AF Management

Principles of AF management: key points

• Assessment of thromboembolic risk and antithrombotic treatment for patients at risk
• A choice of:
  • Restoration and maintenance of sinus rhythm (rhythm control)
    • – using electrical cardioversion, drugs, ablation, or surgery may be particularly useful in younger patients with structurally normal hearts and paroxysmal AF, or persistent AF of recent onset
    • – surgery suitable even in long standing AF, but associated with substantial morbidity and mortality
  • Acceptance of the arrhythmia and control of the ventricular rate (rate control)
    • – using drugs (usually β or calcium channel blockers with or without digoxin), or occasionally atrioventricular node ablation and implantation of a permanent pacemaker
    • – may be more appropriate in elderly patients with hypertension or structural heart disease and persistent or permanent arrhythmia, especially if this can be tolerated symptomatically
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AF is a common and increasingly prevalent arrhythmia that is associated with substantial morbidity and mortality. Because of the limited efficacy of catheter based treatments, especially for patients with persistent AF, and the substantial morbidity and mortality associated with surgery for the arrhythmia, pharmacological therapy remains the mainstay of treatment for the majority of patients. The optimum treatment strategy for patients with persistent AF remains controversial, with some clinicians favouring rhythm control and others rate control. Ultimately, treatment needs to be individualised, based on symptomatology and the likelihood of maintenance of sinus rhythm. Regardless of these controversies in arrhythmia management, anticoagulation or antiplatelet therapy for stroke prevention form an integral part of treatment of patients with AF and risk factors for thromboembolism.

The predominant focus of recent developments in pharmacological therapy for AF has been the development of novel class III antiarrhythmic agents, each with characteristic effects on potassium channels. In general, these agents have proven moderately efficacious but carry a significant risk of proarrhythmia. While research in this field continues, other drugs such as specific serotonin receptor antagonists continue to be developed. Further developments in catheter ablation technologies may greatly facilitate safe isolation of multiple pulmonary veins for patients with predominantly paroxysmal AF, whereas improvements in linear catheter ablation technologies, accompanied by three dimensional atrial mapping and catheter navigation, may facilitate creation of linear left atrial lesions, which appear to be critical for the successful treatment of patients with persistent arrhythmia.