistency of data regarding the natural history of patients affected by idiopathic dilated cardiomyopathy (IDCM) and atrial fibrillation (AF). We examined the prognostic implications of AF in a subset of patients with IDCM. Methods:We analyzed the data of 539 patients with IDCM enrolled in the Heart Muscle Disease Registry of Trieste.Results: At baseline, 52 (9.6%) of 539 patients had AF. There was no difference in survival of patients with either AF or sinus rhythm at enrollment (P=.28). During long-term follow-up (90±58 months), AF was detected on ECG/ECG-Holter monitoring in 28 (5.7%) of 487 patients in sinus rhythm at baseline. Predictors of new onset of AF at multivariate analysis were a more dilated left atrium (OR 1.35, 95% CI 1.06-1.72; P=.01) and a lower left ventricle ejection fraction (for 10% decrease, OR 2.41, 95% CI 1.24-4.69, P=.016). Patients developing AF had higher mortality/heart transplantation rate compared to patients who maintained sinus rhythm during follow-up (P<.001). At multivariate analysis, new onset AF (HR 3.67, 95% CI 2.07-6.5; P<.001) in the first three years after diagnosis, but not baseline AF, was found to be independently associated with a worse outcome. Conclusions:Atrial fibrillation is relatively frequent in patients with IDCM. The early development of AF during follow-up, but not its presence at baseline, is associated with poor survival.

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Section: Linkedmentioning

confidence: 99%

Impact of Atrial Fibrillation on Outcome of Patients with Idiopathic Dilated Cardiomyopathy: Data from the Heart Muscle Disease Registry of Trieste

Aleksova¹,

Merlo²,

Zecchin³

et al. 2010

Clinical Medicine & Research

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“…2 There is increasing evidence that AF, at least in some population subsets, may be part of a spectrum of atherosclerotic vascular disease, hypertension, inflammation, diastolic dysfunction, and the metabolic syndromes. AF is part of a family of atrial tachyarrhythmias (Figure 1).…”

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confidence: 99%

Atrial Fibrillation: A Perspective

Wyse

Gersh

2004

Circulation

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A trial fibrillation (AF) is a common clinical problem that is increasing in prevalence 1 and is inextricably linked to another burgeoning cardiovascular problem, namely, congestive heart failure. 2 There is increasing evidence that AF, at least in some population subsets, may be part of a spectrum of atherosclerotic vascular disease, hypertension, inflammation, diastolic dysfunction, and the metabolic syndromes. AF is part of a family of atrial tachyarrhythmias (Figure 1). A panel of experts has recently characterized the definition and position of AF within this group of tachyarrhythmias. 3 Nonetheless, this family of tachyarrhythmias is closely interrelated, and the individual tachyarrhythmias often coexist in the same patient. Although the present discussion focuses on AF, many of the points made with regard to AF apply to these other tachyarrhythmias to varying degrees.Recently, international panels of experts have also created clinical practice guidelines 4 and perspectives on future research directions 5 for AF. These documents are a rich source of reference to the vast literature on AF. It is not the intention of the present article to review this literature, and, in particular, it is not intended that the reader will use the present article as a manual for managing AF. However, the perspective is intended to provide a framework for rational thinking about the management of AF. Inside the Basic Scientist's BoxA schema of how a basic scientist might currently view AF is presented in Figure 2. In this schema, modulating factors surround the basic elements of arrhythmogenesis, and the focus is on the mechanisms for initiation and perpetuation of AF. In this particular paradigm, a trigger and substrate interact to form a reentrant circuit or circuits, but provision is also provided for a trigger to lead directly to AF. The consequences of the interaction between triggers and substrate are dependent in part on the milieu created by multiple modulating factors and in particular the autonomic nervous system. The relative influence of these pathways in the pathogenesis of AF has always been controversial, and their deemed importance has waxed and waned over the years. Until recently, reentry based on the multiple wavelet hypothesis, attributed to Moe and Abildskov, 6 has held predominance, partly because of the mapping experiments of Allessie and colleagues. 7 However, the multiple wavelet hypothesis was preceded by hypotheses that invoked single or multiple rapidly firing foci and other reentry concepts (see Waldo 8 for a review). Recent observations on the initiation of AF from the area of the pulmonary veins 9 and the concepts of fibrillatory conduction and of rotors 10 have rekindled consideration of some of the older concepts, presented some new options, and lessened the dominance of the multiple wavelet hypothesis. However, the relative roles of abnormal automaticity and reentry in the pulmonary vein region for initiation and perpetuation, respectively, of AF are entirely unclear at the present time. Furth...

