FUSTER
ET AL., ACC/AHA/ESC GUIDELINES FOR THE MANAGEMENT OF
PATIENTS WITH ATRIAL FIBRILLATION
J Am Coll Cardiol 2001;38:1266i-1xx
ACC/AHA/ESC
Guidelines for the Management of Patients with Atrial
Fibrillation
IX.
Proposed
Management Strategies
A.
Overview of Algorithms for Management of Patients With
AF
Management
of patients with AF requires knowledge of its pattern
of presentation (paroxysmal, persistent, or permanent)
and decisions about restoration and maintenance of sinus
rhythm, control of the ventricular rate, and anticoagulation.
These issues are addressed in the various management
algorithms for each presentation of AF (Figures 9,
10, 11,
and 12).
1.
Newly Discovered AF (Figure
9)
It
is not always clear whether the initial presentation
of AF is actually the patient's first episode, particularly
in those with minimal or no symptoms of the dysrhythmia,
so both are considered together. In patients who have
self-limited episodes of AF, antiarrhythmic drugs to
prevent recurrence are usually unnecessary unless AF
is associated with severe symptoms related to hypotension,
myocardial ischemia, or HF. Whether these individuals
require long-term or even short-term anticoagulation
is not clear, and the decision must be individualized
for each patient based on the intrinsic risk of thromboembolism.
When AF persists, one option is to accept progression
to permanent AF, with attention to antithrombotic therapy
and control of the ventricular rate. Although it may
seem reasonable to make at least one attempt to restore
sinus rhythm, this may not be in the best interest of
all patients. An example is the older man without risk
factors for thromboembolism in whom asymptomatic AF
is discovered on routine examination and control of
the ventricular rate is readily achieved. Here, the
potential toxicity of antiarrhythmic drugs may outweigh
the benefit of restoration of sinus rhythm. If the decision
is made to attempt to restore and maintain sinus rhythm,
anticoagulation and rate control are important before
cardioversion. Although long-term antiarrhythmic therapy
may not be needed to prevent recurrent AF after cardioversion,
short-term therapy may be beneficial. In patients with
AF of more than 3 months' duration, early recurrence
is common after cardioversion. Antiarrhythmic medication
may be initiated before cardioversion (after adequate
anticoagulation) in such cases to reduce the likelihood
of recurrence, and the duration of drug therapy would
be brief (e.g., 1 month).
2.
Recurrent Paroxysmal AF (Figures 10,11)
In
patients who experience brief or minimally symptomatic
recurrences of paroxysmal AF, it is reasonable to avoid
antiarrhythmic drugs , but troublesome symptoms generally
call for suppressive antiarrhythmic therapy. Rate control
and prevention of thromboembolism are appropriate in
both situations. In any given patient, several different
antiarrhythmic drugs may be effective, and thus the
initial selection is based mainly on safety (Figure
11). For individuals with no or minimal structural
heart disease, flecainide, propafenone, and sotalol
are recommended as initial antiarrhythmic therapy because
they are generally well tolerated and are essentially
devoid of extracardiac organ toxicity. When one or another
of these drugs is ineffective or is associated with
side effects, then second- or third-line choices include
amiodarone, dofetilide, disopyramide, procainamide,
and quinidine, which have greater potential for adverse
reactions. A nonpharmacological approach may be appropriate
for some patients, and this should be considered before
amiodarone therapy is instituted. Occasionally, a consistent
initiating factor may be found, such as vagally mediated
AF (in which case drugs such as disopyramide or flecainide
are appropriate initial agents) or adrenergically induced
AF (for which beta-blockers or sotalol is suggested).
Many
patients with organic heart disease can be broadly categorized
into those with HF, CAD, or hypertension. Other types
of heart disease can be associated with AF, and the
clinician must determine which of these categories best
fits the individual patient. For patients with HF, safety
data support the selection of amiodarone or dofetilide
to maintain sinus rhythm. Patients with ischemic heart
disease often require beta-blocker medication, and sotalol,
a drug with both beta-blocking activity and primary
antiarrhythmic efficacy, is considered first, unless
the patient has HF. Amiodarone and dofetilide are considered
secondary agents, and the clinician may consider disopyramide,
procainamide, or quinidine on an individual basis. In
patients with hypertension without LV hypertrophy, drugs
such as flecainide and propafenone, which do not prolong
repolarization and the QT interval, may offer a safety
advantage and are recommended first. If these agents
either prove ineffective or produce side effects, then
amiodarone, dofetilide, or sotalol represent appropriate
secondary choices. Disopyramide, procainamide, and quinidine
are considered third-line agents in this situation.
Hypertrophied myocardium may be prone to proarrhythmic
toxicity and development of the torsade de pointes type
of ventricular tachycardia. Amiodarone is suggested
as first-line therapy in patients with LV hypertrophy
(wall thickness greater than or equal to 1.4 cm) because
of its relative safety compared with several other agents.
Because neither ECG nor echocardiography invariably
detects LV hypertrophy as defined by measurement of
myocardial mass, clinicians may face a conundrum. The
selection of antiarrhythmic drugs for patients with
a history of hypertension is compounded by the dearth
of prospective, controlled trials comparing the safety
and efficacy of drug therapy for AF.
The
scarcity of data from randomized trials of antiarrhythmic
medications for treatment of patients with AF applies
generally to all patient groups. Accordingly, the drug-selection
algorithm presented here has been developed as a consensus
of experts and is particularly subject to revision as
additional evidence emerges in this field.
3.
Recurrent Persistent AF (Figures 11,12)
Patients
with minimal or no symptoms referable to AF who have
undergone at least 1 attempt to restore sinus rhythm
may remain in AF after its second occurrence, with therapy
for rate control and prevention of thromboembolism as
needed. Alternatively, those with symptoms favoring
sinus rhythm should be treated with an antiarrhythmic
agent (in addition to medications for rate control and
anticoagulation) before cardioversion. The selection
of an antiarrhythmic drug should be based on the same
algorithm used for patients with recurrent paroxysmal
AF.
4.
Permanent AF (Figure 12)
Permanent
AF is the designation given to cases in which sinus
rhythm cannot be sustained after cardioversion of AF
or when the patient and physician have decided to allow
AF to continue without further efforts to restore sinus
rhythm. It is important to maintain control of the ventricular
rate and to use antithrombotic therapy, as outlined
elsewhere in this document, for all patients in this
category.
Copyright
© 2001 by the American College of Cardiology, American
Heart Association, Inc., and the European society of
Cardiology
Published by Elsevier Science Inc.
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