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

Jump to navigation Jump to search
VisualWikitext
(/* 2011 ACCF/AHA/HRS Guidelines for the Management of Patients With Atrial Fibrillation- Sinus Rhythm Management (DO NOT EDIT) Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines for the Ma...)
 
(38 intermediate revisions by 12 users not shown)
Line 1: Line 1:
__NOTOC__
__NOTOC__
 
{| class="infobox" style="float:right;"
{| border="1" style="border-collapse:collapse" cellpadding="3" align="right"
| [[File:Siren.gif|30px|link=Atrial fibrillation resident survival guide]]|| <br> || <br>
| colspan="3" align="center" bgcolor="#ABCDEF" | Conduction
| [[Atrial fibrillation resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|-
| <small>Sinus rhythm</small> [[Image:Heart conduct sinus.gif|none|75px]]
| <small>Atrial fibrillation</small> [[Image:Heart conduct atrialfib.gif|none|100px]]  
|}
|}
{{Infobox_Disease |
  Name          =  |
  Image          =  |
  Caption        =  |
  DiseasesDB    = 1065 |
  ICD10          = {{ICD10|I|48||i|30}} |
  ICD9          = {{ICD9|427.31}} |
  ICDO          = |
  OMIM          = |
  MedlinePlus    = 000184 |
}}
{{Atrial fibrillation}}
{{Atrial fibrillation}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[Varun Kumar, M.B.B.S.]]
{{CMG}}; {{AE}} {{Mitra}} {{CZ}}; [[Varun Kumar, M.B.B.S.]]


==Overview==
==Overview==
Prophylactic [[antiarrhythmic drug therapy]] may be required to maintain sinus rhythm, reduce frequency of symptoms, improve hemodynamic function and exercise capacity and prevent [[tachycardia|tachycardia-induced cardiomyopathy]] secondary to [[atrial fibrillation]]. In patients with [[heart failure]], pharmacological maintenance of sinus rhythm has shown to reduce morbidity.<ref name="pmid10486417">Torp-Pedersen C, Møller M, Bloch-Thomsen PE, Køber L, Sandøe E, Egstrup K et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10486417 Dofetilide in patients with congestive heart failure and left ventricular dysfunction. Danish Investigations of Arrhythmia and Mortality on Dofetilide Study Group.] ''N Engl J Med'' 341 (12):857-65. [http://dx.doi.org/10.1056/NEJM199909163411201 DOI:10.1056/NEJM199909163411201] PMID: [http://pubmed.gov/10486417 10486417]</ref><ref name="pmid9843465">Deedwania PC, Singh BN, Ellenbogen K, Fisher S, Fletcher R, Singh SN (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9843465 Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation: observations from the veterans affairs congestive heart failure survival trial of antiarrhythmic therapy (CHF-STAT). The Department of Veterans Affairs CHF-STAT Investigators.] ''Circulation'' 98 (23):2574-9. PMID: [http://pubmed.gov/9843465 9843465]</ref>
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.
 
==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 [[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>
**[[Flecainide]] and [[propafenone]] are [[Antiarrhythmic agent|class Ic anti-arrhythmics]].
**[[Dofetilide]], [[sotalol]], [[dronedarone]], and [[amiodarone]] are [[Antiarrhythmic agent|class III antiarrhythmics]].
**Other [[Antiarrhythmic agent|anti-arrhythmic drugs]] ([[lidocaine]], [[quinidine]], etc) are not recommended.
**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.
*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> 
*[[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 [[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]].
*[[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 [[Antiarrhythmic agent|anti-arrhythmic drugs]] ([[Antiarrhythmic agent|AADs]]) should be discontinued if a [[patient]]'s ([[atrial fibrillation]] ([[AF]]) becomes permanent.


