Management of Atrial Fibrillation in the Patient With Heart Failure: An Expert Interv

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Management of Atrial Fibrillation in the Patient With Heart Failure: An Expert Interview With S. Adam Strickberger, MD

S. Adam Strickberger, MD, Professor of Medicine, Georgetown University School of Medicine, Washington, DC; Director, Arrhythmia Center, Washington Hospital Center, Washington, DC

Editor's Note:

Patients with both heart failure (HF) and atrial fibrillation (AF) offer a unique set of challenges and limitations for the physicians who treat them. In fact, when these 2 disorders present concurrently, they interact to affect hemodynamic functioning in a variety of ways, with the end result being worsening heart function and a poorer prognosis for the patient. Numerous studies have shown that AF contributes to the progression of HF, and the longer a patient has HF, the greater chance there is of developing AF. These findings point to the importance of appropriately treating both AF and HF simultaneously, but this is often a difficult task. Many AF treatment options are either risky or ineffective in these patients, and physicians often must walk a fine line when choosing which treatment approach to pursue.

To gain a clinical perspective on these issues, Medscape recently spoke with S. Adam Strickberger, MD, Director of the Arrhythmia Center at Washington Hospital Center (Washington, DC). In the following interview, Dr. Strickberger provides an overview of current AF therapeutic options and their advantages and disadvantages in various HF populations. He also shares his thoughts on the use of curative catheter ablation and atrioventricular (AV) node ablation in this patient population. According to Dr. Strickberger, there are numerous factors that need to be taken into consideration when treating AF in patients with HF, but the biggest challenge to physicians still centers on the choice between rate control and rhythm control.
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Heart Failure Performance Measures Not Associated With Improved Clinical Outcomes

January 4, 2007 — Current heart-failure performance measures, with the exception of the prescription of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) at discharge, have little relation to patient mortality or combined mortality/rehospitalization in the first 60 to 90 days after discharge, according to the results of a study published in the January 3 issue of JAMA. The prescription of beta-blockers at discharge, however, while not one of the measures of performance, was associated with the most significant improvement in heart-failure outcomes.
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Statin Therapy Reduces Mortality, Hospitalization Risk in Heart Failure Patients

November 2, 2006 — Patients with heart failure (HF) who start taking statins compared with those who do not will live longer and have a lower hospitalization risk regardless of cholesterol levels, presence or absence of coronary artery disease, and use of other cardiovascular drug therapies, according to a large cohort study.
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Emerging Therapies for the Management of Decompensated Heart Failure. From Bench to Bedside

Abstract

While pharmaceutical innovation has been highly successful in reducing mortality in chronic heart failure, this has not been matched by similar success in decompensated heart failure syndromes. Despite outstanding issues over definitions and end points, we argue in this paper that an unprecedented wealth of pharmacologic innovation may soon transform the management of these challenging patients. Agents that target contractility, such as cardiac myosin activators and novel adenosine triphosphate-dependent transmembrane sodium-potassium pump inhibitors, provide inotropic support without arrhythmogenic increases in cytosolic calcium or side effects of more traditional agents. Adenosine receptor blockade may improve glomerular filtration and diuresis by exerting a direct beneficial effect on glomerular blood flow while vasopressin antagonists promote free water excretion without compromising renal function and may simultaneously inhibit myocardial remodeling. Urodilatin, the renally synthesized isoform of atrial natriuretic peptide, may improve pulmonary congestion via vasodilation and enhanced diuresis. Finally, metabolic modulators such as perhexiline may optimize myocardial energy utilization by shifting adenosine triphosphate production from free fatty acids to glucose, a unique and conceptually appealing approach to the management of heart failure. These advances allow optimism not only for the advancement of our understanding and management of decompensated heart failure syndromes but for the translational research effort in heart failure biology in general.
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