Atrial Fibrillation and Heart Failure With Reduced Ejection Fraction

Atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) frequently occur together as a result of shared functional, structural, and electrical remodeling, thereby worsening the prognosis and quality of life of affected patients. Despite substantial advances in elucidating the complex interplay between AF and HFrEF, numerous critical questions remain unanswered, underscoring the need for continued investigation to address the persistent uncertainties surrounding this challenging comorbidity. The development and wide application of catheter ablation for rhythm control has highlighted the importance of controlling AF in patients with HFrEF, along with the benefits of rhythm control in this population. Whereas early rhythm control appears to be important, many questions remain unanswered about optimal timing parameters, benefits of specific energy sources and lesion sets, and the role of ancillary pharmacologic therapy. Personalized management is essential for optimized care of patients with AF and HFrEF, but extensive additional research is required to enable the individualized care needed. In this narrative review, we aim to analyze the rapidly evolving evidence regarding the interrelationships between these common conditions, discuss the underlying basic mechanisms, review evidence regarding treatment options, and highlight gaps in knowledge.