Atrial fibrillation maintenance of rate control and sinus rhythm: Difference between revisions

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Latest revision as of 05:36, 15 November 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Varun Kumar, M.B.B.S.

Overview

Maintenance of sinus rhythm could be reached by using anti-arrhythmic drug therapy in patients with atrial fibrillation and it is specially recommended in symptomatic patients. There are six anti-arrhythmic drugs recommended and available for sinus rhythm maintannace in atrial fibrillation (AF). Choosing the proper anti-arrhythmic drug based on patient's underlying diseases and possible side effects is critical. Moreover, all of the anti-arrhythmic drugs (AADs) should be discontinued if a patient's (atrial fibrillation (AF) becomes permanent. Catheter-based ablation is an alternative to anti-arrhythmic drugs (AADs) therapy that could be considered as a first-line option at experienced centers.

Maintanance of Sinus Rate

Anti-arrhythmic drug therapy could be useful to maintain sinus rhythm in patients with atrial fibrillation. Although in general rhythm control does not produce better outcomes, compared to rate control in terms of stroke or mortality, it is still one of the main treatments. Nevertheless, a rhythm control approach may be favored if the patient is highly symptomatic, or hemodynamically unstable (often seen in congestive heart failure patients due to loss of the atrial kick in atrial fibrillation (AF)).
There are six anti-arrhythmic drugs (AADs) recommended for atrial fibrillation (AF).^[1]
- Flecainide and propafenone are class Ic anti-arrhythmics.
- Dofetilide, sotalol, dronedarone, and amiodarone are class III antiarrhythmics.
- Other anti-arrhythmic drugs (lidocaine, quinidine, etc) are not recommended.
- It is recommended to select anti-arrhythmic drugs (AADs), based on a patient's underlying heart issues (if any).
In patients with no structural heart disease (no CAD and no CHF), any of the six listed anti-arrhythmic drugs (AADs) is reasonable.
Given the toxicities of amiodarone and concerns about its long term use, amiodarone is not recommended for first-line therapy. It should be used only if other agents have failed or are contraindicated.^[1]^[2] It should be used only if other agents have failed or are contraindicated.
The class Ic AADs (flecainide and propafenone) are contraindicated in patients who are suffering from Coronary heart disease. Class Ic AADs have been found to cause increased death and cardiac arrest in patients post-MI.^[3]
Flecainide, propafenone, dofetilide, and sotalol are not recommended for patients with severe left ventricular hypertrophy (LVH).
In patients with CHF, amiodarone and dofetilide are recommended.
All of these drugs carry a risk of pro-arrhythmia. Dofetilide and sotalol particularly prolong the QT interval and increase risk of Torsade de pointes. Hence, these drugs must initiated in the hospital to allow for careful monitoring of the QT interval.
anti-arrhythmic drugs (AADs) therapy does not obviate the need for anticoagulation in atrial fibrillation patients.
Catheter-based ablation is an alternative to anti-arrhythmic drugs (AADs) therapy that should be considered as a first-line option at experienced centers ^[1] per the 2014 AHA guidelines.
Surgical atrial fibrillation ablation can be considered if the patient needs cardiac surgery for another reason, or as a last recourse if other options have failed.
All of the anti-arrhythmic drugs (AADs) should be discontinued if a patient's (atrial fibrillation (AF) becomes permanent.

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)^[4]

Rhythm Control

Antiarrhythmic Drugs to Maintain Sinus Rhythm

Class I
"1. Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended. (Level of Evidence: C)"
"2. The following antiarrhythmic drugs are recommended in patients with AF to maintain sinus rhythm, depending on underlying heart disease and comorbidities: a. Amiodarone, b. Dofetilide, c. Dronedarone, d. Flecainide, e. Propafenone, f. Sotalol. (Level of Evidence: A)"
"3. The risks of the antiarrhythmic drug, including proarrhythmia, should be considered before initiating therapy with each drug. (Level of Evidence: C)"
"4. Owing to its potential toxicities, amiodarone should only be used after consideration of risks and when other agents have failed or are contraindicated. (Level of Evidence: C)"

Class III: Harm
"1. Antiarrhythmic drugs for rhythm control should not be continued when AF becomes permanent (Level of Evidence: C) including dronedarone. (Level of Evidence: B)"
"2. Dronedarone should not be used for treatment of AF in patients with New York Heart Association (NYHA) class III and IV HF or patients who have had an episode of decompensated HF in the past 4 weeks. (Level of Evidence: B)"

