ACC/AHA/ESC 2006 Guidelines for management of Atrial Fibrillation- ‘Theurapeutic Options’

Pharmacological and Nonpharmacological Therapeutic Options:
Drugs and ablation are effective for both rate and rhythm control, and in special circumstances surgery may be the
preferred option. Regardless of the approach, the need for anticoagulation is based on stroke risk and not on whether sinus rhythm is maintained. For rhythm control, drugs are
typically the first choice and LA ablation is a second-line choice, especially in patients with symptomatic lone AF. In some patients, especially young ones with very symptomatic AF who need sinus rhythm, radiofrequency ablation may be preferred over years of drug therapy. Because the Left Atrial Appendage is the site of over 95% of detected thrombi, this structure should be removed from the circulation when possible during cardiac surgery in patients at risk of developing postoperative AF, although this has not been proved to prevent stroke.

Drugs are the primary treatment for rate control in most patients with AF. While ablation of the AV conduction system and permanent pacing (the “ablate and pace” strategy) is an option that often yields remarkable symptomatic relief, growing concern about the negative effect of long-term RV pacing makes this a fallback rather than a primary treatment strategy. LV pacing, on the other hand, may overcome many of the adverse hemodynamic effects associated with RV pacing.

Heart Rate Control Versus Rhythm Control:

Distinguishing Short-Term and Long-Term Treatment Goals:

For patients with symptomatic AF lasting many weeks, initial therapy may be anticoagulation and rate control, while the long-term goal is to restore sinus rhythm. When cardioversion is contemplated and the duration of AF is unknown or exceeds 48h, patients who do not require long-term anticoagulation may benefit from short-term anticoagulation. If rate control offers inadequate symptomatic relief, restoration of sinus rhythm becomes a clear long-term goal. Early cardioversion may be necessary if AF causes hypotension or worsening HF, making the establishment of sinus rhythm a combined short- and long-term therapeutic goal. In some circumstances, when the initiating pathophysiology of AF is reversible, as for instance in the setting of thyrotoxicosis or after cardiac surgery, no long-term therapy may be necessary.

AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) found no difference in mortality or stroke rate between patients assigned to one strategy or the other. The RACE (Rate Control vs. Electrical cardioversion for persistent atrial fibrillation) trial found rate control not inferior to rhythm control for prevention of death and morbidity.

The AFFIRM, RACE, PIAF (Pharmacologic Intervention in Atrial Fibrillation), and STAF (Strategies of Treatment of Atrial Fibrillation) studies found no differences in quality of life with rhythm control compared with rate control. Rhythm control in the PIAF and How to Treat Chronic Atrial Fibrillation (HOT CAFÉ) studies resulted in better exercise tolerance than rate control, but this did not translate into improved quality of life.

Ref: J. Am. Coll. Cardiol. 2006;48;e149-e246

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