Download management of patients with acute heart failure and atrial fibrillation

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]
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Taiwan Crit. Care Med.2010;11:188-191
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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.
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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
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