II. Precautions
-
Atrial Fibrillation Rate Control has historically been preferred for most patients due to Antiarrhythmics adverse events
- However rhythm control is better at reducing symptoms, and improves ventricular function
- Rhythm control also reduces stroke risk and mortality in first year
- Carlsson (2003) J Am Coll Cardiol 41(10): 1690-6 [PubMed]
- Newer studies compared rate control to catheter ablation
- Catheter ablation appears superior to rate control in comorbid Heart Failure
- Marrouche (2018) N Engl J Med 378:417-27 [PubMed]
- Catheter ablation instead of Antiarrhythmic drugs is associated with lower Atrial Fib recurrence, and lower complications rates
- Rhythm control may be preferred in high risk cardiovascular patients in Atrial Fibrillation <1 year
- NNT 91 to prevent one cardiovascular death, hospitalization or Cerebrovascular Accident in 5 years
- But rhythm control is associated with serious complications in 2% of patients
- Camm (2022) J Am Coll Cardiol 79(19): 1932-48 [PubMed]
- Kirchhof (2020) N Engl J Med 383(14): 1305-16 [PubMed]
III. Indications: Chronic Atrial Fibrillation
- Symptomatic patients
- Younger patients (esp. <65 years old)
- Poor rate control with recurrent hospitalizations
- Lone Atrial Fibrillation with initial presentation
- Precipitating factor has been corrected or controlled
IV. Management
- Intermittent paroxysmal Atrial Fibrillation
- Chronic rhythm control is combined with rate control and Anticoagulation
- Rhythm Control Agent Selection
- See Atrial Fibrillation Pharmacologic Cardioversion (reviews the Antiarrhythmic agents as they apply to cardioversion)
- Better tolerated agents (but contraindicated in CHF, structural heart disease, CAD)
- Agents with fewer contraindications (may be used in CHF, CAD), but with increased adverse effects
V. References
- (2023) Presc Lett 30(2): 9-10