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Atrial Fibrillation : Evolving Strategies for Treatment

By Martin LeBoutillier, III, MD, Cardiovascular Surgeon
and Hope Helfeld, DO, Cardiologist
The Chester County Hospital

Published: February 4, 2008

Atrial Fibrillation (AF) is the most common arrhythmia, accounting for about one third of all hospitalizations for cardiac rhythm disturbances. An estimated 2.2 million people in the United States have recurrent or persistent AF. In the last two decades the number of hospital admissions for AF has increased 66%, raising the cost of AF to our society to the billions.

In the past year, two consensus papers have been published summarizing accepted treatment protocols for AF management. A significant portion of our understanding of the mechanisms of AF has been clarified only recently. Hence, treatment strategies are in flux as we incorporate this new information into patient care.

A change is occurring in the understanding of the prognosis for patients with AF, even those who have no symptoms (asymptomatic). As stated in the ACC/AHA Guidelines, "AF is associated with an increased long-term risk of stroke, heart failure, and all-cause mortality, especially in women." Previously we may have been comfortable with long-term rate control and anti-thrombotic therapy in an asymptomatic 70-year-old. But the evidence is mounting that there is risk in this approach and better treatment strategies are evolving. The risk for stroke alone becomes prohibitive as our patients age. Annualized risk may only be 1.5% per year in patients in their fifties, but that rises to more than 20% for those in their eighties - more than 20% each year.

The debate about rate control vs. sinus rhythm control is still ongoing. The guidelines allow that either strategy is sometimes acceptable in the management of AF. Current published studies have not found a survival advantage to either approach. However, it is becoming clear that the associated mortality and morbidity from rhythm control is due to the risks of the medications being used to maintain normal sinus rhythm. Those patients maintained in sinus rhythm off antiarrhythmic drugs did significantly better than those with rate control still in AF.

Catheter-based and surgical ablations provide widely available proven methods to help patients achieve sinus rhythm with the best hope for discontinuation of antiarrhythmic drugs. Both approaches essentially use energy sources either inside the heart or on the surface of the heart to create areas of block in the cardiac tissue that abnormal rhythms may not pass through. This has the effect of isolating areas of fibrillation thus preventing the arrhythmia from reaching the remaining normal cardiac conduction system.

Catheter-based and surgical approaches have benefits and drawbacks. A patient may not be a candidate for one or the other or either. However, in a properly selected patient, the results may be tremendously beneficial. As of now, the consensus guidelines allow for consideration for ablation in those patients with symptomatic fibrillation who have failed at least one antiarrhythmic medication, or select symptomatic patients with heart failure.

Several trials are ongoing to analyze results from improved catheter and surgical techniques, the results of which will have a significant affect on future guidelines and treatment strategies. It is safe to say that the day is not far off when ablation may be offered as a first-line treatment for the majority of patients with AF.

This article was published as part of the Daily Local News Medical Column series which appears every Monday. It has been reprinted by permission of the Daily Local News.

Last Updated: 7/27/2009