Heart failure and atrial flutter: a systematic review of current knowledge and practices

Abstract

While the interplay between heart failure (HF) and atrial fibrillation (AF) has been extensively studied, little is known regarding HF and atrial flutter (AFL), which may be managed differently. We reviewed the incidence, prevalence, and predictors of HF in AFL and vice versa, and the outcomes of treatment of AFL in HF. A systematic literature review of PubMed/Medline and EMBASE yielded 65 studies for inclusion and qualitative synthesis. No study described the incidence or prevalence of AFL in unselected patients with HF. Most cohorts enrolled patients with AF/AFL as interchangeable diagnoses, or highly selected patients with tachycardia‐induced cardiomyopathy. The prevalence of HF in AFL ranged from 6% to 56%. However, the phenotype of HF was never defined by left ventricular ejection fraction (LVEF). No studies reported the predictors, phenotype, and prognostic implications of AFL in HF. There was significant variation in treatments studied, including the proportion that underwent ablation. When systolic dysfunction was tachycardia‐mediated, catheter ablation demonstrated LVEF normalization in up to 88%, as well as reduced cardiovascular mortality. In summary, AFL and HF often coexist but are understudied, with no randomized trial data to inform care. Further research is warranted to define the epidemiology and establish optimal management.

Clinical outcomes after catheter ablation of atrial arrhythmias guided by ultra-high density mapping system in heart failure patients

“…In the particular setting of HF patients, the overlap between AF and AT is important and should justify to study these atrial arrhythmias together. 17 In our study, the high proportion of AT was consistent with the high proportion of repeated procedures as previous ablation can lead to additional atrial scar and subsequent complex ATs. In our study, the type of arrhythmia was not predictive of recurrence.…”

Association between sodium-glucose cotransporter-2 inhibitors and incident atrial fibrillation/atrial flutter in heart failure patients with reduced ejection fraction: a meta-analysis of randomized controlled trials

“…In the same context, the Catheter Ablation Versus Standard Conventional Treatment in Patients With Left Ventricular Dysfunction and Atrial Fibrillation (CASTLE-AF) study indicated that maintenance of sinus rhythm in patients with HFrEF by catheter ablation of AF significantly reduces mortality [21]. Even though AFL is much less well studied, it is considered to have similar clinical significance and consequences to AF [3]. Therefore, prevention of AF and/or AFL is of particular importance in the setting of HFrEF.…”

“…In patients with HFrEF, AF, especially if new-onset or paroxysmal, has been associated with a significantly increased risk of adverse outcomes [2]. Additionally, atrial flutter (AFL), although much less well studied, is considered to have a similar clinical impact [3]. Furthermore, AF and AFL impose significant therapeutic challenges in the setting of HFrEF [4].…”

Impact of cavotricuspid isthmus ablation for typical atrial flutter and heart failure in the elderly—results of a retrospective multi-center study

“…With an incidence of around 88/100,000 person-years in the general population and 567/100,000 in patients over 80 years old, atrial flutter (AFL) is one of the most common arrhythmias ( 1 ). Electrophysiologically it is a macro-reentry circuit around the tricuspid annulus using the cavotricuspid isthmus (CTI) as a critical passage at the inferior boundary.…”

“…The pathophysiological mechanism of AFL consists of greatly increased atrial frequencies that lead to a consecutive overload of the atria, to a reduced filling of the atria and ultimately to a reduced ejection of blood volume from both the atria and the ventricles. Tachycardic conduction of AFL to the ventricles can induce tachymyopathy ( 1 ).…”