Atrial Fibrillation

• Issues in Management of AF

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• Should We Maintain Sinus Rhythm?
• The AFFIRM trial
• The SAFE-T trial- amiodarone vs sotalol vs placebo

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• Anticoagulation in AF
  • Risk of Thromboembolism-CHADS2
  • "Moderate Risk" Patients
  • "High-Risk" Patients
  • Secondary Prevention
  • Target INR level for AF patients
  • Maintain INR in theurapeutic range

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• Clopidogrel
  • Anticoagulation slightly better than Clopidogrel with Aspirin
  • Clopidogrel with Asprin better than Aspirin alone for those not eligible for anticoagulation

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• Cardioversion
• Role of Transoesophageal Echo in Cardioversion

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• Use of ACE-inhibitors or ARBs
• ACE-inhibitors may reduce the risk of recurrent PAF in those with lone PAF

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• Non-Pharmacological Therapy
• Options

Non-Rheumatic Atrial Fibrillation

Should we accept chronic atrial fibrillation or attempt to maintain sinus rhythm?

The SAFE-T trial

The Sotalol Amiodarone Atrial Fibrillation Efficacy Trial (SAFE-T) was published in the New England Journal of Medicine (N Engl J Med 2005;352:1861-72)

In the introduction, the investigators state that different results may have been obtained if the best approach to maintain sinus rhythm had been used in previous trials that compared rhythm control vs rate control strategies in atrial fibrillation.

In other words, experts in this field are not all united in believing that rate control is the best approach for patients with atrial fibrillation. We should remain receptive to using a rhythm control approach in patients that tolerate atrial fibrillation poorly, including those whose heart rate is not easily controlled and also including those who develop heart failure when in atrial fibrillation.

The SAFE-T trial compared placebo, amiodarone and sotalol in patients with atrial fibrillation. Patients were in NYHA class I or II, with a mean ejection fraction of about 50% and LA dimension of 47-49mm.

About a quarter of patients randomised to amiodarone or sotalol reverted to sinus rhythm before DC cardioversion.

Approximately a quarter of patients failed DC cardioversion but the failure rate was higher by a few percent in the placebo group.

On treatment analysis showed that those that remained on amiodarone had median times to recurrent atrial fibrillation of 809 days compared with 209 days for sotalol and 82 days for placebo.

However, in the group with ischaemic heart disease, the median on treatment time to recurrent atrial fibrillation with amiodarone was 569 days compared with 428 days with sotalol. In other words, although amiodarone was also more effective in patients with ischaemic heart disease compared with sotalol, the differences between the two drugs was less than in patients without ischaemic heart disease.

Also of interest is that of those patients that had been in atrial fibrillation for more than one year prior to entry into the trial, there was a relatively low rate of recurrence of atrial fibrillation after one year in the amiodarone group (45%) compared with sotalol (74%) or placebo (92%).

Dr Hitesh Patel, Cardiologist
17th June, 2005