Class IIa
"1. A rhythm-control strategy with pharmacological therapy can be useful in patients with AF for the treatment of tachycardia-induced cardiomyopathy. (Level of Evidence: C)"

Class IIb
"1. It may be reasonable to continue current antiarrhythmic drug therapy in the setting of infrequent, well-tolerated recurrences of AF, when the drug has reduced the frequency or symptoms of AF. (Level of Evidence: C)"

AF Catheter Ablation to Maintain Sinus Rhythm

Class I
"1. AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm control strategy is desired. (Level of Evidence: A)"
"2. Prior to consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual patient is recommended. (Level of Evidence: C)"

Class III: Harm
"1. AF catheter ablation should not be performed in patients who cannot be treated with anticoagulant therapy during and following the procedure. (Level of Evidence: C)"
"2. AF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation. (Level of Evidence: C)"

Class IIa
"1. AF catheter ablation is reasonable for selected patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication. (Level of Evidence: A)"
"2. In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm control strategy prior to therapeutic trials of antiarrhythmic drug therapy, after weighing risks and outcomes of drug and ablation therapy. (Level of Evidence: B)"

Class IIb
"1. AF catheter ablation may be considered for symptomatic long-standing (>12 months) persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication, when a rhythm control strategy is desired. (Level of Evidence: B)"
"2. AF catheter ablation may be considered prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication for symptomatic persistent AF, when a rhythm control strategy is desired. (Level of Evidence: C)"

Pharmacological Agents for Preventing AF and Maintaining Sinus Rhythm

Therapies to maintain sinus rhythm
Treatment	Efficacy	Adverse effects	Contraindications	Precausions
Drug therapy
Beta-blockers	Low Sinus rhythm is maintained in <20% of patients Symptoms are reduced in >=20% of patients	Fatigue Bradycardia Monitor for bradycardia	Bradycardia Hypotension	Monitor for bradycardia
Nondihydropyridine Calcium Channel Blockers: Verapamil Diltiazem	Low Sinus rhythm is maintained in <20% of patients Symptoms are reduced in >=20% of patients	Edema Bradycardia Hypotension	Bradycardia [[Hypotension Heart failure with reduced ejection fraction
Flecainide	Moderate AF is prevented or reduced in 50-70% of patients	Uncommon Proarrhythmia risk in patients with structural heart disease	Structural heart disease (proarrhythmia risk)	Evaluate for ischemic heart disease before initiation of therapy
Propafenone	Moderate AF is prevented or reduced in 50-70% of patients	Dysgeusia	Structural heart disease (proarrhythmia risk)	Evaluate for ischemic heart disease before initiation of therapy
Quinidine	Moderate AF is prevented or reduced in 50-70% of patients	Gastrointestinal side effects	QT prolongation	Monitor for QT prolongation, polymorphic ventricular tachycardia
Disopyramide	Moderate AF is prevented or reduced in 50-70% of patients	Antimuscarinic effects Urinary retention	QT prolongation Heart failure	Monitor for QT prolongation,
Dronendrone	Moderate AF is prevented or reduced in 50-70% of patients	Uncommon	Heart failure	Monitor for: Fluid retention Hepatitis
Dofetilide	Moderate AF is prevented or reduced in 50-70% of patients	QT prolongation	QT prolongation Advanced renal disease	Monitor for QT prolongation (should be initiated in hospital)
Sotalol	Moderate AF is prevented or reduced in 50-70% of patients	QT prolongation Fatigue Bradycardia Hypotension	QT prolongation Advanced renal disease Bradycardia	Monitor for QT prolongation
Amiodarone	High AF is prevented or reduced in 80% of patients	Bradycardia Thyroid diseases Hepatitis Interstitial lung disease (pulmonary fibrosis) Neurologic dysfunction Photosensitivity	Bradycardia Hyperthyroidism	Monitor for systemic toxicities involving the thyroid, liver, lungs, and nervous system Monitor for drug interactions
Interventional procedures
Catheter ablation	High 60-80% of patients with paroxysmal AF are free from AF at 1 year 50% of patients with persistent AF are free from AF at 1 year Reduced AF burden	Procedure-related complications Risks associated with sedation and anesthesia Transient arrhythmia (for 3 months) For patients with persistent AF, a second procedure s often needed	Risks associated with sedation and anesthesia Catheter ablation is contraindicated if: vascular access is not possible vascular access is associated with high risks anticoagulation is contraindicated	Monitor for procedure-related complications (within the first 4 weeks) such as: tamponade esophageal injury Pulmonary vein stenosis (within months) Conversion of AF to rapid atrial flutter
Surgery (Maze procedure)	High AF is prevented in 80% of patients	Risks associated with anesthesia and surgery	Surgical contraindications	Monitor for complications of surgery

