New AF with a fast rate and a weak ventricle — case discussion

Objectives

1. Control the ventricular rate in AF with LVEF of 40% or less (ESC 2024).^[1]
2. Start stroke prevention using CHA2DS2-VA and choose the anticoagulant.^[1]
3. Recognise possible tachycardia-induced cardiomyopathy and plan rhythm control, including where catheter ablation fits.^[1]

Candidate brief

Practice case discussion; this is not a real patient. You are the cardiology registrar asked to see him on the ward. In 15 minutes, give your assessment, immediate plan and longer-term plan.

Expected actions

• Confirm the rhythm. Confirmation by an ECG is recommended to establish the diagnosis of clinical AF and commence risk stratification and treatment (ESC 2024, Class I, level A).^[1]
• Check stability. He is alert and normotensive, so this is not the setting of acute or worsening haemodynamic instability, in which electrical cardioversion is recommended to improve immediate patient outcomes (ESC 2024, Class I, level C).^[1]
• Congestion first. Diuretics are recommended in patients with AF, heart failure and congestion to alleviate symptoms and facilitate better AF management (ESC 2024, Class I, level C); he has been decongested and is now euvolaemic.^[1]
• Control the rate. With LVEF of 40% or less, beta-blockers and/or digoxin are recommended to control heart rate and reduce symptoms (ESC 2024, Class I, level B); ESC Table 12 lists beta-blockers as contraindicated in acute heart failure and history of severe bronchospasm, and he now has neither; in its long-term rate control table the ACC/AHA classes non-dihydropyridine calcium channel blockers in AF with LVEF below 40% as COR 3: Harm (LOE C-LD), given their potential to exacerbate heart failure, and in AF with heart failure finds digoxin reasonable for rate control, combined with other rate-controlling agents or as monotherapy if other agents are not tolerated (COR 2a, LOE B-R).^[1][2]
• Prevent stroke. His CHA2DS2-VA score is 3 (heart failure 1, hypertension 1, age 65–74 years 1), and a CHA2DS2-VA score of 2 or more is recommended as an indicator of elevated thromboembolic risk for decisions on initiating OAC (ESC 2024, Class I, level C); OAC is recommended in patients with clinical AF at elevated thromboembolic risk to prevent ischaemic stroke and thromboembolism (Class I, level A), and DOACs are recommended in preference to VKAs to prevent ischaemic stroke and thromboembolism, except in patients with mechanical heart valves or moderate-to-severe mitral stenosis (Class I, level A); he has neither.^[1]
• Think tachycardia-induced cardiomyopathy. The ACC/AHA says that with a new diagnosis of HFrEF and AF, arrhythmia-induced cardiomyopathy should be suspected and an early and aggressive approach to rhythm control is recommended (COR 1, LOE B-NR).^[2]
• Plan rhythm control. AF catheter ablation is recommended in AF and HFrEF with high probability of tachycardia-induced cardiomyopathy, to reverse LV dysfunction (ESC 2024, Class I, level B), and should be considered in selected AF patients with HFrEF to reduce heart failure hospitalisation and prolong survival (ESC 2024, Class IIa, level B). Amiodarone is recommended in patients with AF and HFrEF requiring long-term antiarrhythmic drug therapy to prevent recurrence and progression of AF, with careful consideration and monitoring for extracardiac toxicity (ESC 2024, Class I, level A). The ACC/AHA finds catheter ablation beneficial in appropriate patients with AF and HFrEF on GDMT with a reasonable expectation of procedural benefit, to improve symptoms, quality of life, ventricular function and cardiovascular outcomes (COR 1, LOE A), and dofetilide or amiodarone reasonable for long-term maintenance of sinus rhythm in AF with HFrEF (LVEF 40% or less) (COR 2a; LOE A for dofetilide, B-NR for amiodarone).^[1][2]
• Anticoagulate around procedures. Therapeutic OAC for at least 3 weeks (adherence to DOACs or INR 2.0 or more for VKAs) is recommended before scheduled cardioversion of AF to prevent procedure-related thromboembolism (ESC 2024, Class I, level B), and initiation of OAC is recommended at least 3 weeks before catheter-based ablation in AF patients at elevated thromboembolic risk, to prevent peri-procedural ischaemic stroke and thromboembolism (Class I, level C).^[1]
• Treat the heart failure. SGLT2 inhibitors are recommended for patients with heart failure and AF regardless of LVEF to reduce heart failure hospitalisation and cardiovascular death (ESC 2024, Class I, level A).^[1]
• Follow up. After recovery of LV function in AF-induced cardiomyopathy, long-term surveillance can be beneficial to detect recurrent AF, in view of the high risk of recurrence of arrhythmia-induced cardiomyopathy (ACC/AHA 2023, COR 2a, LOE B-NR).^[2]

Marking

Pass:

• Uses a beta-blocker and/or digoxin for rate control in AF with LVEF of 40% or less (ESC 2024).^[1]
• Starts OAC on the CHA2DS2-VA score, preferring a DOAC (ESC 2024).^[1]
• Raises tachycardia-induced cardiomyopathy and plans rhythm control, placing catheter ablation by the ESC 2024 heart failure rows: Class I in HFrEF with high probability of tachycardia-induced cardiomyopathy, to reverse LV dysfunction; Class IIa in selected HFrEF, to reduce heart failure hospitalisation and prolong survival; or by the ACC/AHA 2023 row: beneficial in appropriate patients with AF and HFrEF on GDMT with reasonable expectation of procedural benefit, to improve symptoms, quality of life, ventricular function and cardiovascular outcomes (COR 1, LOE A).^[1][2]

Fail:

• Gives verapamil or diltiazem despite LVEF of 30%.^[1][2]
• Withholds anticoagulation because the AF might prove paroxysmal, or gives aspirin instead.^[1]