心房颤动对慢性收缩性心力衰竭患者远期预后影响分析

目的 探讨心房颤动(房颤)对慢性收缩性心力衰竭(chronic systolic heart failure,CSHF)住院患者远期预后的影响.方法 回顾性调查和分析湖北地区8地市12家三级甲等医院2000年至2010年CSHF住院患者资料,单因素Kaplan-Meier曲线分析房颤和非房颤组总死亡、心血管病死亡、心脏泵功能衰竭死亡(心力衰竭死亡)、心脏性猝死和栓塞相关死亡差异.多因素Cox生存分析确认心力衰竭患者不同预后的危险因素.结果 ①共16681例患者纳入本次研究.房颤组与非房颤组相比,年龄(64.54 ±13.61)岁比(62.19±15.07)岁(P＜0.01)、左心室射血分数(LVEF)37.43± 12.72比38.42±13.96(P＜0.01)、心功能Ⅲ～Ⅳ级(NYHA分级)患者(5547/81.49％比7121/72.12％,P＜0.01)和病因等因素存在差异.②单因素Kaplan-Meier曲线分析发现,房颤组和非房颤组在总死亡、心血管病死亡、心力衰竭死亡和栓塞相关死亡存在差异,而在心律失常相关的心脏性猝死两组间差异无统计学意义.③多因素Cox回归分析发现房颤不是总死亡、心血管病死亡、心力衰竭死亡和心脏性猝死增加的独立危险因素,而增加栓塞相关死亡(HR=2.134,95％ CI,1.846～2.430,P＜0.0l)结论 房颤不增加CSHF患者远期总死亡、心血管病死亡、心力衰竭死亡和心脏性猝死,而增加栓塞相关死亡.提示房颤引起CSHF患者远期预后不良的原因可能在于其并发症.     

Clinical characteristics and prognostic impact of atrial fibrillation in patients with chronic heart failure

AIM To assess the prevalence, clinical characteristics and independent prognostic impact of atrial fibrillation(AF) in chronic heart failure(CHF) patients, and the potential protective effect of disease-modifying medications, particularly beta-blockers(BB). METHODS We retrospectively reviewed the charts of patients referred to our center since January 2004, and collected all clinical information available at their first visit. We assessed mortality to the end of June 2015. We compared patients with and without AF, and assessed the association between AF and all-cause mortality by multivariate Cox regression and Kaplan-Meyer analysis, particularly accounting for ongoing treatment with BB.RESULTS A total of 903 patients were evaluated(mean age 68 ± 12 years, 73% male). Prevalence of AF was 19%, ranging from 10% to 28% in patients ≤ 60 and ≥ 77 years, respectively. Besides the older age, patients with AF had more symptoms(New York Heart Association II-III 60% vs 44%), lower prevalence of dyslipidemia(23% vs 37%), coronary artery disease(28% vs 52%) and left bundle branch block(9% vs 16%). On the contrary, they more frequently presented with an idiopathic etiology(50% vs 24%), a history of valve surgery(13% vs 4%) and received overall more devices implantation(31% vs 21%). The use of disease-modifying medications(i.e., BB and ACE inhibitors/angiotensin receptor blockers) was lower in patients with AF(72% vs 80% and 71% vs 79%, respectively), who on the contrary were more frequently treated with symptomatic and antiarrhythmic drugs including diuretics(87% vs 69%) and digoxin(51% vs 11%). At a mean follow-up of about 5 years, all-cause mortality was significantly higher in patients with AF as compared to those in sinus rhythm(SR)(45% vs 34%, P value 0.05 for all previous comparisons). However, in a multivariate analysis including the main significant predictors of allcause mortality, the univariate relationship between AF and death(HR = 1.49, 95%CI: 1.15-1.92) became not statistically significant(HR = 0.98, 95%CI: 0.73-1.32). Nonetheless, patients with AF not receiving BB treatment were found to have the worst prognosis, followed by patients with SR not receiving BB therapy and patients with AF receiving BB therapy, who both had similarly worse survival when compared to patients with SR receiving BB therapy.CONCLUSION AF was highly prevalent and associated with older age, worse clinical presentation and underutilization of disease-modifying medications such as BB in a population of elderly patients with CHF. AF had no independent impact on mortality, but the underutilization of BB in this group of patients was associated to a worse long-term prognosis.     