Sources

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation^[4]

ACCF/AHA/HRS 2011 Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation^[5]

ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines^[6]

ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter^[7]

ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation^[8]

References

↑ ^1.0 ^1.1 ^1.2 Craig T. January, MD, PhD, FACC; L. Samuel Wann, MD, MACC, FAHA; Joseph S. Alpert, MD, FACC, FAHA; Hugh Calkins, MD, FACC, FAHA, FHRS; Joaquin E. Cigarroa, MD, FACC; Joseph C. Cleveland, Jr., MD, FACC; Jamie B. Conti, MD, FACC, FHRS; Patrick T. Ellinor, MD, PhD, FAHA; Michael D. Ezekowitz, MB, ChB, FACC, FAHA; Michael E. Field, MD, FACC, FHRS; Katherine T. Murray, MD, FACC, FAHA, FHRS; Ralph L. Sacco, MD, FAHA; William G. Stevenson, MD, FACC, FAHA, FHRS; Patrick J. Tchou, MD, FACC; Cynthia M. Tracy, MD, FACC, FAHA; Clyde W. Yancy, MD, FACC, FAHA. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive SummaryA 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(21):2246-2280
↑ Dingxin Qin, George Leef, Mian Bilal Alam, Rohit Rattan, Mohamad Bilal Munir, Divyang Patel, Furqan Khattak, Evan Adelstein, Sandeep K. Jain, Samir Saba. Mortality risk of long-term amiodarone therapy for atrial fibrillation patients without structural heart disease. Cardiology Journal 2015;22(6):622-629.
↑ Echt et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo: the cardiac arrhythmia suppression trial. NEJM 1991; 324(12): 781-788.
↑ ^4.0 ^4.1 January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.
↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897
↑ Abraham NS, Hlatky MA, Antman EM, Bhatt DL, Bjorkman DJ, Clark CB; et al. (2010). "ACCF/ACG/AHA 2010 Expert Consensus Document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents". Circulation. 122 (24): 2619–33. doi:10.1161/CIR.0b013e318202f701. PMID 21060077.
↑ Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117 (8):1101-20. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199
↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: 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 (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781

Template:WikiDoc Sources CME Category::Cardiology

[:0-1] 1.0 ^1.1 ^1.2 Craig T. January, MD, PhD, FACC; L. Samuel Wann, MD, MACC, FAHA; Joseph S. Alpert, MD, FACC, FAHA; Hugh Calkins, MD, FACC, FAHA, FHRS; Joaquin E. Cigarroa, MD, FACC; Joseph C. Cleveland, Jr., MD, FACC; Jamie B. Conti, MD, FACC, FHRS; Patrick T. Ellinor, MD, PhD, FAHA; Michael D. Ezekowitz, MB, ChB, FACC, FAHA; Michael E. Field, MD, FACC, FHRS; Katherine T. Murray, MD, FACC, FAHA, FHRS; Ralph L. Sacco, MD, FAHA; William G. Stevenson, MD, FACC, FAHA, FHRS; Patrick J. Tchou, MD, FACC; Cynthia M. Tracy, MD, FACC, FAHA; Clyde W. Yancy, MD, FACC, FAHA. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive SummaryA 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(21):2246-2280

[2] Dingxin Qin, George Leef, Mian Bilal Alam, Rohit Rattan, Mohamad Bilal Munir, Divyang Patel, Furqan Khattak, Evan Adelstein, Sandeep K. Jain, Samir Saba. Mortality risk of long-term amiodarone therapy for atrial fibrillation patients without structural heart disease. Cardiology Journal 2015;22(6):622-629.

[3] Echt et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo: the cardiac arrhythmia suppression trial. NEJM 1991; 324(12): 781-788.

[JanuaryWann2014-4] 4.0 ^4.1 January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.

