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Taiwan Crit. Care Med.2010;11:188-191 Lung-Ching Chen et al. MANAGEMENT OF PATIENTS WITH ACUTE HEART FAILURE AND ATRIAL FIBRILLATION Lung-Ching Chen, Chia-Yu Chou Abstract Acute heart failure (AHF) patients are commonly encountered in intensive care units (ICUs) and their managements are challenging to intensivists. Atrial fibrillation (AF) is one of the most common cardiac rhythms among patients of AHF. It is estimated that 20% to 30% of AHF patients have rapid AF during acute stage of hospital admission. The relationship between AHF and AF is complex in the sense that they interact with each other. Acute heart failure will cause rapid AF, and rapid AF may in turn precipitate AHF. When the above 2 conditions present together, the morbidity and mortality of patients will increase, attributable to both the underlying disease condition and from the therapy used. Intensivists taking care of AHF patients with rapid AF should carefully evaluate the patient and consider 3 different situations: 1. Patients with newly onset acute heart failure with newly onset AF; 2. Patients of chronic heart failure with newly onset AF; and 3. Patients of decompensated chronic heart failure with chronic AF and rapid ventricular response. Other considerations which will influence the treatment strategy include: 1. Is the patient’s baseline left ventricular systolic function preserved or reduced? 2. What is the duration of the AF episode? 3. Is the patient already treated with antiarrhythmic drugs for rhythm control or using only rate control agents, with or without anticoagulation? 4. What comorbidities are present? In this article management strategies according to different clinical scenarios will be discussed. Key words: Atrial fibrillation, Heart failure, Antiarrhythmia agents Introduction of AHF patients have rapid AF during acute stage of hospital admission.1 Although AHF and rapid AF occurring together are so frequently encountered in clinical practice, there are only few published data that specifically address this problem. Clinicians frequently make treatment decisions without adequate evidence or consensus expert opinion. Acute heart failure (AHF) patients are commonly encountered in intensive care units (ICUs) and their managements are challenging to intensivists. Atrial fibrillation (AF) is one of the most common cardiac rhythms among patients of AHF. It is estimated that 20% to 30% Correspondence: Dr. Lung-Ching Chen Department of Critical Care Medicine, Taipei Veterans General Hospital, No. 201 Sec. 2, Shih-Pai Road, Taipei, Taiwan Phone: 886-2-2875-7887; Fax: 886-2-2875-7890; E-mail: [email protected] 188 Taiwan Crit. Care Med.2010;11:188-191 !"#$%& '()*+ Interaction Between Heart Failure and Atrial Fibrillation Goals of Management The general goals of AHF management are to improve symptoms, restore oxygenation, improve organ perfusion, and limit cardiac and renal injury.4 Standard therapies for AHF include use of vasodilators, oxygen, loop diuretics, positive inotropic agents, and mechanical devices to support ventilation or cardiac output. In AHF patients with rapid AF, there are also increased risk of thromboembolic complications. Therefore, management of AHF patients with rapid AF involves three objectives: rate control; correction of the rhythm disturbance; and prevention of thromboembolism.5 The relationship between AHF and AF is complex in the sense that they interact with each other. Acute heart failure will cause rapid AF, and rapid AF may in turn precipitate AHF. When the above 2 conditions present together, the morbidity and mortality of patients will increase, attributable to both the underlying disease condition and from the therapy used.2 Specifically speaking, untoward effects of rapid AF in patients with AHF include loss of atrial ‘kick’ which may reduce cardiac output by 25%, and rapid and irregular ventricular rates which impede adequate diastolic filling of the left ventricle. Both of the above 2 mechanisms may account for reduced cardiac output, then leading to worsening the heart failure situation. Calcium channel blockers, beta blockers and some antiarrhythmic agents may also in themselves carry some risk to depressing the myocardial contractility. On the other hand, acute worsening HF will lead to volume overload thus increasing the atrial stretch, and the sympathetic tone will be over stimulated secondary to reduced cardiac output. All these changes will render the AF more difficult and resistant to treatment using either a rate- control or a rhythmcontrol strategy (Fig. 1). Assessment Intensivists taking care of AHF patients with rapid AF should carefully evaluate the patient and thoroughly review the clinical history which provides critical information that should be used to guide therapy. There may be 3 different clinical situations: 1. Patients with newly onset acute heart failure with newly onset AF; 2. Patients of chronic heart failure with newly onset AF; and 3. Patients of decompensated chronic heart failure with chronic AF and rapid ventricular response. Other considerations which will influ- Fig. 1. Interactions between acute heart failure and atrial fibrillation. Modified from reference 3. 