Pharmacological Management of Atrial Fibrillation Across the Heart Failure Ejection Fraction Spectrum: Rate Control, Rhythm Control, and Beyond

Purpose of Review To summarise the contemporary pharmacological management of atrial fibrillation (AF) in heart failure (HF), focusing on rate and rhythm control and upstream therapies across the ejection fraction spectrum. Recent Findings Rate control remains a cornerstone of AF management, particularly in permanent AF or haemodynamically fragile patients, with beta-blockers, digoxin, and non-dihydropyridine calcium channel blockers selected according to ejection fraction phenotype. Concurrently, increasing evidence supports early rhythm-control strategies because of their prognostic benefits in HF populations, with current guidelines reinforcing a left ventricular ejection fraction (LVEF)-guided approach to antiarrhythmic drug selection. Beyond conventional drugs, HF guideline-directed medical therapy (GDMT) is emerging as an important upstream pharmacological strategy for modulation of the arrhythmogenic substrate. Summary AF management in HF requires an integrated, phenotype-oriented approach combining symptom control, thromboembolic prevention, and optimisation of GDMT. LVEF remains a key determinant of pharmacological safety and therapeutic selection, whereas haemodynamic status primarily guides acute management decisions.