[pmid21382897-5] Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897

[pmid21060077-6] Abraham NS, Hlatky MA, Antman EM, Bhatt DL, Bjorkman DJ, Clark CB; et al. (2010). "ACCF/ACG/AHA 2010 Expert Consensus Document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents". Circulation. 122 (24): 2619–33. doi:10.1161/CIR.0b013e318202f701. PMID 21060077.

[pmid18283199-7] Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117 (8):1101-20. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199

[pmid16908781-8] Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: 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 (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781

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v t e Electrocardiography
Overview	History of the EKG • EKG interpretation basics • Normal sinus rhythm
EKG Complexes	P wave • QRS complex • ST Segment • T wave • T wave alternans • Tombstone T wave • U wave Osborn wave • H wave • K wave • Delta wave NSSTW changes
EKG Intervals	PR Interval • QRS Interval • ST Interval • QT Interval
Conduction System & Bradycardia	Cardiac pacemaker • SA node • AV node• Bundle of His • Purkinje fibers • Sinus bradycardia • First Degree AV Block • Second Degree AV Block • Complete or Third-Degree AV Block • Concealed conduction • AV Junctional Rhythms • LBBB • LAHB • LPHB • RBBB • Trifascicular block
Atrial Arrhythmias	Sinus tachycardia • Premature Atrial Contractions (PACs) • Ectopic Atrial Rhythm • Paroxysmal Atrial Tachycardia (PAT) • Paroxysmal Atrial Tachycardia (PAT) with Block • Multifocal Atrial Tachycardia (MAT) • Atrial Flutter • Atrial Fibrillation • Wandering atrial pacemaker
Ventricular Arrhythmias	Differential Diagnosis of Tachycardia with a Wide QRS Complex • Accelerated Idioventricular Rhythm • Ventricular Parasystole • Premature Ventricular Contractions (PVCs) • Ventricular tachycardia • Ventricular Fibrillation • Sudden cardiac death
EKG Abnormalities in Disease States	Hypertrophy & Dilatation • Right atrial enlargement • Left atrial enlargement • Biatrial enlargement • Left Ventricular Hypertrophy • Right Ventricular Hypertrophy • Biventricular Hypertrophy • Acute myocardial infarction • NSTEMI • STEMI • Tombstone ST elevation • Right ventricular myocardial infarction • Atrial infarction Pre-excitation Syndromes • Wolff-Parkinson-White Syndrome • Lown Ganong Levine Syndrome • Mahaim Type Preexcitation Cardiomyopathies • Arrhythmogenic Right Ventricular Dysplasia • Dilated Cardiomyopathy • Hypertrophic Cardiomyopathy Drug Effects on the EKG • Adenosine • β-blockers • Digitalis • Quinidine • Procainamide • Disopyramide • Lidocaine • Tocainide and Mexiletine • Phenytoin • Encainide, Flecainide and Propafenone • Amiodarone • Bretylium • Ca Channel Blockers • Phenothiazines • Tricyclic Antidepressants • Lithium Congenital Heart Disease • Dextrocardia • Atrial Septal Defect • Ventricular Septal Defect • Tetralogy of Fallot • Conjoined Twins or Siamese Twins • Congenital heart block Electrolyte Disturbances • Hyperkalemia • Hypokalemia • Hypercalcemia • Hypocalcemia • Nonspecific Changes Other Heart Diseases • Pericarditis • Myocarditis • Tamponade • Heart Transplantation • Sick Sinus Syndrome • Long QT Syndrome Inherited Disease • Brugada Syndrome Systemic Diseases • CNS Disease • Cardiac Tumors Heart Transplantation • EKG Changes in patient with Heart Transplantation Exogenous Effects • Hypothermia • Chest Trauma • Insect Bites • Electric Injuries
Technical Issues and Potential Errors in Interpretation	Artifacts • Lead Placement Errors • The EKG in a Patient with a Pacemaker • EKG in athletes

