Heart failure with preserved ejection fraction and atrial fibrillation: vicious twins

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are age-related conditions that are increasing in prevalence, commonly co-exist and share clinical features. This review provides a practical update on the epidemiology, pathophysiology, diagnosis and management of patients with concomitant HFpEF and AF. Epidemiologic studies highlight the close and complex links, between HFpEF and AF, the shared risk factors, the high AF occurrence in the natural history of HFpEF, and the independent contribution of each condition to poor outcomes. The diagnosis of HFpEF in the setting of AF is challenging, since symptoms overlap. AF is associated with changes in echocardiographic parameters and circulating natriuretic peptides that confound HFpEF diagnosis. Symptomatic improvement with diuretic therapy supports the presence of HFpEF in patients with concomitant AF. Important knowledge gaps need to be addressed by a multidisciplinary and translational research approach, in order to develop novel therapies that can improve prognosis.