Arrhythmia-induced cardiomyopathy: focus on atrial fibrillation

Abstract

Arrhythmias and heart failure (HF) are common causes of morbidity and premature death worldwide, and patients who present with both conditions have particularly poor outcomes. Arrhythmia-induced cardiomyopathy (AIC) is a condition in which arrhythmias, often atrial fibrillation (AF), but also frequent atrial or ventricular ectopic beats, cause or aggravate HF. The hallmark of this condition is partial or complete reversibility of left ventricular systolic dysfunction after restoration of normal sinus rhythm. Differentiation between HF that causes arrhythmias and arrhythmias that cause HF remains challenging, leads to the underuse of rhythm-control therapy and, consequently, to the under-diagnosis of AIC. In this Review, we describe the various pathophysiological mechanisms of AIC, with a focus on AF as the underlying arrhythmia. We then discuss the epidemiology, clinical presentation and assessment of patients with AIC, with consideration of the complex interactions between AF and left ventricular dysfunction. We also present the therapeutic approach taken in patients presenting with suspected AIC, including restoration of sinus rhythm to unmask a diagnosis of AIC and treatment of HF. We conclude with a discussion of priorities for future research and the observation that there is an urgent need for objective, easily quantifiable parameters to identify patients with AIC.