@@ Line 5: / Line 5: @@
 |}
 {{Atrial fibrillation}}
-{{CMG}}; {{AE}} {{CZ}}; [[Varun Kumar, M.B.B.S.]]
+{{CMG}}; {{AE}} {{Mitra}} {{CZ}}; [[Varun Kumar, M.B.B.S.]]
 ==Overview==
+Maintenance of [[sinus rhythm]] could be reached by using [[arrhythmia|anti-arrhythmic drug]] [[therapy]] in [[patients]] with [[atrial fibrillation]] and it is specially recommended in [[symptom|symptomatic]] [[patients]]. There are six [[Antiarrhythmic agent|anti-arrhythmic drugs]] recommended and available for [[sinus rhythm]] maintannace in [[atrial fibrillation]] ([[AF]]). Choosing the proper [[Antiarrhythmic agent|anti-arrhythmic drug]] based on [[patient]]'s underlying [[diseases]] and possible [[Adverse effect (medicine)|side effects]] is critical. Moreover, all of the [[Antiarrhythmic agent|anti-arrhythmic drugs]] ([[Antiarrhythmic agent|AADs]]) should be discontinued if a [[patient]]'s ([[atrial fibrillation]] ([[AF]]) becomes permanent. [[Catheter ablation|Catheter-based ablation]] is an alternative to [[Antiarrhythmic agent|anti-arrhythmic drugs]] ([[Antiarrhythmic agent|AADs]]) [[therapy]] that could be considered as a first-line option at experienced centers.
-Anti-arrhythmic drug therapy may be useful to maintain [[sinus rhythm]] in patients with atrial fibrillation.  Although in general rhythm control does not produce better outcomes than rate control in terms of stroke or mortality, rhythm control may be desired in certain situations.  A rhythm control approach may be favored if the patient is highly symptomatic when in AF, or does not tolerate AF well hemodynamically (often seen in CHF patients due to loss of the atrial kick in AF).
+==Maintanance of Sinus Rate==
+*[[arrhythmia|Anti-arrhythmic drug]] [[therapy]] could be useful to maintain [[sinus rhythm]] in [[patients]] with [[atrial fibrillation]]. Although in general [[sinus rhythm|rhythm]] control does not produce better outcomes, compared to [[heart rate|rate]] control in terms of [[stroke]] or [[mortality]], it is still one of the main [[treatments]]. Nevertheless, a [[sinus rhythm|rhythm control]] approach may be favored if the [[patient]] is highly [[symptom|symptomatic]], or [[Hypotension|hemodynamically unstable]] (often seen in [[congestive heart failure]] [[patients]] due to loss of the [[atrial kick]] in [[atrial fibrillation]] ([[AF]])).
-There are six anti-arrhythmic drugs (AADs) recommended for AF.  Flecainide and propafenone are class Ic anti-arrhythmics.  Dofetilide, sotalol, dronedarone, and amiodarone are class III anti-arrhythmics <ref name=":0">Craig T. January, MD, PhD, FACC; L. Samuel Wann, MD, MACC, FAHA; Joseph S. Alpert, MD, FACC, FAHA; Hugh Calkins, MD, FACC, FAHA, FHRS; Joaquin E. Cigarroa, MD, FACC; Joseph C. Cleveland, Jr., MD, FACC; Jamie B. Conti, MD, FACC, FHRS; Patrick T. Ellinor, MD, PhD, FAHA; Michael D. Ezekowitz, MB, ChB, FACC, FAHA; Michael E. Field, MD, FACC, FHRS; Katherine T. Murray, MD, FACC, FAHA, FHRS; Ralph L. Sacco, MD, FAHA; William G. Stevenson, MD, FACC, FAHA, FHRS; Patrick J. Tchou, MD, FACC; Cynthia M. Tracy, MD, FACC, FAHA; Clyde W. Yancy, MD, FACC, FAHA.  2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive SummaryA 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(21):2246-2280
+*There are six [[Antiarrhythmic agent|anti-arrhythmic drugs]] ([[Antiarrhythmic agent|AADs]]) recommended for [[atrial fibrillation]] ([[AF]]).<ref name=":0">Craig T. January, MD, PhD, FACC; L. Samuel Wann, MD, MACC, FAHA; Joseph S. Alpert, MD, FACC, FAHA; Hugh Calkins, MD, FACC, FAHA, FHRS; Joaquin E. Cigarroa, MD, FACC; Joseph C. Cleveland, Jr., MD, FACC; Jamie B. Conti, MD, FACC, FHRS; Patrick T. Ellinor, MD, PhD, FAHA; Michael D. Ezekowitz, MB, ChB, FACC, FAHA; Michael E. Field, MD, FACC, FHRS; Katherine T. Murray, MD, FACC, FAHA, FHRS; Ralph L. Sacco, MD, FAHA; William G. Stevenson, MD, FACC, FAHA, FHRS; Patrick J. Tchou, MD, FACC; Cynthia M. Tracy, MD, FACC, FAHA; Clyde W. Yancy, MD, FACC, FAHA.  2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive SummaryA 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(21):2246-2280
