Management of Heart Failure with Preserved Ejection Fraction and Atrial Fibrillation

Understanding the HFpEF-AF Relationship

Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) frequently coexist, with AF prevalence increasing with heart failure severity, from 4% in NYHA class I to 40% in NYHA class IV patients 1
These conditions can perpetuate and exacerbate each other through mechanisms such as rate-dependent worsening of cardiac function, fibrosis, and activation of neurohumoral vasoconstrictors 1
AF can worsen HFpEF symptoms, and conversely, worsening HF can promote a rapid ventricular response in AF 1

The American College of Cardiology recommends SGLT2 inhibitors (empagliflozin or dapagliflozin) as first-line disease-modifying therapy for most HFpEF patients, including those with AF 2
EMPEROR-Preserved demonstrated a significant 21% reduction in the primary composite endpoint of HF hospitalization or cardiovascular death with empagliflozin, driven mostly by a 29% reduction in HF hospitalizations 2

For HFpEF patients with AF, rate control is generally the preferred initial strategy over rhythm control, according to the American College of Cardiology 1
Beta-blockers are the preferred agents for achieving rate control in HFpEF patients with AF due to their favorable effects on controlling ventricular response 1
Non-dihydropyridine calcium channel antagonists (such as diltiazem) can be effective for rate control, particularly when used in combination with digoxin 1

Loop diuretics should be used at the lowest effective dose to manage congestion and improve symptoms, as recommended by the American Heart Association 5
Mineralocorticoid receptor antagonists (MRAs) like spironolactone may be beneficial in patients with LVEF on the lower end of the preserved spectrum (closer to 50%) 5
Angiotensin receptor-neprilysin inhibitors (ARNi) or angiotensin receptor blockers (ARBs) may be beneficial in selected patients, especially those with LVEF on the lower end of the preserved spectrum 5

Optimize blood pressure control to target <130/80 mmHg using appropriate antihypertensive medications, as recommended by the American College of Cardiology 2
Manage diabetes with preference for SGLT2 inhibitors given their additional heart failure benefits 3

AV node ablation should not be performed without a pharmacological trial to achieve ventricular rate control, according to the American College of Cardiology 1
Do not delay initiation of SGLT2 inhibitors which have proven mortality benefits 3

Consider AV node ablation and cardiac resynchronization therapy device placement when rate control cannot be achieved either because of drug inefficacy or intolerance, as recommended by the American College of Cardiology 1