心房颤动对慢性收缩性心力衰竭患者和射血分数正常心力衰竭患者预后的影响

目的 探讨心房颤动（简称房颤）对慢性收缩性心力衰竭（CSHF）及慢性射血分数正常心力衰竭（HF-PSF）住院患者预后的影响。方法 前瞻性分析武汉地区4家三级甲等教学医院848例心力衰竭（简称心衰）患者,根据左室射血分数分为CSHF组（n=560）、HFPSF组（n=288）。 每组根据有无房颤又分为房颤与非房颤亚组。 单因素Kaplan-Meier曲线分别分析CSHF和HFPSF患者房颤亚组和非房颤亚组总死亡 、 心脏泵功能衰竭死亡（心衰死亡）、 心源性猝死和栓塞相关死亡的差异 。多因素Cox风险比例模型分别比较CSHF和HFPSF患者房颤亚组与非房颤亚组不同预后的差异。 结果 单因素分析发现, CSHF和HFPSF组房颤亚组与非房颤亚组总死亡无差异。CSHF组中与非房颤亚组（n=374）相比,房颤亚组（n = 186）心衰死亡增高（P = 0. 01）、栓塞相关死亡增加（P0.05）。 多因素Cox风险比例模型分析发现房颤增加CSHF患者栓塞相关死亡风险（HR = 2. 106,95% CI：1. 436 - 2.719,P〈0. 01）。 结论 房颤对CSHF和HFPSF患者预后的影响存在差异,仅增加CSHF患者栓塞相关死亡风险。房颤影响CSHF患者预后的原因可能不在于心律失常本身而在于其并发症。     

慢性心力衰竭患者血清尿酸水平与心房颤动发生的关系及预测价值

目的 探讨慢性心力衰竭患者血清尿酸(SUA)水平与心房颤动(房颤)发生的关系及预测价值.方法 回顾性分析湖北地区2000年1月1日至2010年5月31日期间心力衰竭住院患者(包括多次入院患者的首次和末次入院)临床资料,所有患者均电话随访.按随访结果将患者分为房颤组和无房颤组、死亡组和存活组.单因素和多因素Cox分析心力衰竭患者房颤的危险因素,多元Logistic回归分析和ROC曲线评价SUA水平对房颤预测的敏感性和特异性.结果 入选的16681例患者中,房颤6807例.多因素分析显示SUA水平与房颤密切相关.平均随访5年后,多元Logistic回归分析显示SUA水平(HR 1.084,95％ CI 1.017-1.144,P＜0.001)、利尿剂(HR 1.549,95％ CI 1.246-1.854,P＜0.001)和心功能(NYHA分级,HR 1.237,95％ CI 1.168-1.306,P＜0.001)是房颤发生的独立预测因子.ROC曲线显示SUA增加房颤发生的敏感性和特异性(Wald x2 1494.88,P＜0.001;95％ CI 57.7％-60.0％).结论 SUA水平与心力衰竭患者房颤的发生有密切关系.     

利尿剂对慢性收缩性心力衰竭患者心房颤动发生的影响

目的 探讨慢性心力衰竭(chronic systolic heart failure,CSHF)患者利尿剂种类和用量对心房颤动(房颤)发生风险和预后的影响.方法 回顾性分析湖北地区16 681例CSHF住院患者(包括多次入院患者的首次和末次入院)临床资料,所有患者电话随访.以随访结果将患者分为死亡组和存活组;根据多次入院患者首次及末次临床资料将患者分为房颤组和无房颤组、不同利尿剂组、利尿剂不同剂量组.多因素Cox回归分析影响CSHF患者房颤发生风险和总死亡的独立危险因素,ROC曲线评价利尿剂对房颤预测的敏感性和特异性;多因素Cox风险比例模型分析不同利尿剂组、利尿剂不同剂量组房颤发生风险.结果 ①利尿剂(HR 1.549,95％ CI l.246 ～1.854,P＜0.01)是CSHF患者房颤发生的独立危险因素,ROC曲线分析发现,利尿剂增加预测房颤发生的特异性(83.9％对82.3％);②氢氯噻嗪和呋塞米增加房颤发生风险;氢氯噻嗪＞40 mg/d和呋塞米≥40 mg/d增加房颤发生风险;③不同种类利尿剂均不增加CSHF患者总死亡率.结论 利尿剂是CSHF患者房颤发生的独立危险因素.氢氯噻嗪＞40 mg/d和呋塞米≥0 mg/d增加房颤发生风险.     