-</ref>.  Other anti-arrhythmic drugs (lidocaine, quinidine, etc) are not recommended.  The recommended AAD is based on a patient's underlying heart issues (if any).
+</ref>
+**[[Flecainide]] and [[propafenone]] are [[Antiarrhythmic agent|class Ic anti-arrhythmics]].
-In patients with no structural heart disease (no CAD and no CHF), any of the six listed AADs is reasonable.  Given the toxicities of amiodarone and concerns about its long term use, amiodarone is not recommended for first line therapy <ref name=":0" /><ref>Dingxin Qin, George Leef, Mian Bilal Alam, Rohit Rattan, Mohamad Bilal Munir, Divyang Patel, Furqan Khattak, Evan Adelstein, Sandeep K. Jain, Samir Saba.  Mortality risk of long-term amiodarone therapy for atrial fibrillation patients without structural heart disease.  Cardiology Journal 2015;22(6):622-629.</ref>.  It should be used only if other agents have failed or are contraindicated.
+**[[Dofetilide]], [[sotalol]], [[dronedarone]], and [[amiodarone]] are [[Antiarrhythmic agent|class III antiarrhythmics]].
+**Other [[Antiarrhythmic agent|anti-arrhythmic drugs]] ([[lidocaine]], [[quinidine]], etc) are not recommended.
-In patients with CAD, the class Ic AADs (flecainide and propafenone) are contraindicated.  Class Ic AADs have been found to cause increased death and cardiac arrest in patients post-MI <ref>Echt et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo: the cardiac arrhythmia suppression trial.  NEJM 1991; 324(12): 781-788.</ref>.  Any of the class III AADs (sotalol, dronedarone, dofetilide, amiodarone) are appropriate in CAD patients, but amiodarone should not be used as first line therapy, for the reasons mentioned above.
+**It is recommended to select [[Antiarrhythmic agent|anti-arrhythmic drugs]] ([[Antiarrhythmic agent|AADs]]), based on a [[patient]]'s underlying [[heart disease|heart issues]] (if any).
+*In [[patients]] with no [[structural heart disease]] (no [[Coronary heart disease|CAD]] and no [[congested heart failure|CHF]]), any of the six listed [[Antiarrhythmic agent|anti-arrhythmic drugs]] ([[Antiarrhythmic agent|AADs]]) is reasonable.
-Flecainide, propafenone, dofetilide, and sotalol are not recommended for patients with severe LVH.
+*Given the [[Toxicity|toxicities]] of [[amiodarone]] and concerns about its long term use, [[amiodarone]] is not recommended for first-line [[therapy]]. It should be used only if other agents have failed or are [[contraindication|contraindicated]].<ref name=":0" /><ref>Dingxin Qin, George Leef, Mian Bilal Alam, Rohit Rattan, Mohamad Bilal Munir, Divyang Patel, Furqan Khattak, Evan Adelstein, Sandeep K. Jain, Samir Saba.  Mortality risk of long-term amiodarone therapy for atrial fibrillation patients without structural heart disease.  Cardiology Journal 2015;22(6):622-629.</ref>  It should be used only if other agents have failed or are contraindicated.
+*The [[Antiarrhythmic agent|class Ic AADs]] ([[flecainide]] and [[propafenone]]) are [[contraindication|contraindicated]] in [[patients]] who are suffering from [[Coronary heart disease]]. [[Antiarrhythmic agent|Class Ic AADs]] have been found to cause increased death and [[cardiac arrest]] in [[patients]] post-MI.<ref>Echt et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo: the cardiac arrhythmia suppression trial.  NEJM 1991; 324(12): 781-788.</ref>
-In patients with CHF, only amiodarone and dofetilide are recommended.
+*[[Flecainide]], [[propafenone]], [[dofetilide]], and [[sotalol]] are not recommended for [[patients]] with severe [[left ventricular hypertrophy]] ([[Left ventricular hypertrophy|LVH]]).
