AF management comprises of
- therapies with prognostic impact - anticoagulation and treatment of cardiovascular conditions
- therapies predominantly providing symptomatic benefit - rate control and rhythm control (1)
The main goals in the management of atrial fibrillation are:
- urgent control of the ventricular rate during paroxysmal or persistent AF
- restoration of sinus rhythm by pharmacologic or electrical means
- prevention of thromboembolic complications
- prevention of recurrence of AF following successful restoration of sinus rhythm
- long-term rate control in those with permanent AF (2)
The therapeutic interventions may be considered under the following headings:
- general measures
- non-drug management
- drug management
Indications for emergency rhythm control (4):
Patients with ongoing atrial fibrillation at the time of initial evaluation, as confirmed by 12 lead electrocardiography, and
- with very slow or rapid ventricular rates (typically <40 bpm and >150 bpm),
- evidence of hemodynamic instability,
- severe symptoms,
- or decompensated heart failure
- should be referred to the emergency department for stabilization and possible electrical cardioversion
- in case of unknown duration of atrial fibrillation
- cardioversion should be preceded by transesophageal echocardiography to rule out intracardiac thrombus
- patients are required to be on anticoagulation for at least four weeks after electrical cardioversion to reduce the risk of thromboembolism
NICE state (3) rhythm control should be favoured if:
- atrial fibrillation has a reversible cause
- heart failure thought to be primarily caused by atrial fibrillation
- new-onset atrial fibrillation
- atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
- for whom a rhythm-control strategy would be more suitable based on clinical judgement
Ponamgi et al state rhythm control should be favored (4):
- in the presence of significant atrial fibrillation related symptoms or presumed tachycardia induced cardiomyopathy
- may also be preferable in younger (<65 years) patients with paroxysmal atrial fibrillation, as rate control alone is likely to result in progression to longstanding persistent atrial fibrillation over a period of time, which will later be more difficult to control and carries a risk of development of tachycardia induced cardiomyopathy
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