Treatment of Atrial Fibrillation
- Prystowsky EN, Padanilam BJ, Fogel RI.
- Treatment of Atrial Fibrillation. JAMA 2015;314:278-288.
The following are key points to remember from this review of therapies for atrial fibrillation (AF):
- Modification of AF risk factors such as hypertension, obesity, and obstructive sleep apnea can reduce the AF burden, but usually does not eliminate AF long-term.
- Clinical trials have demonstrated that a pharmacologic rhythm-control strategy has no advantage over a rate-control strategy in older patients (mean age 68-70 years).
- Some data suggest that a rhythm-control strategy provides a survival advantage compared to a rate-control strategy in patients younger than 65 years.
- The decision on whether to use a rhythm-control versus rate-control strategy should be individualized based on symptoms, age, comorbidities, and patient preference.
- The selection of an antiarrhythmic medication for rhythm control should be based primarily on safety and secondarily on efficacy.
- Antiarrhythmic drugs rarely totally suppress AF and do not need to do so to be considered clinically efficacious. A reduction in symptom burden that improves quality of life often is an acceptable goal of therapy.
- Dofetilide is the only antiarrhythmic medication that must be started in a hospital setting. Other antiarrhythmic medications often can be started safely on an outpatient basis in low-risk patients.
- Catheter ablation generally is reserved for patients with symptomatic AF who have not responded adequately to drug therapy.
- Counting redo procedures, the long-term efficacy of catheter ablation is approximately 80%.
- A number of randomized trials have demonstrated the superiority of catheter ablation over drug therapy for the elimination of AF episodes and symptoms.
- Direct current cardioversion is indicated when urgent cardioversion is needed or when it is necessary for conversion to sinus rhythm.
- The most appropriate targets for rate control are ≤80/minute at rest and ≤110/minute during mild exercise such as walking.
- Beta-blockers and non-dihydropyridine calcium channel blockers are the preferred agents for rate control.
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