189 Taiwan Crit. Care Med.2010;11:188-191 Lung-Ching Chen et al. possible. Anticoagulation status must be known if any form of cardioversion is to be attempted, unless the episode is definitely known to be of less than 48 hours duration. The appropriate drug of choice for either rate control or rhythm control should be guided by the patients’ left ventricular function. Concomitant disorders such as renal disease, pulmonary disease or infection may also require specific therapy.6 The Atrial Fibrillation and Heart Failure Trial has shown no benefit associated with a rhythm control strategy.7 However, in patients with new- or recent-onset AF, an attempt at cardioversion and drug therapy is reasonable, with the final decision on a longterm strategy based on symptoms, drug tolerance, and the frequency of recurrent episodes. ence the treatment strategy include: 1. Is the patient’s baseline left ventricular systolic function preserved or reduced? 2. What is the duration of the AF episode? 3. Is the patient already treated with antiarrhythmic drugs for rhythm control or using only rate control agents, with or without anticoagulation? 4. What comorbidities are present?3 Potential precipitating factors and comorbidies should be identified and if possible, corrected. For example, electrolyte abnormalities, hyperthyroidism, alcohol consumption, mitral valve disease, acute ischemia, cardiac surgery, acute pulmonary disease, infection, and uncontrolled hypertension. Rate Control or Rhythm Control? Whether a rate control or a rhythm control strategy should be employed will depend very much on the clinical scenario. The duration of AF episode will affect decisions about the advisability and potential for spontaneous, pharmacological, or electrical cardioversion and selection of agents for rhythm or rate control. In the first kind of clinical scenario in which patients have newly onset acute heart failure with newly onset AF, regardless whether the AF episode itself has rapidly precipitated heart failure in a previously stable patient or worsening heart failure has triggered an acute episode of AF, the potential for successful early restoration of sinus rhythm is high if the heart failure symptoms can be controlled. A second kind of clinical scenario is that a patient develops an episode of AF for which the patient is either unaware or does not seek medical attention, and gradually the patient develops AHF and presents with severe symptoms. For this kind of patients, the AF would probably not convert spontaneously and an initial rate control strategy would seem appropriate. They may be candidates for a later cardioversion attempt. The third kind of clinical scenario refers to patients of decompensated chronic heart failure with chronic AF and rapid ventricular response due to some kind of stress. For this kind of patients longterm restoration of sinus rhythm will rarely be References 1. Krum H, Gilbert RE. Demographics and concomitant disorders in heart failure. Lancet 2003;362:147-158. 2. Stevenson WG, Stevenson LW. Atrial fibrillation and heart failure: five more years. N Engl J Med 2004; 351:2437. 3. DiMarco JP. Atrial fibrillation and acute decompensated heart failure. Circ Heart Fail 2009;2:72-73. 4. Dickstein K, Cohen-Solai A, Filippatos G, McMurray JJV, Ponikowski P, Poole-Wilson PA, Stromberg A, van Veldhuisen DJ, Atar D, Hoes AW, Keren A, Mebazza A, Nieminen M, Priori SG, Swedberg K. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008. Eur Heart J 2008;29: 2388-2442. 5. Efremidis M, Pappas L, Sideris A, Filippatos G. Management of atrial fibrillation in patients with heart failure. J Card Fail 2008;14:232-237. 6. Kanji S, Steward R, Fergusson DA, McIntyre L, Turgeon AF, Herbert PC. Treatment of new onset atrial fibrillation in noncardiac intensive care unit patients: a systemic review of randomized controlled trials. Crit Care Med 2008;36:1620-1624. 7. Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, Lee KL, Bourassa MG, Arnold MO, Buxton AE, Camm AJ, Connolly SJ, Dubuc M, Ducharme A, Guerra PG, Hohnloser SH, Lambert J, Le Heuzey J-Y, O’Hara G, Pederson OD, Rouleau J-L, Singh BN, Stevenson LW, Stevenson WG, Thibault B, Waldo AL, for the Atrial Fibrillation and Congestive Heart Failure Investigators. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med 2008;358:2667-2677. 190 !"#$%& '()*+ Taiwan Crit. Care Med.2010;11:188-191 !"#$%& '()*+,-. 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