低钠血症对慢性心力衰竭的预后价值

目的 探讨慢性心力衰竭患者低钠血症的预后价值.方法 对2007年1月至2013年1月于我院急诊内科住院治疗资料完整的786例慢性心力衰竭患者进行回顾性分析,根据入院24～48 h血清钠离子浓度最低值分为三组：A组,钠离子≥135 mmol/L;B组,钠离子120～135 mmol/L;C组,钠离子≤120 mmol/L.比较各组心功能、血清钾离子浓度、住院病死率等指标.结果 住院期间存活714例,死亡72例,存活组与死亡组平均血清钠离子浓度分别为（134.00±5.83）mmol/L和（121.00±7.15）mmol/L,差异有统计学意义（P＜0.01）,而血清钾离子浓度分别为（4.4±0.6）mmol/L和（4.3±0.8）mmol/L,差异无统计学意义（P＞0.05）.三组住院病死率分别为：A组7.8％（36/461）,B组8.0％（23/289）,C组36.1％（13/36）,C组病死率明显高于A组和B组,差异有统计学意义（P＜0.01）;A组与B组比较差异无统计学意义（P＞0.05）.结论 低钠血症是慢性心力衰竭患者预后不良的重要危险因素.     

Prognostic value of sequential measurements of amino-terminal prohormone of B-type natriuretic peptide in ambulatory heart failure patients

BACKGROUND: We evaluated the prognostic value of sequential NT-proBNP values in ambulatory heart failure patients after discharge, investigating whether the current value or the recent percent change is more important. METHODS AND RESULTS: In 166 patients, NT-proBNP was measured at discharge from heart failure hospitalisation and three months later. The combined endpoint of death or heart failure rehospitalisation was evaluated after a maximum of 18 months or at follow-up closure. During a mean observation time of 14+/-4 months, 63 patients (38%) reached the endpoint. In multiple Cox analysis, NT-proBNP three months after discharge (NT-proBNP-3Mo) and NT-proBNP percent change (NT-proBNP-%change) were the only independent predictors of the endpoint among various clinical and laboratory variables. After definition of a high- (n=83, 57% endpoints) and a low-NT-proBNP patient subgroup (n=83, 19% endpoints) according to the median NT-proBNP-3Mo (1751 pg/ml), NT-proBNP-%change was the strongest predictor in the high-NT-proBNP subgroup. In the low-NT-proBNP subgroup, NT-proBNP-3Mo was the only independent predictor. CONCLUSIONS: In ambulatory heart failure patients, the prognostic value of sequential NT-proBNP measurements depends on the magnitude of the current NT-proBNP value. Recent percent changes in NT-proBNP provide important prognostic information in patients with high NT-proBNP but not in patients with low NT-proBNP.     

The diagnostic utility of N-terminal pro-B-type natriuretic peptide for the detection of major structural heart disease in patients with atrial fibrillation.

AIMS: To assess the role of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the diagnosis of major structural heart disease (MSHD) in patients with atrial fibrillation (AF) compared with those with sinus rhythm (SR) using receiver operator characteristic (ROC) analysis. NT-proBNP is elevated in MSHD and heart failure (HF). AF, a common finding in HF and MSHD, is also associated with raised plasma NT-proBNP. As a result, the utility of NT-proBNP for predicting MSHD may be reduced. METHODS AND RESULTS: One thousand four hundred and seventy-six patients underwent assessment at a single centre, performed without the knowledge of NT-proBNP levels. MSHD included left ventricular (LV) systolic and diastolic dysfunctions, left-sided valvular disease, right heart disease (including pulmonary hypertension) and severe LV hypertrophy. One hundred and fifty-five patients were excluded due to renal impairment, atrial flutter, or a pacemaker. Seven hundred and ninety-three patients were diagnosed with MSHD. Median NT-proBNP concentrations for patients with MSHD were 960 (IQR 359-2625) pg/mL and 2491 (1443-4368) pg/mL for SR (n = 591) and AF (n = 202), respectively (P < 0.001). Patients without MSHD had NT-proBNP levels of 179 (90-401) pg/mL and 1000 (659-1760) pg/mL for SR (n = 454) and AF (n = 74), respectively (P < 0.001). The area under the ROC curve for NT-proBNP to detect MSHD was 0.79 for SR (95% CI 0.77-0.82) and 0.78 for AF (95% CI 0.72-0.84). NT-proBNP cut-off levels necessary to achieve a 1 in 100 false negative rate were 27.5 (7.5-30.5) pg/ml and 524 (253-662) pg/ml for SR and AF, respectively. CONCLUSION: NT-proBNP performs as well in patients with SR as in those with AF. However, significantly higher cut-off levels are required for patients with AF to achieve similar levels of diagnostic specificity.     

