When is a rhythm control strategy appropriate? Which patients are candidates for amiodarone? When is AF ablation the answer? Here, a top-line review of rhythm control for atrial fibrillation.
Pharmacologic rhythm control is often preferred in younger patients and those who are highly symptomatic with AF. It can also be used in patients with poorly rate-controlled AF or poorly tolerated AF. It is a Class IIb recommendation in those who have or are at risk for tachycardia-induced cardiomyopathy.
A pharmacologic rhythm control strategy should not be pursued-or should be discontinued-when AF becomes permanent. Discontinue rhythm control if drug toxicity outweighs benefit or drug cannot be tolerated.
When coronary artery disease has been ruled out with a stress test, a class IC agent (flecainide or propafenone) is preferred, given the favorable efficacy and safety profiles. NB: These agents can, on occasion, “organize” AF into atrial flutter.
If coronary artery disease or heart failure is documented and rhythm control is still preferred, alternative antiarrhythmics (amiodarone, dofetilide) should be used. Because of its toxicity, amiodarone should only be considered after other agents have failed or are otherwise contraindicated.
Refer for AF ablation therapy when a rhythm control strategy is desired and the patient is refractory to or intolerant of at least 1 class I or III antiarrhythmic medication (class I recommendation). Rarely, ablation can be used as a first-line therapy. This is currently a class IIa recommendation in the European consensus statement.
The pendulum for management of atrial fibrillation continues to swing away from universal rate control as the primary strategy to achieving rhythm control for an increasing number of patients. At the same time, there are more treatment options available to achieve rhythm control. These 5 slides offer a quick top-line review of pharmacologic and procedural choices and when they apply.
January CT, Wann LS, Calkins H, et al. 2014 AHA/ACC/HRS Guideline 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 Heart Rhythm Society. J Am Coll Cardiol. 2014;64:2246-2280. doi:10.1016/j.jacc.2014.03.021.
2. Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace. 2012;14:528-606. [Epub 2012 Mar 1]. doi:10.1093/europace/eus027.