Atrial Fibrillation: Rate/Rhythm ControlNon Pharmacological Management

Dr Akshay Mehta Dr B Nanavati Hospital Asian Heart Institute

Two most important things to know

Type of AF

Symptoms due to AF

First Diagnosed Episode of AF

Paroxysmal(usually <= 48 h)

Persistent (> 7 days or requires CV)

Long standing Persistent ( >1 year)

Permanent (accepted)

EHRA score of AF-related symptoms

EHRA class Explanation

EHRA I ‘No symptoms’

EHRA II ‘Mild symptoms’; normal daily activity not affected

EHRA III ‘Severe symptoms’; normal daily activity affected

EHRA IV ‘Disabling symptoms’; normal daily activity discontinued

Choosing Rate v/s Rhythm Control

Two types of settings

Acute/Unstable

Non acute/Stable

Acute/Unstable setting

Rate Control Rhythm Control

Cause: underlying cond severe AF Sx orEx- pneumonia, PE, Thyroid h-dynamic instab

No severe AF Sx or h-dynamic instab pharmac cv electric cv

Older age

Large LA

How Rate Control ?

Acute/Unstable setting

Rhythm control – (Sx or hemody instab) Pharmac cv Electrical cv

* <48 hrs *can > 48 hrs * No electrolyte *ischemia imbalance *hypoten * No ECG *HF sign of severe *Preexcited AF with ongoing ishemia instability * Hemodynamic stable + , -

ESC 2012

Recommendations for anticoagulation pericardioversion

………..recommendations for anticoagulation pericardioversion

Non Acute/Stable Setting :

Rate Control v/s Rhythm control

INCLUDES RATE CONTROL

OAC for Both

AIMS of management of AF patients:

• Prevent complications

• Reduce symptoms (palpitations, dyspnoea, fatigue, and dizziness)

antithrombotic therapy control of ventricular rate Rx of associated CV disease

• ± Additional rhythm control therapy by cardioversion, antiarrhythmic drug therapy, or ablation therapy

Randomized trials comparing rate control with rhythm control

• Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) : no difference in all cause mortality (primary outcome) or stroke rate

• The Rate Control versus Electrical cardioversion for persistent atrial fibrillation (RACE) trial :rate control not inferior to rhythm control for prevention of cardiovascular mortality and morbidity (composite endpoint).

• The Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial : in patients with an LVEF ≤35%, no difference in

cardiovascular mortality (primary outcome) symptoms of congestive heart failure, or in the secondary outcomes

including death from any cause and worsening of heart failure

However….• These studies enrolled predominantly older patients (average

70 y)

• Most of whom had persistent AF and heart disease,

• Follow-up extended over just a few years

• Pts were at a stage where difficult to maintain sinus rhythm

Hence :

• Data don’t necessarily apply in young

• Must not lose “window” of opportunity due to electrical and

structural remodeling

Hence…

Rate control may be reasonable initial therapy in

older patients with persistent AF with mild

symptoms

For younger individuals, especially those with

paroxysmal lone AF, rhythm control may be a better

initial approach.

When to do Rate Control ?

How to do long-term rate control

How MUCH rate control ?

resting<110/mt

< 80, 110

Rate ControlSymptoms

More strict rate controlExercise test if excessive heart rate is

anticipated during exercise

24 h ECG for safety

No or tolerable symptoms

Accept lenient rate control

Rhythm Control

Rhythm control therapy is reasonable to ameliorate symptoms, in paroxysmal/persistent

AF

When to do Rhythm Control ?

AAD Therapy to maintain sinus rhythm in patients with recurrent paroxysmal or persistent

atrial fibrillation.

Copyright © American Heart Association

β-Blockers are recommended for prevention of adrenergic AF-I C & should be consideredfor rhythm (+ rate) control in a first episode of AF - IIa

2011 Writing Group Members et al. Circulation 2011;123:104-123

Antiarrhythmic drugs v/s left atrial ablation for rhythm control in AF ESC 2012

Catheter ablation for AF using the CARTO contact mapping system

Recommendations for surgical ablation of AF

Recommendations for LAA closure/occlusion/excision - ESC 2012

Recommendation for atrioventricular node ablation in AF patients

Should be considered When the rate cannot be controlled with pharmacological agents and when AF cannot be prevented by antiarrhythmic therapy or is

associated with intolerable side effects, when direct catheter-based or surgical ablation of AF is not indicated,

has failed, or is rejected. IIa Should be considered for patients with permanent AF and an indication

for CRT (IIa)Should be considered for CRT nonresponders in whom AF prevents

effective biventricular stimulation and amiodarone is ineffective or contraindicated- IIa

• In patients with any type of AF and severely depressed LV function biventricular stimulation should be considered after AV node ablation.

Summary- management of patients with recurrent paroxysmal AF

Recurrent Paroxysmal AF

Minimal or no symptoms

Anticoagulation and rate control* as needed

No drug for prevention of AF

Disabling symptoms in AF

Anticoagulation and rate control as needed

AAD therapy *

AF ablation if AAD

treatment fails

Summary- management of patients with recurrent persistent or permanent AF

Recurrent Persistent AF

Minimal or no symptoms

Anticoagulation and rate control*

as needed

Disabling symptoms in AF

Anticoagulation and rate control

AAD drug therapy

Electrical cardiovers

ion as needed

Permanent AF

Anticoagulation and rate control* as needed

THANK YOU!!!