The comorbidity of atrial fibrillation and heart failure: a challenge for electrical therapies

Atrial fibrillation (AF) and heart failure mainly occur in older patients. Keystones of management are the optimal medical treatment of AF and heart failure, the use of oral anticoagulation, the case-specific decision to use rhythm or rate control, and the primary prevention of sudden cardiac death. Optimal medical heart failure therapy improves outcome and reduces the onset of new AF. The two options to treat AF, rhythm and rate control, have so far mainly been assessed in patients with preserved LV function. There have been some observations that persistence of sinus rhythm may prevent further deterioration of heart failure patients. Electrical therapies specially developed for the treatment of paroxysmal AF are preventive pacing with the use of pacing algorithms providing permanent atrial pacing above sinus rate and cardiac resynchronization therapy (CRT) for patients suffering from advanced heart failure. One important limitation of CRT is new onset of AF after implantation. A possible solution is the use of CRT devices, which also provide preventive pacing for suppression of AF. The efficacy of this approach combined with pacemaker-CRT or ICD-CRT is being tested in the randomized MASCOT study, which has completed patient enrolment.