慢性心力衰竭患者血浆心钠素水平的变化及人工合成心钠素的干预作用

目的探讨慢性心力衰竭（CHF）时血浆心钠素（ANP）水平的变化及人工合成心钠素对慢性CHF患者的治疗效果。方法慢性CHF患者80例随机分为心钠素治疗组和常规治疗组各40例。常规治疗组常规使用强心剂、利尿剂、硝酸酯类药物。心钠素治疗组在常规治疗措施基础上给予心钠素220mg静脉滴注，每日1次，治疗2周。结果治疗前CHF组血浆ANP水平为（198．5±68．9）pg／ml，LVEF为（36．8±8．7）％，明显低于对照组的（289．8±0．2）pg／ml和（63．2±10．8）％（P〈O．01）。NYHAⅡ级、Ⅲ级、Ⅳ级患者血浆ANP浓度分别为（235．7±73．8）pg／ml、（200．3±67．9）pg／ml和（156．7±69．1）pg／ml，均明显低于对照组（P〈0．01）。冠心病CHF、高血压心脏病CHF、瓣膜病CHF和扩张型心肌病CHF患者血浆ANP浓度分别为（200．9±57．2）pg／ml、（195．6±75．3）pg／ml、（190．1±82．6）pg／ml和（193．6±79．8）pg／ml，不同病因组患者的ANP水平差异无统计学意义（P〉0．05）。治疗后心钠素治疗组HR、SBP、DBP较治疗前及常规治疗组明显降低（P〈0．05），LVEF、ANP、BNP较治疗前及常规治疗组明显升高（P〈0．05）。心钠素治疗组总有效率为87．5％，高于常规治疗组的62．5％（P〈O．01）。结论慢性CHF患者血浆心钠素水平明显降低，且随心衰程度的加重明显降低。人工合成的心钠素有助于改善心衰患者的临床症状和心功能。     

Exercise-induced biphasic increase in circulating NT-proBNP levels in patients with chronic heart failure

BACKGROUND: Exercise increases natriuretic peptide levels in chronic heart failure (CHF) patients, but the effect is considered minor. We assessed acute and short-term release (<24 h) of NT-proBNP in CHF patients after a maximal cardiopulmonary exercise test (CPET) and 2 different submaximal training sessions. METHODS AND RESULTS: 102 CHF patients either performed CPET (Group 1), a 1 h endurance (Group 2) or a combined endurance-resistance training session (Group 3). NT-proBNP concentration was determined before, at exercise cessation and after 18-22 h (Protocol A). In 20 patients, samples were obtained before, at exercise cessation, after 15, 30, 45, 60, 90 min, 2, 3, 4, 5, 6, 12, 22 h (Protocol B). Protocol A: At peak exercise, a 15%, 11% and 17% relative increase (p<0.001 vs baseline, all 3 groups) was seen, with a return to baseline after 18-22 h. The increase correlated with indicators of more advanced heart failure. Protocol B: A biphasic pattern was derived with a first peak within 1 h of exercise termination and a second peak (39%, 31% and 33% higher than baseline; p<0.05, all 3 groups) after 4-12 h. CONCLUSIONS: The observed biphasic release of B-type natriuretic peptides supports standardization of sampling, taking recent exercise into account.     

Cardiac resynchronization therapy in patients with heart failure and atrial fibrillation: importance of new-onset atrial fibrillation and total atrial conduction time