+*In [[patients]] with [[congested heart failure|CHF]], [[amiodarone]] and [[dofetilide]] are recommended.
-All of these drugs carry a risk of pro-arrhythmia.  Dofetilide and sotalol particularly prolong the QT interval and can increase risk for Torsades.  These drugs are initiated in the hospital to allow for careful monitoring of the QT interval.
+*All of these [[drugs]] carry a risk of [[arrhythmia|pro-arrhythmia]]. [[Dofetilide]] and [[sotalol]] particularly prolong the [[QT interval]] and increase risk of [[Torsade de pointes]]. Hence, these [[drugs]] must initiated in the hospital to allow for careful monitoring of the [[QT interval]].
+*[[Antiarrhythmic agent|anti-arrhythmic drugs]] ([[Antiarrhythmic agent|AADs]]) [[therapy]] does not obviate the need for [[anticoagulation]] in [[atrial fibrillation]] [[patients]].
-Anti-arrhythmic drug therapy does not obviate the need for anticoagulation in AF patients.  Catheter-based ablation is an alternative to anti-arrhythmic drug therapy that should be considered as a first line option at experienced centers <ref name=":0" /> per the 2014 AHA guidelines.  Surgical AF ablation can be considered if the patient needs cardiac surgery for another reason, or as a last recourse if other options have failed.
+*[[Catheter ablation|Catheter-based ablation]] is an alternative to [[Antiarrhythmic agent|anti-arrhythmic drugs]] ([[Antiarrhythmic agent|AADs]]) [[therapy]] that should be considered as a first-line option at experienced centers <ref name=":0" /> per the 2014 AHA guidelines.
+*[[surgery|Surgical]] [[atrial fibrillation]] [[ablation]] can be considered if the [[patient]] needs [[heart|cardiac]] [[surgery]] for another reason, or as a last recourse if other options have failed.
-All of the AADs should be discontinued if a patient's AF becomes permanent.
+*All of the [[Antiarrhythmic agent|anti-arrhythmic drugs]] ([[Antiarrhythmic agent|AADs]]) should be discontinued if a [[patient]]'s ([[atrial fibrillation]] ([[AF]]) becomes permanent.
 ==2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)<ref name="JanuaryWann2014">{{cite journal|last1=January|first1=C. T.|last2=Wann|first2=L. S.|last3=Alpert|first3=J. S.|last4=Calkins|first4=H.|last5=Cleveland|first5=J. C.|last6=Cigarroa|first6=J. E.|last7=Conti|first7=J. B.|last8=Ellinor|first8=P. T.|last9=Ezekowitz|first9=M. D.|last10=Field|first10=M. E.|last11=Murray|first11=K. T.|last12=Sacco|first12=R. L.|last13=Stevenson|first13=W. G.|last14=Tchou|first14=P. J.|last15=Tracy|first15=C. M.|last16=Yancy|first16=C. W.|title=2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000041}}</ref>==
 ===Rhythm Control===
-====Pharmacological Agents for Preventing AF and Maintaining Sinus Rhythm====
 =====Antiarrhythmic Drugs to Maintain Sinus Rhythm=====
@@ Line 108: / Line 107: @@
 |-
 | bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''2.''' [[AF]] [[catheter ablation]] may be considered prior to initiation of [[antiarrhythmic|antiarrhythmic drug therapy]] with a class I or III [[antiarrhythmic|antiarrhythmic medication]] for symptomatic persistent [[AF]], when a rhythm control strategy is desired. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+|}
+====Pharmacological Agents for Preventing AF and Maintaining Sinus Rhythm====
+{| class="wikitable"
+| colspan="5" align="center" style="background: #4479BA; color: #FFFFFF " |'''Therapies to maintain sinus rhythm'''
+|-
+| align="center" |'''Treatment'''
+| align="center" |'''Efficacy'''
+| align="center" |'''Adverse effects'''
+| align="center" |'''Contraindications'''
+| align="center" |'''Precausions'''
+|-
+| colspan="5" align="left" style="background: #4479BA; color: #FFFFFF " |'''Drug therapy'''
+|-
+|[[Beta-blockers]]
+|
+*Low
+*Sinus rhythm is maintained in <20% of patients