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“…9) An inappropriate rapid ventricular response with AF/ AFL causes the elevation of myocardial O 2 demand and insufficient diastolic filling pressure that results in further deterioration of heart failure. 10) Depressed cardiac function sometimes requires IABP insertion but an irregular ventricular response often poses a barrier to its effective hemodynamic support.…”

Section: Discussionmentioning

confidence: 99%

An Experience of Landiolol Use for an Advanced Heart Failure Patient With Severe Hypotension

et al. 2015

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SummaryTachyarrhythmias such as atrial fibrillation (AF) or atrial flutter (AFL) sometimes invoke life-threatening collapse of hemodynamics in patients with severe heart failure. Recently, landiolol, an ultra-short acting β1-selective antagonist, has been reported to be safe and useful for the treatment of supraventricular tachyarrhythmias with reduced left ventricular function. Here we report a case of advanced heart failure with severe hypotension who was treated successfully by landiolol for rapid AF. The patient was a 20-year old male with dilated cardiomyopathy. He presented with low output syndrome in spite of optimal medical therapy and was referred to our department to consider ventricular assist device implantation and heart transplantation. Soon after admission, he developed rapid atrial fibrillation at 180 beats per minute (bpm) followed by severe hypotension and liver enzyme elevation. Low dose landiolol at 2 μg/kg/minute was started because digoxin was not effective. After landiolol administration, his heart rate decreased to 110 bpm, and finally returned to sinus rhythm without hemodynamic deterioration. Intra-aortic balloon pumping was inserted soon after sinus recovery and he was discharged successfully with an implantable left ventricular assist device. (Int Heart J 2015; 56: 564-567) Key words: Atrial fibrillation, Stage D heart failure, Negative chronotropic effect, Ventricular assist device I t is well known that β blocker treatment is crucial for the improvement of prognosis among patients with systolic heart failure. 1-3) However, the usage of β blockers during the acute phase of decompensated heart failure is still a matter of debate. Propranolol, a classic intravenous form of β blocker, has been used widely for perioperative arrhythmias. However, there are concerns about bronchospasm due to the non-selectivity of β adrenergic receptors. Their long half-life period may also result in the prolongation of adverse events if they occur.Landiolol was developed in Japan and introduced as an ultra-short acting intravenous β blocker. It has very high selectivity for β1 receptors and is rapidly degraded by carboxylesterase and cholinesterase in the liver and blood, respectively. Recently, many papers have reported on the benefits of landiolol for the control of perioperative tachyarrhythmias. 4) However, the indication of landiolol has been limited in patients with preserved ejection fraction, and only digoxin is indicated to control heart rate in patients with severe left ventricular (LV) dysfunction.The J-Land study (Japanese landiolol versus digoxin study) demonstrated that landiolol achieved faster control of heart rate among AF/AFL patients with LV dysfunction compared with digoxin. 5,6) The safety profiles were comparable between the two drugs. In the J-Land study, however, patients with severe LV dysfunction (ejection fraction: EF < 25%) or severe hypotension (systolic blood pressure < 90 mmHg) were excluded and there has been limited experience of landiolol among such patients. We here r...

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Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale for therapy

Cited by 841 publications

References 46 publications

Impact of Atrial Fibrillation on Outcome of Patients with Idiopathic Dilated Cardiomyopathy: Data from the Heart Muscle Disease Registry of Trieste

Impact of Atrial Fibrillation on Outcome of Patients with Idiopathic Dilated Cardiomyopathy: Data from the Heart Muscle Disease Registry of Trieste

Atrial Fibrillation: A Perspective

An Experience of Landiolol Use for an Advanced Heart Failure Patient With Severe Hypotension

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