Aims: Cardiac resynchronization therapy (CRT) is an established therapyfor patients with heart failure and sinus rhythm (SR), but itsvalue in atrial fibrillation (AF) remains unclear. Furthermore,response to CRT may be difficult to predict in these patients.The aim of our study was to investigate whether predictors forCRT success differ between patients with AF and SR and to studythe influence of present or developing AF on response to CRT. Methods and results: We examined consecutive patients in whom CRT was implanted disregardingthe atrial rhythm. Atrial fibrillation was defined as eithercurrent or earlier AF, response to CRT was defined as a decreasein the left ventricular end-systolic volume of 10% after 6 months.Total atrial conduction time (TACT), a measure to predict therisk of developing AF, was determined by echocardiography. Weincluded 114 patients, of whom 56 (49%) were known with AF (23current AF and 33 earlier AF). The other 58 patients had nohistory of AF. After 6 months, response in current and earlierAF and that in SR patients was comparable (56, 58 and 55%, respectively).In AF patients, multivariate analysis revealed a shorter TACTat baseline [odds ratio (OR) 16.7 (1.5–185.3), P = 0.02]and an interventricular mechanical delay (IVMD) >40 ms [OR10.4 (1.0–110.9), P = 0.05] as predictors for response.Non-responders more frequently suffered from new-onset AF (P= 0.02). Conclusion: Failure to CRT is associated with new-onset AF. Total atrialactivation time may be a parameter to predict response in AFpatients.     

血浆脑钠素和心钠素对2型糖尿病舒张性心功能不鹊恼锒弦庖邋

采用固相免疫放射分析方法测定47例心脏舒张功能障碍(DHF)的2型糖尿病(DM)患者血浆脑钠素(BNP)和心钠素(ANP)浓度,并与DM心功能正常组(24例)及正常对照组(12名)进行对比分析。结果显示血浆BNP、ANP水平随着DHF程度加重而逐渐升高,而且E/A比值与BNP(r=-0.669,P<0.01)和ANP(r=-0.579,P<0.01)均呈显著负相关,提示血浆ANP、BNP是诊断2型DM心脏舒张功能不全的良好生化指标。     

Management of atrial fibrillation in patients with heart failure.

Atrial fibrillation (AF) and chronic heart failure (CHF) are two major and even growing cardiovascular conditions that often coexist. However, few data are available to guide treatment of AF in patients with CHF. This review summarizes current literature concerning the following topics: (i) prognostic relevance of AF in patients with CHF, (ii) relevance and strategies of rhythm and rate control in patients with AF and CHF, and (iii) options for prevention of AF in patients with ventricular dysfunction. In conclusion, AF is associated with increased mortality in CHF patients. However, it is not clear whether there is a causal relationship. Emerging strategies to prevent the occurrence of AF are promising tools that might improve quality of life and survival in patients with CHF.     

1410例慢性心力衰竭合并心房颤动住院病例回顾性分析

目的分析慢性心力衰竭合并心房颤动住院病例的特点。方法采用2中心、回顾性、对照研究。对病例在年代(Ⅰ、Ⅱ、Ⅲ组)、性别、年龄分期等方面的特点进行分析。结果入选1 410例,年龄呈现老龄化(P<0.01)。心功能以NYHAⅢ、Ⅳ级为主,占87.9%。Ⅰ和Ⅱ组的首位病因是风湿性心脏病,Ⅲ组则是冠心病。随着年龄的增加,女性患者心房颤动比例减少。老年前期首位病因是风湿性心脏病,老年期和高龄老年期则为冠心病。总的好转率82.9%,总的病死率12.6%,后者以Ⅲ组最低(P<0.01)。死亡病例的首位病因逐渐由风湿性心脏病演变为冠心病,死因以非心脏性原因死亡居多,其次为心功能恶化。结论慢性心力衰竭合并心房颤动住院病例的首位病因从风湿性心脏病演变为冠心病;高龄、冠心病合并心房颤动可能逐渐成为慢性心力衰竭的主要流行趋势。     

慢性心衰患者QRS时程和新发房颤的相关性研究

目的 探讨慢性心衰患者QRS时程（QRSd）增宽对新发房颤的预测价值.方法 选择患有心衰但无房颤病史的患者1098例,将其分为三组：QRSd≤120 ms、120 ms〈QRSd〈150 ms及QRSd≥150 ms组,随访跟踪各组新发房颤的概率.通过二元分析和多元logistic回归分析探讨QRS时程和房颤新发概率之间的相关性.结果 对患者群体的统计表明,房颤的新发概率为35.7%.通过二元分析发现,房颤的新发概率存在组间差别（21.7%、35.9%、42.5%,P〈0.01）;进一步通过多元回归发现,QRS时程是独立的影响因素.结论 QRS是慢性心衰患者新发房颤的独立预测因素.     

