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Feature Article

Management of atrial fibrillation

Martin Stiles, Prashanthan Sanders
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Abstract

Atrial fibrillation (AF) is a commonly encountered clinical arrhythmia associated with significant increases in the risk of death, congestive heart failure and embolic phenomena, including stroke. Management strategies for AF are aimed at controlling the ventricular rate while accepting ongoing AF, or at restoring and maintaining sinus rhythm.

Key Points

  • Atrial fibrillation (AF) is a commonly encountered clinical arrhythmia and is associated with significant increases in the risk of death, congestive heart failure and embolic phenomena, including stroke.
  • Management strategies for AF are aimed at either controlling the ventricular rate while accepting ongoing AF, or at restoring and maintaining sinus rhythm. Clinical trials of pharmacological strategies have shown no significant difference in mortality or thromboembolism risk between rate or rhythm control.
  • Patients with new-onset AF often revert to sinus rhythm soon after presentation; conversion to sinus rhythm may be assisted by the use of medications, or by electrical means in those in whom cardiac output is compromised. In other patients, ventricular rate control may be achieved by medication.
  • In patients who have recurrent or persistent AF, ventricular rate control can usually be achieved using pharmacological therapies. AV node ablation and permanent pacing is an alternative rate control strategy.
  • Electrical or pharmacological cardioversion may be chosen to restore and maintain sinus rhythm. Although not a first-line treatment for AF, catheter ablation can be used to restore sinus rhythm in patients with symptoms refractory to medical treatment.
  • Risk stratification for stroke permits an informed decision on patients’ requirements for anticoagulation. This decision is independent of whether a rate or rhythm control strategy is chosen for AF management. Simple risk calculation can guide the choice of antithrombotic.

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