AF Management
10 points to Remember
1. AF does not have to be "IRREGULAR".
AF w/ high grade AV block w/ slow junctional escape.
AF w/ BiV pacing s/p AV nodal ablation.
..depends on the AV nodal function.
2. Rhythm control should be considered urgently in...
AF with extremely fast conduction via accessory pathway (AF w/WPW), AF with end-organ damage such as STEMI or acute pulmonary edema.
3. Risk factor management is the first step in long-term AF management.
Risk Factor Management (weight control, exercise, treatment of hypertension, OSA, DM, and smoking cessation) slows
the progression of AF and reduces AF burden.
4. For stroke risk evaluation, use CHA2DS2-VaSc in most but NOT all.
In AF patients with mechanical valve, moderate-to-severe mitral stenosis, or hypertrophic cardiomyopathy,
OAC is indicated regardless of the CHA2DS2-VaSc score.
5. How good are the OACs?
1. Any OACs (either warfarin or NOACs) reduce stroke by approximately 70%.
2. Compared to warfarin, NOACs are associated with approximately 50% lower incidence of intracranial hemorrhage.
6. Rate control for live, Rhythm control for love.
1. Rate control is often sufficient to improve AF-related symptoms.
2. Rate control is essential in AF management regardless of whether rhythm or rate control strategy is chosen.
3. All trials that have compared rhythm vs. rate control have resulted in neutral outcomes in major CV endpoints.
7. Amiodarone is NOT the first line for rate control.
1. May consider amiodarone after beta-blocker for rate control in acute AF with HF.
2. Choice of medications for rate control depends on LVEF.
3. The prevalence of adverse effects related to amiodarone is up to 15% in the first year and 50% in case of prolonged treatment.
8. Class IC AAD is effective if you know how to use it.
| Agents | Acute Conversion (<7d) | Chronic Conversion (>7d) |
LVH | CAD | CHF |
AV node blocking property | ECG features prompting discontinuation |
| Flecainde | Y | N | N | N | N |
None |
QRS>25% wider |
| Propafenone | Y | N | N | N | N |
Minimal |
QRS>25% wider |
| Amiodarone | Y | Y | Y | Y | Y |
Moderate |
QTc>500ms |
| Dronedarone | N | N | Y | Y | Y for mild form |
Moderate |
QTc>500ms |
| Sotalol | N | N | N | Y | N |
A lot |
QTc>500ms or QTc increases >60ms |
| Ibutilide (IV) | Y | Y | Careful |
None |
Careful in long QTc |
| Vernakalant (IV) | Y | N | Y | Y for stable CAD | Y for mild form |
Moderate |
Avoid in QTc>440 |
AFL with 1:1 AV conduction in an AF patient while on Propafenone w/o BB.
1. Class IC AADs (Flecainide & Propafenone) are very effective for acute AF conversion in patients without structural heart disease.
2. IC AADs have little beta blocking effect. AFL with 1:1 AV conduction may occur if administered without AV nodal blocking agent.
9. Ablation has its role BUT not because the patient would like to omit anticoagulation.
In symptomatic AF patients, catheter ablation improves symptoms and reduces recurrent AF.
In AF with HFrEF patients, catheter ablation reduces CV death and HF hospitalization.
10. The term 'Lone AF' should be avoided.
..With more ways to evaluate structural heart diseases, less and less 'LONE' AF is detected.
..AF is a progressive disease. Even in the previously-called 'lone AF' patients, the prognosis is not benign.
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