CORRESPONDENCE: LETTER TO THE EDITOR
Guidelines for Atrial Fibrillation in Heart Failure Need To Be Clarified
Marcelle D. Smit, MD,
Dirk J. Van Veldhuisen, MD, PhD and
Isabelle C. Van Gelder, MD, PhD*
* Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands (Email: i.c.van.gelder{at}thorax.umcg.nl).
We want to congratulate Nieuwlaat et al. (1) for their report from the Euro Heart Survey, providing valuable insights into the management of atrial fibrillation (AF) and heart failure (HF) in daily clinical practice. They concluded that patients with AF and HF might be severely undertreated with regard to HF therapy and rate control, referring to the guidelines for AF (2) and for HF (3). Nevertheless, we are not sure whether these patients are always undertreated.
First of all, the investigators considered a combination of a beta-blocker, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and oral anticoagulation to be "the full package" for AF and (systolic) HF. We want to emphasize, however, that it has never been established that beta-blockers improve morbidity and mortality in HF patients with AF. Indeed, post hoc analyses of the CIBIS II (The Cardiac Insufficiency Bisoprolol Study II) and MERIT-HF (Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure) studies were not able to demonstrate that beta-blockers decreased morbidity and mortality in HF patients that had AF (4,5). Certainly prospective randomized trials are needed to elucidate whether beta-blockers improve outcome in HF patients that are also known with AF, especially considering that these conditions often coexist.
Second, the investigators believed that 40% of patients with HF and permanent AF were receiving inadequate rate control because they had a resting heart rate of  80 beats/min, implying that 80 beats/min is the maximal target for rate control. Though this target has been used before (6,7), there is no evidence as to which rate control target we should aim for. In fact, an analysis of patients with advanced HF demonstrated that outcome was similar in patients who had a lower heart rate than 80 beats/min as in patients who had a higher heart rate than 80 beats/min (8). The RACE II (Rate Control Efficacy in Permanent Atrial Fibrillation) study, investigating the optimal heart rate in permanent AF with or without HF by randomizing patients to either strict (heart rate <80 beats/min and heart rate during minor exercise <110 beats/min) or lenient (heart rate <110 beats/min) rate control, is much awaited for to clarify this clinically relevant issue (9).
In conclusion, the article by Nieuwlaat et al. (1) tells us much about daily clinical practice in treatment of patients with AF and HF, but it also emphasizes the need for evidence-based, unambiguous recommendations concerning beta-blocker use and rate control target in AF patients with HF.
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1. Nieuwlaat R, Eurlings LW, Cleland JG, et al. Atrial fibrillation and heart failure in cardiology practice: reciprocal impact and combined management from the perspective of atrial fibrillation: results of the Euro Heart Survey on atrial fibrillation J Am Coll Cardiol 2009;53:1690-1698.[Abstract/Free Full Text]2. Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) J Am Coll Cardiol 2006;48:854-906.[Free Full Text] 3. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail 2008;10:933-989.[CrossRef][Web of Science][Medline] 4. Lechat P, Hulot JS, Escolano S, et al. Heart rate and cardiac rhythm relationships with bisoprolol benefit in chronic heart failure in CIBIS II Trial Circulation 2001;103:1428-1433.[Abstract/Free Full Text] 5. Van Veldhuisen DJ, Aass H, El Allaf AD, et al. MERIT-HF Study Group Presence and development of atrial fibrillation in chronic heart failure. Experiences from the MERIT-HF Study. Eur J Heart Fail 2006;8:539-546.[Abstract/Free Full Text] 6. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation N Engl J Med 2002;347:1825-1833.[CrossRef][Web of Science][Medline] 7. Roy D, Talajic M, Nattel S, et al. Rhythm control versus rate control for atrial fibrillation and heart failure N Engl J Med 2008;358:2667-2677.[CrossRef][Medline] 8. Rienstra M, Van Gelder IC, Van den Berg MP, Boomsma F, Hillege HL, Van Veldhuisen DJ. A comparison of low versus high heart rate in patients with atrial fibrillation and advanced chronic heart failure: effects on clinical profile, neurohormones and survival Int J Cardiol 2006;109:95-100.[CrossRef][Web of Science][Medline] 9. Van Gelder IC, Van Veldhuisen DJ, Crijns HJ, et al. Rate Control Efficacy in Permanent Atrial Fibrillation: a comparison between lenient versus strict rate control in patients with and without heart failure. Background, aims, and design of RACE II. Am Heart J 2006;152:420-426.[CrossRef][Web of Science][Medline]
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