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):

  1. 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.
  2. 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).
  3. Some data suggest that a rhythm-control strategy provides a survival advantage compared to a rate-control strategy in patients younger than 65 years.
  4. The decision on whether to use a rhythm-control versus rate-control strategy should be individualized based on symptoms, age, comorbidities, and patient preference.
  5. The selection of an antiarrhythmic medication for rhythm control should be based primarily on safety and secondarily on efficacy.
  6. 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.
  7. 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.
  8. Catheter ablation generally is reserved for patients with symptomatic AF who have not responded adequately to drug therapy.
  9. Counting redo procedures, the long-term efficacy of catheter ablation is approximately 80%.
  10. A number of randomized trials have demonstrated the superiority of catheter ablation over drug therapy for the elimination of AF episodes and symptoms.
  11. Direct current cardioversion is indicated when urgent cardioversion is needed or when it is necessary for conversion to sinus rhythm.
  12. The most appropriate targets for rate control are ≤80/minute at rest and ≤110/minute during mild exercise such as walking.
  13. Beta-blockers and non-dihydropyridine calcium channel blockers are the preferred agents for rate control.

Clinical Topics: Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Prevention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Exercise, Hypertension, Sleep Apnea

Keywords: Adrenergic beta-Antagonists, Anti-Arrhythmia Agents, Arrhythmias, Cardiac, Atrial Fibrillation, Calcium Channel Blockers, Catheter Ablation, Dihydropyridines, Electric Countershock, Exercise, Hypertension, Obesity, Primary Prevention, Risk Factors, Sleep Apnea, Obstructive, Walking

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