美托洛尔对慢性心力衰竭伴慢性心房颤动患者的作用

目的:探讨地高辛联用美托洛尔对慢性心力衰竭(CHF)伴慢性心房颤动(AF)患者的疗效。方法:选择CHF伴慢性AF患者106例,随机分为地高辛治疗组(54例)和美托洛尔+地高辛组(52例),观察两组1月疗效并随访1年期间因心脏原因的再住院率、死亡率。结果:治疗1月后,与地高辛组相比,美托洛尔+地高辛组静息心室率[(91.6±8.5)次/min比(72.8±9.7)次/min]和运动前后即刻心室率差值显著降低[(23.1±4.2)次/min比(12.3±4.7)次/min],6min步行距离显著增加[(256.4±90.4)m比(299.8±94.1)m],P均<0.05;随访1年,与地高辛组相比,美托洛尔+地高辛组因心力衰竭再住院率(42.6%比19.2%)、死亡率(20.4%比11.5%)明显降低,NYHA分级明显改善、6min步行距离明显增加,左室舒张末容积、左室收缩末容积明显减小,左室射血分数明显提高,生活质量明显改善,P均<0.05。结论:在常规用药的基础上,地高辛联用美托洛尔的1月疗效与1年后疗效都明显优于单用地高辛的治疗。     

快速测定脑利钠肽预测充血性心力衰竭患者预后的价值

目的　探讨快速测定脑利钠肽预测充血性心力衰竭近期预后的价值。方法　 70例充血性心力衰竭住院患者 ,NYHA心功能Ⅲ级 3 7例、Ⅳ级 3 3例。入院时、出院前或临终前 2 4小时内分别测定血浆BNP ,分析住院治疗前后BNP水平变化与心源性死亡、3 0天内再住院事件的关系。结果　 2 3例患者出现终点事件 (因心功能恶化死亡 6例、再住院 17例 ) ,其入院时BNP水平 ( 15 16pg/ml± 872pg/ml)高于未发生临床终点者 ( 10 3 7pg/ml± 65 4pg/ml) ,P <0 .0 1;发生临床终点者住院期间BNP升高 3 18pg/ml ,而未发生终点事件的患者 ,住院期间BNP平均降低 3 5 9pg/ml ,P <0 .0 1;BNP升高组患者发生临床终点 68.2 % ,BNP降低组患者发生临床终点 16.7% ,P <0 .0 0 5。结论　BNP水平可预测失代偿充血性心力衰竭患者的近期预后     

Systematic review of the management of atrial fibrillation in patients with heart failure.

AIMS: To systematically review the management of atrial fibrillation (AF) in patients with heart failure. METHODS: Studies investigating the management of AF in patients with heart failure published between 1967 to 1998 were identified using MEDLINE, the Cochrane register and Embase databases. Reference lists from relevant papers and reviews were hand searched for further papers. RESULTS: Eight studies pertaining to acute and twenty-four pertaining to chronic AF were identified. For patients with acute AF ventricular rate control, anticoagulation and treatment of heart failure should be pursued simultaneously before cardioversion is attempted. Digoxin is relatively ineffective at controlling ventricular response and for cardioversion. Intravenous diltiazem is rapidly effective in controlling ventricular rate and limited evidence suggests it is safe. Amiodarone controls ventricular rate rapidly and increases the rate of cardioversion. There are insufficient data to conclude that immediate anti-coagulation, trans-oesophageal echocardiography to exclude atrial thrombi followed by immediate cardioversion is an appropriate strategy. Patients with chronic AF should be anti-coagulated unless contra-indications exist. It is not clear whether the preferred strategy should be cardioversion and maintenance of sinus rhythm with amiodarone or ventricular rate control of AF combined with anticoagulation to improve outcome including symptoms, morbidity and survival. Electrical cardioversion has a high initial success rate but there is also a high risk of early relapse. Amiodarone currently appears the most effective and safest therapy for maintaining sinus rhythm post-cardioversion. Digoxin is fairly ineffective at controlling ventricular rate during exercise. Addition of a beta-blocker reduces ventricular rate and improves symptoms. Whether digoxin is required in addition to beta-blockade for the control of AF in this setting is currently under investigation. If pharmacological therapy is ineffective or not tolerated then atrio-ventricular node ablation and permanent pacemaker implantation should be considered. CONCLUSION: There is a paucity of controlled clinical trial data for the management of AF among patients with heart failure. The interaction between AF and heart failure means that neither can be treated optimally without treating both. Presently treatment should be on a case by case basis.