Managing Atrial Fibrillation in Heart Failure: In Whom, When, and How?

Atrial fibrillation (AF) and heart failure (HF) are common, interdependent conditions that frequently coexist and amplify each other's progression and adverse outcomes. Managing AF in patients with HF remains complex and requires individualized decisions regarding rhythm vs. rate control, anticoagulation, and comorbidity optimization. Recent randomized trials and updated guidelines have reshaped therapeutic paradigms, favoring early rhythm control in appropriately selected patients. The bidirectional AF-HF interplay involves shared pathophysiological mechanisms-neurohormonal activation, structural remodeling, and atrial myopathy-leading to progressive systolic and diastolic dysfunction. Identifying "in whom" rhythm control yields prognostic benefit is essential, especially among patients with reduced ejection fraction (EF) and those with symptomatic AF or tachycardia-induced cardiomyopathy. Catheter ablation has emerged as a preferred rhythm-control strategy in HF with reduced EF, supported by CASTLE-AF, RAFT-AF, EAST-AFNET 4 and recent meta-analyses showing improved survival and HF hospitalization rates. Novel pulsed-field ablation technologies may further enhance safety in this vulnerable population. Optimal timing ("when") favors early intervention before advanced remodeling, while the choice of "how" depends on AF burden, HF phenotype, and comorbidities. Anticoagulation with direct oral anticoagulants remains central to reducing thromboembolic risk, with attention to renal function, frailty, and polypharmacy. This narrative review synthesizes current evidence and offers a pragmatic clinical algorithm for managing AF in HF, emphasizing integrated, multidisciplinary, and patient-centered care strategies.