Management of Patients with Atrial Fibrillation: Focus on Treatment Options

Abstract

Atrial fibrillation (AF) is leading cardiac arrhythmia with important clinical implications. Its diagnosis is usually made on the basis on 12-lead ECG or 24-hour Holter monitoring. More and more clinical evidence supports diagnostic use of cardiac event recorders and cardiovascular implantable electronic devices (CIED). Treatment options in patients with atrial fibrillation are extensive and are based on chosen rhythm and/or rate control strategy. The use and selected contraindications to AF related pharmacotherapy, including anticoagulants are shown. Nonpharmacological treatments, comorbidities and risk factors control remain mainstay in the treatment of patients with AF. Electrical cardioversion consists important choice in rhythm control strategy. Much progress has been made in the field of catheter ablation and cardiac surgery methods. Left atrial appendage occlusion/closure may be beneficial in patients with AF. CIED are used with clinical benefits in both, rhythm and rate control. Pacemakers, implantable cardioverter-defibrillators and cardiac resynchronization therapy devices with different pacing modes have guaranteed place in the treatment of patients with AF. On the other hand, the concepts of permanent leadless cardiac pacing, atrial dyssynchrony syndrome treatment and His-bundle or para-Hisian pacing have been proposed. This review summarizes and discusses current and novel treatment options in patients with atrial fibrillation.

Keywords: Ablation; Atrial Fibrillation; CRT; ICD; Pacemaker; Treatment.

Figure 1.. Overview of clinical management of patients with atrial fibrillation

AF, atrial fibrillation; HF, heart failure; DDD, dual chamber pacemaker; ICD, implantable cardioverter-defibrillator; CRT-P/D, cardiac resynchronization therapy-pacemaker/defibrillator. ^ not recommended in left ventricular hypertrophy >15mm or ≥14mm (ibutilide) ^^ not for cardioversion. * some of these drugs should not be used in decompensated heart failure and/or in patients with pre-excitation

Figure 2.. Overview of atrial fibrillation ablation indications

AF, atrial fibrillation

Figure 3.. Overview of current options and/or guidelines recommendations for cardiovascular implantable electronic devices use in patients with AF. Based on,[57,58] other references are cited throughout the text

AV, atrioventricular; AVB, atrioventricular block; CIED, cardiovascular implantable electronic devices; EF, ejection fraction; NYHA, New York Heart Association; BiV, biventricular; other abbreviations as in Fig. 1