Management strategies for atrial fibrillation

Abstract

Atrial fibrillation is the most prevalent cardiac arrhythmia, affecting 10% of those aged over 80 years. Despite multiple treatment options, it remains an independent prognostic marker of mortality due to its association with clinical sequelae, particularly cerebrovascular events. Management can be broadly divided into treatment of the arrhythmia, via rhythm or rate control, and stroke thromboprophylaxis via anticoagulation. Traditional options for pharmacotherapy include negatively chronotropic drugs such as β-blockers, and/or arrhythmia-modifying drugs such as amiodarone. More recently, catheter ablation has emerged as a suitable alternative for selected patients. Additionally, there has been extensive research to assess the role of novel oral anticoagulants as alternatives to warfarin therapy. There is mounting evidence to suggest that they provide comparable efficacy, while being associated with lower bleeding complications. While these findings are promising, recent controversies have arisen with the use of novel oral anticoagulants. Further research is warranted to fully elucidate mechanisms and establish antidotes so that treatment options can be appropriately directed.

Keywords: Atrial fibrillation; arrhythmia-modifying drugs; catheter ablation; novel anticoagulants; warfarin.

Figure 1.

Management algorithm for atrial fibrillation (adapted from 2010 ESC guidelines). For patients with haemodynamic compromise secondary to atrial fibrillation, acute direct current cardioversion is the treatment of choice. For those without haemodynamic compromise, once appropriate anticoagulation has been initiated, a choice can be made between rate and rhythm control. In both cases, pharmacotherapy plays an important role. The drugs typically used for rate control are β-blockers, non-dihydropyridine calcium channel blockers and digoxin. Acute chemical cardioversion is usually achieved with intravenous amiodarone or flecainide, although novel alternatives such as vernakalant and ibutilide are now available. Amiodarone, flecainide and sotalol are the drugs of choice for longer-term pharmacological rhythm control.