Arq. Bras. Cardiol. 2025; 122(4): e20240585

Treating Patients with Heart Failure with Reduced Ejection Fraction (HFrEF) and Atrial Fibrillation: We Need to Talk About the Fifth Pillar

Mauricio Pimentel , Lucas Simonetto Faganello , Ana Paula Arbo Magalhães, Eduardo Caberlon , Leandro Ioschpe Zimerman

DOI: 10.36660/abc.20240585i

Heart failure with reduced ejection fraction (HFrEF) is a complex clinical syndrome characterized by symptoms of dyspnea and worsening functional capacity resulting from reduced cardiac output in patients with left ventricular ejection fraction (LVEF) ≤40%. HFrEF represents an important public health problem, being one of the main causes of hospital admission, with high morbidity and mortality rates. Based on large randomized clinical trials, the standard treatment for patients with HFrEF until the late 1990s consisted of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs). After about two decades, a new era in the treatment of HFrEF began with the publication of randomized clinical trials on new classes of drugs: angiotensin receptor-neprilysin inhibitors (ARNIs) and sodium-glucose co-transporter 2 (SGLT2) inhibitors. Based on this evidence, the guidelines defined the four pillars of HFrEF treatment: ACEIs or ARNIs, beta-blockers, MRAs, and SGLT2 inhibitors.^, In addition to pharmacological treatment, the implantation of a cardioverter-defibrillator and cardiac resynchronization therapy are also indicated for patients with specific clinical features.

Atrial fibrillation (AF) and HFrEF share common risk factors and often coexist, leading to exacerbation of clinical condition and poorer prognosis for both. The diagnosis of AF in patients with HFrEF is associated with increased mortality. HFrEF is a risk factor for increased incidence of AF and is associated with a higher risk of stroke in patients with AF. The importance of determining the best therapeutic approach for patients with AF and HFrEF led to randomized clinical trials comparing rhythm control and heart rate control strategies. The Dofetilide in Patients with Congestive Heart Failure and Left Ventricular Dysfunction (DIAMOND-CHF) study compared the use of dofetilide with placebo in patients with ventricular dysfunction. In the analysis of patients with AF, it was shown that the use of dofetilide resulted in a higher rate of reversion and maintenance of sinus rhythm, but with no effect on overall mortality. The Rhythm Control versus Rate Control for Atrial Fibrillation and Heart Failure (AF-CHF) study compared rhythm control strategies (cardioversion and antiarrhythmic drug, with amiodarone being the drug of choice) to heart rate control in patients with LVEF ≤ 35%. The rhythm control strategy did not show a reduction in cardiovascular mortality compared to heart rate control. It is important to note that, during follow-up, 58% of the patients in the rhythm control group had a recurrence of AF. In fact, the rhythm control strategy was not very effective in maintaining patients in sinus rhythm.

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