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

Issues in the management of atrial fibrillation

1. Is cardioversion worth attempting? In most instances of new-onset atrial fibrillation, cardioversion should be considered. However, in the AFFIRM trial attempting to maintain sinus rhythm did not reduce mortality. In those who have had recurrent atrial fibrillation or very prolonged persistent atrial fibrillation the approach may be one of acceptance of chronic atrial fibrillation.
2. Transoesophageal echocardiography can be used to reduce delays to cardioversion but may not be readily available in all institutions.
3. What is the risk of thromboembolism? Does the absolute benefit from anticoagulation with warfarn exceed the risk of serious bleeding? In high-risk patients, including the elderly, the benefit usually exceeds the risk.
4. Is the heart rate response to atrial fibrillation adequately controlled, not only at rest but also with effort? Poor rate control with effort may result in impaired exercise tolerance- particularly in those with impaired LV function including those with significant isolated diastolic dysfunction. A simple test is to ask the patient to walk a short distance to determine if the heart rate response seems excessive and indicates needs for additional therapy.
   Calcium channel blockers such as diltiazem and verapamil, betablockers, and digoxin are non-antiarrhythmic agents that can be used to control heart rate response. Digoxin should probably only be used as a second- or third-line agent, and ensuring digoxin levels are not elevated.
5. What is the cause of atrial fibrillation? Is there an underlying cause that requires specific management?