II. Precautions

  1. Atrial Fibrillation Rate Control has historically been preferred for most patients due to adverse events with Antiarrhythmics
    1. Carlsson (2003) J Am Coll Cardiol 41(10): 1690-6 [PubMed]
  2. Newer studies compared rate control to catheter ablation
    1. Catheter ablation appears superior to rate control in comorbid Heart Failure
    2. Marrouche (2018) N Engl J Med 378:417-27 [PubMed]
  3. Catheter ablation instead of Antiarrhythmic drugs is associated with lower Atrial Fib recurrence, and lower complications rates
    1. Andrade (2023) N Engl J Med 388(2):105-116 +PMID: 36342178 [PubMed]
  4. Rhythm control may be preferred in high risk cardiovascular patients in Atrial Fibrillation <1 year
    1. NNT 91 to prevent one cardiovascular death, hospitalization or Cerebrovascular Accident in 5 years
    2. But rhythm control is associated with serious complications in 2% of patients
    3. Camm (2022) J Am Coll Cardiol 79(19): 1932-48 [PubMed]
    4. Kirchhof (2020) N Engl J Med 383(14): 1305-16 [PubMed]

III. Indications: Chronic Atrial Fibrillation

  1. Symptomatic patients
  2. Younger patients (esp. <65 years old)
  3. Poor rate control with recurrent hospitalizations
  4. Lone Atrial Fibrillation with initial presentation
  5. Precipitating factor has been corrected or controlled

IV. Management

  1. Intermittent paroxysmal Atrial Fibrillation
    1. See Episodic Atrial Fibrillation Home Management
  2. Chronic rhythm control is combined with rate control and Anticoagulation
    1. See Atrial Fibrillation Rate Control
    2. See Atrial Fibrillation Anticoagulation
  3. Rhythm Control Agent Selection
    1. See Atrial Fibrillation Pharmacologic Cardioversion (reviews the Antiarrhythmic agents as they apply to cardioversion)
    2. Better tolerated agents (but contraindicated in CHF, structural heart disease, CAD)
      1. Flecainide
      2. Propafenone
    3. Agents with fewer contraindications (may be used in CHF, CAD), but with increased adverse effects
      1. Amiodarone

V. References

  1. (2023) Presc Lett 30(2): 9-10

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