==Sinus Rhythm Control==
==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>==


==2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (Updating the 2006 Guideline) (DO NOT EDIT)
===Rhythm Control===
<ref name="pmid21182985">{{cite journal| author=Wann LS, Curtis AB, January CT, Ellenbogen KA, Lowe JE, Estes NA et al.| title=2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (Updating the 2006 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Heart Rhythm | year= 2011 | volume= 8 | issue= 1 | pages= 157-76 | pmid=21182985 | doi=10.1016/j.hrthm.2010.11.047 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21182985  }} </ref>==


===Maintenance of Sinus Rhythm (DO NOT EDIT)<ref name="pmid21182985">{{cite journal| author=Wann LS, Curtis AB, January CT, Ellenbogen KA, Lowe JE, Estes NA et al.| title=2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (Updating the 2006 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Heart Rhythm | year= 2011 | volume= 8 | issue= 1 | pages= 157-76 | pmid=21182985 | doi=10.1016/j.hrthm.2010.11.047 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21182985  }} </ref>===
=====Antiarrhythmic Drugs to Maintain Sinus Rhythm=====


{|class="wikitable"
{| class="wikitable" style="width: 80%;"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Before initiating [[antiarrhythmic drug therapy]], treatment of precipitating or reversible causes of [[AF]] is recommended. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' Before initiating [[antiarrhythmic|antiarrhythmic drug therapy]], treatment of precipitating or reversible causes of [[AF]] is recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|-
|bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Catheter ablation performed in experienced centers* is useful in maintaining sinus rhythm in selected patients with significantly symptomatic, paroxysmal AF who have failed treatment with an antiarrhythmic drug and have normal or mildly dilated left atria, normal or mildly reduced LV function, and no severe pulmonary disease. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' The following [[antiarrhythmic|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]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' The risks of the antiarrhythmic drug, including proarrhythmia, should be considered before initiating therapy with each drug. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''4.''' Owing to its potential toxicities, [[amiodarone]] should only be used after consideration of risks and when other agents have failed or are contraindicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
|}


{|class="wikitable"
{| class="wikitable" style="width: 80%;"
|-
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
| colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III: Harm]]
|-
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Antiarrhythmic therapy]] with a particular drug is not recommended for maintenance of [[sinus rhythm]] in patients with [[AF]] who have well-defined risk factors for [[proarrhythmia]] with that agent. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
| bgcolor="LightCoral" |<nowiki>"</nowiki>'''1.''' [[Antiarrhythmic|Antiarrhythmic drugs]] for rhythm control should not be continued when [[AF]] becomes permanent ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' including [[dronedarone]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' Pharmacological therapy is not recommended for maintenance of [[sinus rhythm]] in patients with advanced sinus node disease or AV node dysfunction unless they have a functioning [[electronic cardiac pacemaker]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LightCoral" |<nowiki>"</nowiki>'''2.''' [[Dronedarone]] should not be used for treatment of [[AF]] in patients with [[NYHA|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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}


{|class="wikitable"
{| class="wikitable" style="width: 80%;"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Pharmacological therapy can be useful in patients with [[AF]] to maintain [[sinus rhythm]] and prevent [[tachycardia]]-induced [[cardiomyopathy]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])<nowiki>"</nowiki>
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' A rhythm-control strategy with pharmacological therapy can be useful in patients with [[AF]] for the treatment of [[tachycardia]]-induced [[cardiomyopathy]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
{| class="wikitable" style="width: 80%;"
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Infrequent, well-tolerated recurrence of [[AF]] is reasonable as a successful outcome of [[antiarrhythmic drug therapy]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' Outpatient initiation of [[antiarrhythmic drug therapy]] is reasonable in patients with [[AF]] who have no associated [[heart disease]] when the agent is well tolerated. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' It may be reasonable to continue current [[antiarrhythmic|antiarrhythmic drug therapy]] in the setting of infrequent, well-tolerated recurrences of [[AF]], when the drug has reduced the frequency or symptoms of [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
====AF Catheter Ablation to Maintain Sinus Rhythm====
 
