Abstract
Atrial fibrillation (AF) is the most common clinically significant arrhythmia seen by clinicians. Prevalence is as high as 9.0% in patients aged ≥ 80 years, and incidence is projected to be more than 5.6 million patients in the U.S. by 2050. Recently, new trials have challenged the traditional belief that rhythm control is inherently superior to rate control in these patients. This article reviews the basic tenets of treatment for AF and discusses how new trial data integrate into these protocols. A concise treatment algorithm is provided and new and upcoming more aggressive interventional treatment options are discussed. This review is designed to help the general practitioner decide how to treat patients in the outpatient setting, evaluate which patients should be hospitalized for management, and which patients should be referred to a cardiologist.
Keywords: atrial fibrillation, antiarrhythmics, ablation
Full Text
The Full Text of this article is available as a PDF (41.6 KB).
References
- 1. Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE: Prevalence of diagnosed atrial fibrillation in adults: National implications for rhythm management and stroke prevention: The AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study. J Am Med Assoc 2001; 285: 2370–2375 [DOI] [PubMed] [Google Scholar]
- 2. Prostowsky E, Klein G: Cardiac Arrhythmias An Integrated Approach for the Clinician. New York: McGraw‐Hill Inc., 1994. [Google Scholar]
- 3. Moe GK, Abildskov JA: Atrial fibrillation as a self‐sustaining arrhythmia independent of focal discharge. Am Heart J 1959; 58: 59–70 [DOI] [PubMed] [Google Scholar]
- 4. Allessie MA, Bonke FI, Schopman FJ: Circus movement in rabbit atrial muscle as a mechanism of tachycardia. III. The “leading circle” concept: A new model of circus movement in cardiac tissue without the involvement of an anatomical obstacle. Circ Res 1977; 41 (1): 9–18 [DOI] [PubMed] [Google Scholar]
- 5. Lévy S, Maarek M, Coumel P, Guize G, Lekieffre J, Medvedowsky J, Sebaoun A: College of French Cardiologists. Characterization of different subsets of atrial fibrillation in general practice in France: The ALFA study. Circulation 1999; 99: 3028–3035 [DOI] [PubMed] [Google Scholar]
- 6. Nunain SO: Determinants of the course and prognosis of atrial fibrillation In Atrial Arrhythmias: Current Concepts and Management (Eds. Touboul P. and Waldo A.) pp. 350–358. St. Louis: Mosby Year Book, 1990. [Google Scholar]
- 7. Maloney JD, Milner L, Barold S, Czerska B, Markel M: Two‐staged biatri‐al linear and focal ablation to restore sinus rhythm in patients with refractory chronic atrial fibrillation: Procedure experience and follow‐up beyond 1 year. Pacing Clin Electrophysiol 1998; 21 (11, Pt2): 2527–2532 [DOI] [PubMed] [Google Scholar]
- 8. Capucci A, Lenzi T, Boriani G, Trisolino G, Binetti N, Cavazza M, Fontana G, Magnani B: Effectiveness of loading oral flecainide for converting recent‐onset atrial fibrillation to sinus rhythm in patients without organic heart disease or with only systemic hypertension. Am J Cardiol 1992; 70: 69–72 [DOI] [PubMed] [Google Scholar]
- 9. Norgaard BL, Wachtell K, Christensen PD, Madsend B, Johansen JB, Christiansen EH, Graff O, Simonsen EH, for the Danish Dofetilide in Atrial Fibrillation and Flutter Study Group: Efficacy and safety of intravenously administered dofetilide in acute termination of atrial fibrillation and flutter : A multicenter, randomized, double‐blind, placebo‐controlled trial. Am Heart J 1999; 137: 1062–1069 [DOI] [PubMed] [Google Scholar]
- 10. Klein A, Grimm RA, Murray RD, Apperson‐Hansen C, Stat M, Asinger RW, Black IW, Davidoff R, Erbel R, Halperin JL, Orsinelli DA, Porter TR, Stoddard MF, for the Assessment of Cardioversion Using Transesophageal Echocardiography Investigators : Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med 2001; 344: 1411–1420 [DOI] [PubMed] [Google Scholar]
- 11. The Atrial Fibrillation Follow‐up Investigation of Rhythm Management (AFFIRM) Investigators : A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002; 347: 1825–1833 [DOI] [PubMed] [Google Scholar]
- 12. Van Gelder IC, Hagens VE, Bosker HA, Kingma JA, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermans A, Tijssen J, Crijns H, for the Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group : A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002; 347: 183 4–1840 [DOI] [PubMed] [Google Scholar]
- 13. Lemery R: Ablation Techniques. Canadian Association of Cardiac Rehabilitation News letter 2002; 10 (2), online reference (http://www.cacr.ca/news/ 2002/0210Lemery.htm) [Google Scholar]
- 14. Wharton JM: Ablation of atrial fibrillation: A procedure come of age? Curr Contr Trials Cardiovasc Med 2001; 2: 67–70 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Chen S, Tai CT, Hsieh MH, Tsai C, Lin YK, Ding Y, Chang M: Radio‐frequency catheter ablation of atrial fibrillation initiated by spontaneous ec‐topic beats. Curr Cardiol Rep 2000; 2: 322–328 [DOI] [PubMed] [Google Scholar]
- 16. Wolf PA, Dawber TR, Thomas HE Jr, Kannel WB: Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: The Framingham Study. Neurology 1978; 28: 973–977 [DOI] [PubMed] [Google Scholar]
- 17. Wolf PA, Abbott RD, Kannel WB: Atrial fibrillation as an independent risk factor for stroke: The Framingham Study. Stroke 1991; 22: 983–988 [DOI] [PubMed] [Google Scholar]
- 18. Carson PE, Johnson GR, Dunkman WB, Fletcher RD, Farrell L, Cohn JN, for the V‐HeFT VA Cooperative Studies Group: The influence of atrial fibrillation on prognosis in mild to moderate heart failure : The V‐HeFT Studies. Circulation 1993; 87:VI–102–VI–110. [PubMed] [Google Scholar]
- 19. Dries DL, Exner DV, Gersh BJ, Domanski MJ, Waclawic MA, Stevenson LW: Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: A retrospective analysis of the SOLVD trials: Studies of Left Ventricular Dysfunction. J Am Coll Cardiol 1998; 32: 695–703 [DOI] [PubMed] [Google Scholar]
- 20. Fuster V, Ryden LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay GN, Klein WW, Levy S, McNamara RL, Prystowsky EN, Wann LS, Wyse DG, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC, Klein WW, Alonso‐Garcia A, Blomstrom‐Lundqvist C, De Backer G, Flather M, Hradec J, Oto A, Parkhomenko A, Silber S, Torbicki A: ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: Executive summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences. J Am Coll Cardiol 2001; 38 (4): 1231–1266 [DOI] [PubMed] [Google Scholar]
- 21. Fuster V, Ryden LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay GN, Klein WW, Levy S, McNamara RL, Prystowsky EN, Wann LS, Wyse DG, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC, Klein WW, Alonso‐Garcia A, Blomstrom‐Lundqvist C, De Backer G, Flather M, Hradec J, Oto A, Parkhomenko A, Silber S, Torbicki A: ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: Executive summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences. J Am Coll Cardiol 2001; 38 (4): 1231–1266 [DOI] [PubMed] [Google Scholar]