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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EAtrial fibrillation (AF) in patients with heart failure (HF) is a growing problem because of the increasing incidence of HF related to long-standing hypertension, atrial remodeling due to elevated left ventricular diastolic pressure in HF patients, and the increasing age of the population. This article discusses the treatment of AF in HF patients.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHeart Failure\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EAtrial fibrillation (AF) in patients with heart failure (HF) is a growing problem because of the increasing incidence of HF related to long-standing hypertension, atrial remodeling due to elevated left ventricular diastolic pressure (LVEDP) in HF patients, and the increasing age of the population. Alfred A. Bove, MD, PhD, Temple University Medical School, Philadelphia, Pennsylvania, USA, discussed the treatment of AF in HF patients.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe severity of HF and the incidence of AF are positively correlated; about half of patients with NYHA Class IV HF develop AF [Savelieva I and Camm AJ. \u003Cem\u003EEuropace\u003C\/em\u003E 2004]. Ten-year outcomes from the Framingham study showed that 35% of patients with HF developed AF and 28% of patients with AF developed HF [Wang TJ et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2003]. The Euro Heart Failure study included 10,701 patients hospitalized with HF; 3673 had previous AF, 1001 had new AF, and 6027 did not have AF [Rivero-Ayerza M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2008]. Patients with new-onset AF spent the most days in the intensive care unit (ICU), while those with previous or no AF had the same number of ICU days. Patients with AF when admitted had a mortality rate of 7% compared with about 13% in patients with new AF.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EIn the Get with the Guidelines Registry (US), 31.4% of 99,810 patients admitted for HF had AF [Mountantonakis SE et al. \u003Cem\u003ECirc Heart Fail\u003C\/em\u003E 2012]. Approximately 41.5% of patients in normal sinus rhythm were hospitalized \u0026gt;4 days compared with 48.8% of those with AF. Hospital mortality was higher in patients with AF (4.0%) than in those without AF (2.6%).\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EA study of 1376 patients with NYHA class III\/IV HF and AF evaluated rhythm control (n=682) versus rate control (n=694) for AF [Roy D et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2008]. The Kaplan-Meier curves showed no significant difference between the 2 groups for worsening HF, stroke, and death from any cause. In the Atrial Fibrillation Follow-Up Investigation of Rhythm Management [AFFIRM] trial of rhythm versus rate control for AF, 1 to 3 year outcomes were the same for the rhythm and rate control groups [Ionescu-Ittu R et al. \u003Cem\u003EArch Intern Med\u003C\/em\u003E 2012]. However, mortality significantly decreased in the rhythm control versus rate control group after 5 years (5-year HR, 0.89; 95% CI, 0.81 to 0.96; 8-year HR, 0.77; 95% CI, 0.62 to 0.95; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/27\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022AFFIRM Rate vs Rhythm Control: Mortality.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-365590810\u0022 data-figure-caption=\u0022AFFIRM Rate vs Rhythm Control: Mortality.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/27\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/27\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/27\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12871\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003EAFFIRM Rate vs Rhythm Control: Mortality.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EAFFIRM=Atrial Fibrillation Follow-up Investigation of Rhythm Management.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from F. Bove, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-7\u0022\u003EA study of patients with HF and AF treated with rhythm (n=13) versus rate (n=13) control found that LV fractional shortening significantly increased from 20% to 31% with rhythm control (p\u0026lt;0.0001) [Azpitarte J et al. \u003Cem\u003EChest\u003C\/em\u003E 2001]. Rhythm control patients had significant decreases from baseline in LV end diastolic (LVED) dimension (p=0.014), left atrial diameter (LAD; p=0.003), and heart rate (p\u0026lt;0.0001). These parameters did not change significantly in the rate control group. Lutomsky et al. [\u003Cem\u003EEuropace\u003C\/em\u003E 2008] reported that ablation for paroxysmal AF in patients with ejection fraction (EF) \u0026lt;50% resulted in 50% recurrence rate of AF at 5 months and an increase in LVEF from 41%\u00b16% to 51%\u00b112%. Meanwhile, patients with an LVEF \u226550% had a rate of recurrence of AF of only 27% at 5 months. These data justify efforts to maintain or restore sinus rhythm in patients with heart failure.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EA study of dronedarone in patients with high-risk permanent AF found that dronedarone increased the numbers of patients with HF (43 vs 24; HR, 1.81; 95% CI, 1.10 to 2.99; p=0.02), stroke (23 vs 10; HR, 2.32; 95% CI, 1.11 to 4.88; p=0.02), arrhythmic death (13 vs 4; HR, 3.26; 95% CI, 1.06 to 10.00; p=0.03), and cardiovascular death (21 vs 10; HR, 2.11; 95% CI, 1.00 to 4.49; p=0.046; \u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) compared with placebo [Connolly SJ et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011]. Therefore, dronedarone should be avoided in patients with HF and permanent AF.\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/27\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Dronedarone Increased Deaths, Stroke, and HF.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-365590810\u0022 data-figure-caption=\u0022Dronedarone Increased Deaths, Stroke, and HF.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/27\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/27\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/12\/27\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12872\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003EDronedarone Increased Deaths, Stroke, and HF.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EHF=heart failure.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EReproduced with permission from F. 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