Top Things to Know: Managing Atrial Fibrillation in Patients With Heart Failure and Reduced Ejection Fraction

Published: June 24, 2021

  1. Atrial fibrillation (AF) prevalence in the United States was estimated to be about 5.2 million and is projected to increase to 12.1 million by year 2030. Heart failure (HF) affects more than 6.2 million American adults. The prevalence of HF increases with age, reaching more than 12% in patients older than 80 years of age. AF and HF share common risk factors that are interrelated.
  2. AF and HF are often linked through shared risk factors such as increasing age, hypertension, diabetes, and structural heart disease. In addition, both cause hemodynamic, electrophysiological and neurohormonal changes resulting in adverse cardiac remodeling.
  3. Managing AF in patients with systolic HF or HF with reduced ejection fraction (HFrEF) is a therapeutic challenge with several considerations that are discussed in this scientific statement.
  4. In patients with AF and HFrEF, in addition to therapy targeted for AF, and comprehensive treatment strategy should include maximally tolerated guideline directed HF therapy and lifestyle and aggressive risk factor management.
  5. Patients with AF and HFrEF should be on anticoagulation therapy for stroke prevention based on CHA2DS2VASc score with direct oral anticoagulants (DOACs) as first line option and warfarin as an alternative.
  6. In patients with AF and HFrEF who are deemed candidates for rhythm control, catheter ablation (CA) is preferred over pharmacological therapy alone.
  7. In patients with AF and HFrEF, the decision to undergo CA should take into consideration several factors, including severity of left ventricular (LV) dysfunction, function class, comorbid conditions, hemodynamic stability, ventricular scar burden, duration of AF, and the degree of adverse atrial structural remodeling for determining optimal candidates.
  8. In patients with AF and HFrEF who are deemed candidates for CA, the decision to pursue rate control with or without cardioversion should be individualized according to symptoms and overall clinical status as both strategies are equivalent for outcomes.
  9. Patients with AF and HFrEF selected as good candidates for rhythm control with CA, consider doing the procedure earlier in the natural history of AF and HFrEF versus later.
  10. The interdisciplinary care team collaboration is a gold standard and especially between the HF and electrophysiology specialists which allow for early recognition of these patients, institution of prompt rate control, anticoagulation, and effective rhythm control, preferably by CA.


Gopinathannair R, Chen LY, Chung MK, Cornwell WK, Furie KL, Lakkireddy DR, Marrouche NF, Natale A, Olshansky B, Joglar JA; on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee and Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Hypertension; Council on Lifestyle and Cardiometabolic Health; and the Stroke Council. Managing atrial fibrillation in patients with heart failure and reduced ejection fraction: a scientific statement from the American Heart Association. Circ Arrhythm Electrophysiol. 2021;14:e000078. doi: 10.1161/HAE.0000000000000078