Atrial fibrillation: Effective strategies using the latest tools
Direct oral anticoagulants or warfarin? Rate or rhythm control? Here’s how to determine which strategies to pursue and when.
PRACTICE RECOMMENDATIONS
› Use the CHA2DS2-VASc score to assess the risk of thromboembolism, including ischemic stroke. A
› Consider prescribing a direct oral anticoagulant (DOAC) instead of warfarin for patients with nonvalvular atrial fibrillation (AF) because they are superior at preventing strokes and lowering all-cause mortality in this population. B
› Do not use a DOAC in patients with mechanical heart valves, hemodynamically significant mitral stenosis, or severe chronic kidney disease (estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2). A
› Pursue a rate-control strategy for most patients with AF, although rhythm control may be preferable for younger (<65 years) symptomatic patients. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Indications for rhythm control
The NICE guidelines, which are consistent with the ACC/AHA/HRS guidelines, recommend rate control as the first-line strategy for AF management, except in people:21
- whose AF has a reversible cause
- who have HF believed to be primarily caused by AF
- with new-onset AF
- with atrial flutter that is considered suitable for an ablation strategy to restore sinus rhythm
- for whom a rhythm-control strategy would be more suitable based on clinical judgment.
In addition, patients who continue to experience symptomatic AF despite an adequate trial of rate control should be offered rhythm control.5
Pharmacologic rhythm-control strategies. Antiarrhythmic drugs can be used for chemical cardioversion, reduction of paroxysms, and long-term maintenance of sinus rhythm. The most commonly used antiarrhythmic drugs are Class IC and Class III agents (TABLE 3).5 Tailored drug selection for each patient is key. Patients with left atrial diameters >4.5 cm are less likely to remain in sinus rhythm, and patients with left ventricular hypertrophy are at increased risk for proarrhythmic adverse effects.44 Patients with paroxysmal AF may be candidates for a “pill-in-the-pocket” strategy using propafenone or flecainide.5
AF frequently progresses from paroxysmal to persistent and can subsequently result in electrical and structural remodeling that becomes irreversible over time.45 The patient with uncontrolled symptoms despite attempts at rate control and rhythm control should be promptly referred to an electrophysiologist.
Surgical interventions for rate or rhythm control
Electrophysiology interventions include AV nodal ablation with pacemaker placement for rate control, or catheter-directed ablation (radiofrequency or cryotherapy) for rhythm control. CA appears to be more effective than pharmacologic rhythm control.46,47 Treatment with CA is indicated for symptomatic paroxysmal AF when a rhythm-control strategy is desired and the AF is refractory to, or the patient is intolerant of, at least one class I or III antiarrhythmic medication.5 With these same caveats, CA is a reasonable strategy for symptomatic persistent AF.
Consider more invasive interventions, such as an atrial maze procedure, when patients require cardiac surgery for another indication. Patients with an increased risk of thromboembolism (based on CHA2DS2-VASc) remain at high risk even after successful ablation.48 As a result, some guidelines recommend continued long-term anticoagulation following CA.18,22
CORRESPONDENCE
Philip Dooley, MD, University of Kansas School of Medicine–Wichita Family Medicine Residency at Via Christi, 707 North Emporia, Wichita, KS 67207; philip.dooley@via-christi.org.
ACKNOWLEDGMENTS
We thank Professor Anne Walling, MB, ChB, FFPHM, Department of Family and Community Medicine, University of Kansas School of Medicine–Wichita for her suggestions and critical review of an earlier version of this manuscript.
