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.

BACKGROUND: This study aimed to evaluate the epidemiology, clinical and microbiological features, treatment, and outcomes of infective endocarditis (IE) on the island of Crete, a region with high levels of antimicrobial resistance. MATERIALS AND METHODS: Medical records of all hospitalized patients diagnosed with IE at the University Hospital of Heraklion, Crete, Greece, from 1995 to 2015, were retrospectively reviewed. Patients who met the modified Duke's criteria for definite or possible IE were included. RESULTS: A total of 82 IE patients (median age 67 [range 21–86] years) were included. Most patients suffered from left-sided IE (94%), while most cases of infection occurred in native valves (53.6%). Systemic inflammatory response syndrome criteria were lacking in almost half of the patient population. The leading causative microorganism was Staphylococcus aureus, isolated in 24 cases (29%), followed by Streptococcus spp. in 15 (18%) and Enterococcus spp. in 12 (14.5%). A number of rare and difficult to treat microorganisms had been identified, such as Gemella morbillorum in four cases (4.5%), Streptococcus lugdunensis in two (2.5%) and Streptococcus pneumoniae in one (1%). One patient was serologically positive for Coxiella burnetii (1%). All patients received empirical antimicrobial treatment, proven appropriate in 39 blood culture-positive patients (56.5%). Thirteen (16%) patients were classified as culture negative. Seven patients (8.5%) were surgically treated. In-hospital death occurred in 9 patients (11%). CONCLUSION: Changes in IE profile requires continuous epidemiological updates. Staphylococcus and Streptococcus spp. remain the most common etiologic agents. However, the presence of uncommon and/or difficult to treat pathogens raise concerns on the appropriate prophylaxis as well as empirical treatment.
Coxiella burnetii ; Endocarditis* ; Enterococcus ; Epidemiology* ; Gemella ; Greece* ; Humans ; Medical Records ; Retrospective Studies ; Staphylococcus ; Staphylococcus aureus ; Streptococcus ; Streptococcus pneumoniae ; Systemic Inflammatory Response Syndrome ; Treatment Outcome

BACKGROUND: This study aimed to evaluate the epidemiology, clinical and microbiological features, treatment, and outcomes of infective endocarditis (IE) on the island of Crete, a region with high levels of antimicrobial resistance. MATERIALS AND METHODS: Medical records of all hospitalized patients diagnosed with IE at the University Hospital of Heraklion, Crete, Greece, from 1995 to 2015, were retrospectively reviewed. Patients who met the modified Duke's criteria for definite or possible IE were included. RESULTS: A total of 82 IE patients (median age 67 [range 21–86] years) were included. Most patients suffered from left-sided IE (94%), while most cases of infection occurred in native valves (53.6%). Systemic inflammatory response syndrome criteria were lacking in almost half of the patient population. The leading causative microorganism was Staphylococcus aureus, isolated in 24 cases (29%), followed by Streptococcus spp. in 15 (18%) and Enterococcus spp. in 12 (14.5%). A number of rare and difficult to treat microorganisms had been identified, such as Gemella morbillorum in four cases (4.5%), Streptococcus lugdunensis in two (2.5%) and Streptococcus pneumoniae in one (1%). One patient was serologically positive for Coxiella burnetii (1%). All patients received empirical antimicrobial treatment, proven appropriate in 39 blood culture-positive patients (56.5%). Thirteen (16%) patients were classified as culture negative. Seven patients (8.5%) were surgically treated. In-hospital death occurred in 9 patients (11%). CONCLUSION: Changes in IE profile requires continuous epidemiological updates. Staphylococcus and Streptococcus spp. remain the most common etiologic agents. However, the presence of uncommon and/or difficult to treat pathogens raise concerns on the appropriate prophylaxis as well as empirical treatment.
Coxiella burnetii ; Endocarditis* ; Enterococcus ; Epidemiology* ; Gemella ; Greece* ; Humans ; Medical Records ; Retrospective Studies ; Staphylococcus ; Staphylococcus aureus ; Streptococcus ; Streptococcus pneumoniae ; Systemic Inflammatory Response Syndrome ; Treatment Outcome