Management of AF in Acute Heart Failure

Priority #1 - Cardioversion

Cardioversion if hemodynamic compromises

CARDIOVERSION STRATEGY

Use Maximum Energy
to improve success rate, reduce procedural time, without risk of myocardial injury.

May Use Dual Shock Strategy in Obesity
to improve success rate without increase risk of adverse events.

EHJ 2020 and JAMA Cardiol 2024

EHJ 2020

JAMA Cardiol 2024

#2 Anticoagulation

'C' in CHA2DS2-VASc means clinical heart failure regardless of LVEF.

JACC EP 2022

JACC Cardiol 2024

JACC HF 2016

Clinical heart failure is one of the risk for ischemic stroke in AF.

#3 Why today? Who started first?

Scenarios	AF is known?	Ventricular rate	Other HF triggers	AF is...	Management of AF
1	Yes	120-160	No	causal	rapid rate/rhythm control
2	No	120-160	Yes	consequence	Tx of HF is more important
3	Yes	60-100	Yes	bystander	no change
4	Yes	100-120	??	??	rate control

Eur Heart J Acute Cardiovasc Care 2020.

RATE CONTROL AGENTS

IV Amiodarone
Beware of hypotension from vasodilatory effect of IV form

IV Digoxin
Onset 30 mins, peak action 2 hrs

IV Diltiazem & IV beta-Blocker
Use with caution. Avoid in significant LV dysfunction and hypotension.

IV Magnesium
A natural calcium channel blocker. Modest effect for rate control.

2020 CCS Guidelines for AF and 2023 ACC Guidelines for AF

Acad Emerg Med 2019

Lancet 2016

JACC Adv 2024

J Card Fail 2022

1. AF can be the cause, the consequence, and the bystander during acute HF.
2. For rate control, amiodarone and digoxin are the recommended agents.

#4 Catheter Ablation for Long-term Treatment

NEJM 2018 and Circulation 2024

Circulation 2021

NEJM 2018 and Circulation 2021

JACC 2019

1. Consider catheter ablation in selected HFrEF and possibly HFpEF.
2. Don't forget to encourage lifestyle modification and medication adherence before discharge and at the very first OPD visit.