Atrial Fibrillation Treatment & Management

Patient management for newly diagnosed atrial fibr

Approach Considerations

The cornerstones of atrial fibrillation management are rate control and anticoagulation [3] and rhythm control for those symptomatically limited by AF. The clinical decision to use a rhythm-control or rate-control strategy requires an integrated consideration of several factors, including degree of symptoms, likelihood of successful cardioversion, presence of comorbidities, and candidacy for AF ablation (eg, pulmonary vein electric isolation or MAZE procedure).

Restoration of sinus rhythm with regularization of the heart's rhythm improves cardiac hemodynamics and exercise tolerance. By maintaining the atrial contribution to cardiac output, symptoms of heart failure and overall quality of life can improve. As AF contributes to pathologic atrial and ventricular remodeling, restoration of sinus rhythm can slow or, in some cases, reverse atrial dilatation and left ventricular dysfunction. For these reasons, most clinicians focus initially on restoration and maintenance of sinus rhythm in patients with new-onset AF and opt for a rate-control strategy only when rhythm control fails.

However, several randomized controlled trials have demonstrated that a strategy aimed at restoring and maintaining sinus rhythm neither improves survival nor reduces the risk of stroke in patients with AF.

In the AFFIRM study (Atrial Fibrillation Follow-up Investigation of Rhythm Management), an insignificant trend toward increased mortality was noted in the rate control group, and importantly, no evidence suggested that the rhythm-control strategy protected patients from stroke. In the study, 4060 subjects aged 65 years or older whose AF was likely to be recurrent and who were at risk for stroke were randomized to a strategy of rhythm control (cardioversion to sinus rhythm plus drugs to maintain sinus rhythm) versus a strategy of rate control

(in which no attempt was made to restore or maintain normal sinus rhythm). [23] Clinically silent recurrences of AF in the rhythm-control group are theorized to be responsible for the increased rates of thromboembolic events and mortality noted in this cohort. This underscores the importance of anticoagulation in both rhythm-control and rate-control patients.

New developments aimed at curing AF are being explored actively. By reducing the critical mass required to sustain AF through either surgical or catheter-based compartmentalization of the atria (ie, MAZE procedure), fibrillatory wavelets collide with fixed anatomic obstacles, such as suture lines or complete lines of ablation, thus eliminating or reducing the development of permanent AF. One concern is that an extensive MAZE procedure can render the atrial severely hypocontractile, which may elevate the risk of embolic stroke even if AF is substantively suppressed. Some patients with focal origins of their AF also may be candidates for catheter ablation. Simple electric isolation of the origins of the pulmonary veins has proven roughly 80% successful in substantially reducing frequency and duration of AF in patients who do not tolerate AF well.

AF ablation methods continue to be studied and modified and thus may be considered as a work in progress rather than a mature primary therapy.Go to Catheter Ablation for complete information on this topic.

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Risk-Management Decisions

One of the major management decisions in AF (and atrial flutter ) is determining the risk of stroke and appropriate anticoagulation regimen for low-, intermediate-, and high-risk patients. For each anticoagulant, the benefit in terms of stroke reduction must be weighed against the risk of serious bleeding.

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