{| class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' [[AF]] [[catheter ablation]] is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III [[antiarrhythmic|antiarrhythmic medication]] when a rhythm control strategy is desired. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' Prior to consideration of [[AF]] [[catheter ablation]], assessment of the procedural risks and outcomes relevant to the individual patient is recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
{| class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III: Harm]]
|-
| bgcolor="LightCoral" |<nowiki>"</nowiki>'''1.''' [[AF]] [[catheter ablation]] should not be performed in patients who cannot be treated with [[anticoagulant|anticoagulant therapy]] during and following the procedure. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightCoral" |<nowiki>"</nowiki>'''2.''' [[AF]] [[catheter ablation]] to restore [[sinus rhythm]] should not be performed with the sole intent of obviating the need for [[anticoagulation]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
{| class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''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|antiarrhythmic medication]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''2.''' In patients with recurrent symptomatic paroxysmal [[AF]], [[catheter ablation]] is a reasonable initial rhythm control strategy prior to therapeutic trials of [[antiarrhythmic|antiarrhythmic drug therapy]], after weighing risks and outcomes of drug and [[ablation]] therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{| class="wikitable" style="width: 80%;"
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' In patients with AF without structural or coronary heart disease, initiation of propafenone or flecainide can be beneficial on an outpatient basis in patients with paroxysmal AF who are in sinus rhythm at the time of drug initiation. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' [[Sotalol]] can be beneficial in outpatients in [[sinus rhythm]] with little or no [[heart disease]], prone to paroxysmal [[AF]], if the baseline uncorrected [[QT interval]] is less than 460 ms, serum electrolytes are normal, and risk factors associated with class III drug–related pro-arrhythmia are not present. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) <nowiki>"</nowiki>
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''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|antiarrhythmic medication]], when a rhythm control strategy is desired. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''6.''' Catheter ablation is reasonable to treat symptomatic persistent AF. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
| 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>
|}
|}


{|class="wikitable"
 
====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'''
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|[[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
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Catheter ablation may be reasonable to treat symptomatic paroxysmal AF in patients with significant left atrial dilatation or with significant LV dysfunction. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])<nowiki>"</nowiki>
|}
|}


<nowiki>*</nowiki>Refers to pulmonary vein isolation with catheter ablation. An experienced center is defined as one performing more than 50 AF catheter ablation cases per year. Evidence-based technical guidelines including operator training and experience necessary to maximize rates of successful catheter ablation are not available; each center should maintain a database detailing procedures; success and complications, engage strategies for continuous quality improvement, and participate in registries and other efforts pooling data in order to develop optimal care algorithms.
==Sources==
 
* [http://circ.ahajournals.org/content/early/2014/03/27/CIR.0000000000000041 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation]<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>


==Vote on and Suggest Revisions to the Current Guidelines==
* [http://circ.ahajournals.org/content/123/10/e269.full.pdf ACCF/AHA/HRS 2011 Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation]<ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 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. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>
* [[The Living Guidelines: Diagnosis and Management of Atrial Fibrillation | The AF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]


==Guideline Resources==
* [http://circ.ahajournals.org/content/122/24/2619 ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines]<ref name="pmid21060077">{{cite journal| author=Abraham NS, Hlatky MA, Antman EM, Bhatt DL, Bjorkman DJ, Clark CB et al.| title=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. | journal=Circulation | year= 2010 | volume= 122 | issue= 24 | pages= 2619-33 | pmid=21060077 | doi=10.1161/CIR.0b013e318202f701 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21060077  }}</ref>
*[http://content.onlinejacc.org/cgi/reprint/48/4/e149.pdf ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 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. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref>


*[http://circ.ahajournals.org/content/123/10/e269.full.pdf 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 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. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>
* [http://circ.ahajournals.org/content/117/8/1101.full.pdf ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter]<ref name="pmid18283199">Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18283199 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. [http://dx.doi.org/10.1161/CIRCULATIONAHA.107.187192 DOI:10.1161/CIRCULATIONAHA.107.187192] PMID: [http://pubmed.gov/18283199 18283199]</ref>


