Atrial fibrillation and heart failure with preserved ejection fraction “twindemic”—Shared root causes and treatment targets

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are comorbid conditions that are increasingly prevalent and have a high socioeconomic burden. This article discusses their shared pathophysiology, focusing on the triad of hypertension, obesity, and aging. We highlight the misperception that pharmacological heart rate lowering is beneficial, which has resulted in an overprescription of β-blockers in HFpEF and AF. In contrast, heart rate modulation through accelerated pacing provides hemodynamic and structural advantages, which have yielded significant improvements in quality of life, physical activity, and AF burden in the personalized pacing for diastolic dysfunction and heart failure with preserved ejection fraction (myPACE) trial of patients with preclinical or overt HFpEF.