+*Symptoms are reduced in >=20% of patients
+|
+*Fatigue
+*Bradycardia
+*Monitor for bradycardia
+|
+*Bradycardia
+*Hypotension
+|
+*Monitor for bradycardia
+|-
+|Nondihydropyridine Calcium Channel Blockers:
+*[[Verapamil]]
+*[[Diltiazem]]
+|
+*Low
+*Sinus rhythm is maintained in <20% of patients
+*Symptoms are reduced in >=20% of patients
+|
+*Edema
+*Bradycardia
+*Hypotension
+|
+*[[Bradycardia]]
+*[[Hypotension
+*[[Heart failure with reduced ejection fraction]]
+|
+|-
+|[[Flecainide]]
+|
+*Moderate
+*AF is prevented or reduced in 50-70% of patients
+|
+*Uncommon
+*Proarrhythmia risk in patients with structural heart disease
+|
+*Structural heart disease (proarrhythmia risk)
+|
+*Evaluate for ischemic heart disease before initiation of therapy
+|-
+|[[Propafenone]]
+|
+*Moderate
+*AF is prevented or reduced in 50-70% of patients
+|
+*Dysgeusia
+|
+*Structural heart disease (proarrhythmia risk)
+|
+*Evaluate for ischemic heart disease before initiation of therapy
+|-
+|[[Quinidine]]
+|
+*Moderate
+*AF is prevented or reduced in 50-70% of patients
+|
+*Gastrointestinal side effects
+|
+*QT prolongation
+|
+*Monitor for QT prolongation, polymorphic ventricular tachycardia
+|-
+|[[Disopyramide]]
+|
+*Moderate
+*AF is prevented or reduced in 50-70% of patients
+|
+*Antimuscarinic effects
+*Urinary retention
+|
+*QT prolongation
+*Heart failure
+|
+*Monitor for QT prolongation,
+|-
+|[[Dronendrone]]
+|
+*Moderate
+*AF is prevented or reduced in 50-70% of patients
+|
+*Uncommon
+|
+*Heart failure
+|
+*Monitor for:
+**Fluid retention
+**Hepatitis
+|-
+|[[Dofetilide]]
+|
+*Moderate
+*AF is prevented or reduced in 50-70% of patients
+|
+*QT prolongation
+|
+*QT prolongation
+*Advanced renal disease
+|
+*Monitor for QT prolongation (should be initiated in hospital)
+|-
+|[[Sotalol]]
+|
+*Moderate
+*AF is prevented or reduced in 50-70% of patients
+|
+*QT prolongation
+*Fatigue
+*Bradycardia
+*Hypotension
+|
+*QT prolongation
+*Advanced renal disease
+*Bradycardia
+|
+*Monitor for QT prolongation
+|-
+|[[Amiodarone]]
+|
+*High
+*AF is prevented or reduced in 80% of patients
+|
+*Bradycardia
+*Thyroid diseases
+*Hepatitis
+*Interstitial lung disease (pulmonary fibrosis)
+*Neurologic dysfunction
+*Photosensitivity
+|
+*Bradycardia
+*Hyperthyroidism
+|
+*Monitor for systemic toxicities involving the thyroid, liver, lungs, and nervous system
+*Monitor for drug interactions
+|-
+| colspan="5" align="left" style="background: #4479BA; color: #FFFFFF " |'''Interventional procedures'''
+|-
+|[[Catheter ablation]]
+|
+*High
+**60-80% of patients with paroxysmal [[AF]] are free from AF at 1 year
+**50% of patients with persistent AF are free from AF at 1 year
+**Reduced AF burden
+|
+*Procedure-related complications
+*Risks associated with [[sedation]] and [[anesthesia]]
+*Transient arrhythmia (for 3 months)
+*For patients with persistent AF, a second procedure s often needed
+|
+*Risks associated with [[sedation]] and [[anesthesia]]
+*[[Catheter ablation]] is [[contraindicated]] if:
+**vascular access is not possible
+**vascular access is associated with high risks
+**anticoagulation is contraindicated
+|
+*Monitor for procedure-related complications (within the first 4 weeks) such as:
+**tamponade
+**esophageal injury
+*Pulmonary vein stenosis (within months)
+*Conversion of AF to rapid atrial flutter
+|-
+|Surgery ([[Maze procedure]])
+|
+*High
+*AF is prevented in 80% of patients
+|
+*Risks associated with anesthesia and surgery
+|
+*Surgical contraindications
+|
+*Monitor for complications of surgery
+|-
 |}
@@ Line 137: / Line 326: @@
 [[Category:Electrophysiology]]
 [[Category:Emergency medicine]]
-[[Category:Primary care]]
 [[Category:Up-To-Date]]
 [[Category:Up-To-Date Cardiology]]


Atrial Fibrillation Microchapters
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