*[http://circ.ahajournals.org/content/117/8/1101.full.pdf ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter] <ref name="pmid18283199">Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18283199 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. [http://dx.doi.org/10.1161/CIRCULATIONAHA.107.187192 DOI:10.1161/CIRCULATIONAHA.107.187192] PMID: [http://pubmed.gov/18283199 18283199]</ref>
* [http://content.onlinejacc.org/cgi/reprint/48/4/e149.pdf ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation]<ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 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. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref>


==References==
==References==
{{reflist|2}}
{{reflist|2}}


[[Category:Electrophysiology]]
{{Electrocardiography}}
[[Category:Cardiology]]
{{Circulatory system pathology}}
[[Category:Emergency medicine]]
[[Category:AFib]]
 
[[de:Vorhofflimmern]]
[[fr:Fibrillation auriculaire]]
[[it:Fibrillazione atriale]]
[[nl:Boezemfibrilleren]]
[[ja:心房細動]]
[[no:Atrieflimmer]]
[[pl:Migotanie przedsionków]]
[[ro:Fibrilaţia Atrială]]
[[fi:Eteisvärinä]]
[[zh:心房颤动]]
[[tr:Atriyal fibrillasyon]]


{{WikiDoc Help Menu}}
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
{{WikiDoc Sources}}
[[CME Category::Cardiology]]
[[Category:Arrhythmia]]
[[Category:Cardiology]]
[[Category:Electrophysiology]]
[[Category:Emergency medicine]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date Cardiology]]

Latest revision as of 05:36, 15 November 2021
Resident
Survival
Guide

Atrial Fibrillation Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Atrial Fibrillation from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Special Groups

Postoperative AF
Acute Myocardial Infarction
Wolff-Parkinson-White Preexcitation Syndrome
Hypertrophic Cardiomyopathy
Hyperthyroidism
Pulmonary Diseases
Pregnancy
ACS and/or PCI or valve intervention
Heart failure

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

EKG Examples
A-Fib with LBBB

Chest X Ray

Echocardiography

Holter Monitoring and Exercise Stress Testing

Cardiac MRI

Treatment

Rate and Rhythm Control

Cardioversion

Overview
Electrical Cardioversion
Pharmacological Cardioversion

Anticoagulation

Overview
Warfarin
Converting from or to Warfarin
Converting from or to Parenteral Anticoagulants
Dabigatran

Maintenance of Sinus Rhythm

Surgery

Catheter Ablation
AV Nodal Ablation
Surgical Ablation
Cardiac Surgery

Specific Patient Groups

Primary Prevention

Secondary Prevention

Supportive Trial Data

Cost-Effectiveness of Therapy

Case Studies

Case #1

Atrial fibrillation maintenance of rate control and sinus rhythm On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Atrial fibrillation maintenance of rate control and sinus rhythm

CDC on Atrial fibrillation maintenance of rate control and sinus rhythm

Atrial fibrillation maintenance of rate control and sinus rhythm in the news

Blogs on Atrial fibrillation maintenance of rate control and sinus rhythm

Directions to Hospitals Treating Atrial fibrillation maintenance of rate control and sinus rhythm

Risk calculators and risk factors for Atrial fibrillation maintenance of rate control and sinus rhythm

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

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:
  • Low
  • Sinus rhythm is maintained in <20% of patients
  • Symptoms are reduced in >=20% of patients
  • Edema
  • Bradycardia
  • Hypotension
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
  • 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

References

  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.
  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.
  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
  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.
  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
  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


Template:WikiDoc Sources CME Category::Cardiology

Retrieved from "https://www.wikidoc.org/index.php?title=Atrial_fibrillation_maintenance_of_rate_control_and_sinus_rhythm&oldid=1716518"