Abstract 12766: Treatment of Patients With Atrial Fibrillation and Heart Failure in the AIM-AF (Antiarrhythmic Medication for Atrial Fibrillation) Study: A Physician Survey on the Prescription of Antiarrhythmic Drugs in the US and Europe

Introduction: ACC/AHA/HRS guidelines recommend dofetilide or amiodarone in patients with atrial fibrillation (AF) and symptomatic heart failure (HF). ESC 2020 guidelines added dronedarone (IA) and sotalol (IIbA) as antiarrhythmic drug (AAD) options for patients with AF and HF with preserved ejection fraction (HFpEF), retaining only amiodarone (IA) for AF and HF with reduced ejection fraction (HFrEF). Dronedarone was also added for patients with normal or mildly impaired (but stable) left ventricular function (IA). In both guidelines, catheter ablation (ABL) may be considered in AF and HFrEF to improve outcomes. Methods: An online survey to understand treatment practice in patients with AF and HF was conducted in the US, Germany, Italy, Sweden, and the UK. Respondents were cardiologists or cardiac electrophysiologists (N=629) actively treating ≥10 patients with AF who received AAD therapy and/or had received or were referred for ABL. The survey comprised 96 questions on physician demographics, AF types, and treatment practices. Results: After AF type and symptom status, presence of HF was the third most cited reason to select rhythm control over rate control (13% of respondents). Overall, 39% preferred first-line ABL over AADs in patients with AF and comorbidities such as HF; yet HFrEF was the top-ranked factor for favoring AADs over ABL by 20%. Amiodarone was the AAD selected most often in HFrEF (81%), and HFpEF (60%), and used less in the US than Europe (particularly in HFrEF: 71% vs 91%). Sotalol was selected by 18% as a typical choice for AF with HFrEF (US 25%, Europe 12%), not in accordance with guideline recommendations; class Ic drugs were also selected in HFrEF (US 8%, Europe 4%) contrary to recommendations. Use of dronedarone (18% vs 27%) and sotalol (26% vs 42%) was less common in the US than Europe in patients with HFpEF; use of class Ic agents, against recommendations, was the same in both regions (18%). Conclusions: Presence of HF is frequently considered by physicians in AF treatment decisions, but treatment patterns indicate divergence from guideline recommendations with several specific AADs. However, the guidelines do not clearly define HF and, in clinical practice, use of non-recommended agents appear acceptable to some in individual circumstances.