Atrial Fibrillation: Pharmacological Therapy

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Abstract

Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice. Although once considered a nuisance arrhythmia, recent clinical trial evidence suggests that the presence of AF is an important independent predictor of mortality and morbidity. The primary goals of AF treatment are relief of symptoms and prevention of stroke. The value of anticoagulation with warfarin has been proven unequivocally. Control of ventricular rate with atrioventricular nodal blocking agents—the so-called rate control strategy—is least cumbersome and sometimes the best approach. By contrast, efforts to restore and maintain sinus rhythm using antiarrhythmic drugs—the rhythm control approach—although tedious, may be ideal in patients who are young or highly symptomatic and in those with new-onset AF. The relative merits of both treatment strategies are discussed in this article, emphasizing the excellent clinical trial data that support each.

Section snippets

Problem Statement

The epidemic of atrial fibrillation (AF) affects approximately 1% of the adult population of the United States. It is projected that by the year 2050, there will be almost 15 million patients with AF.1, 2, 3 It is a very common cardiac arrhythmia in clinical practice. Thirty years of follow-up data from the Framingham Study cohort have suggested that the lifetime risk of developing AF is 1 in 4 for men and women older than 40 years with a higher predisposition for men and white Americans.4, 5

Current Therapy of Atrial Fibrillation

Today, therapy for AF is multidimensional with treatment options spanning from pharmacologic therapy to invasive electrophysiological intervention.10 The principle goals of these treatments are relief of symptoms and prevention of stroke. Pharmacologic therapy principally includes anticoagulation with warfarin, control of heart rate or rhythm, and supportive nonarrhythmic drug therapy. There is a consensus regarding the indications and benefits of anticoagulation in AF; however, debate

Classification of Atrial Fibrillation

According to the American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) Task Force on Clinical Guidelines for the management of AF, AF can be classified into 4 types: first detected episode, paroxysmal, persistent, and permanent.10 Paroxysmal AF terminates spontaneously, with episodes typically lasting less than 24 hours and up to 7 days. Persistent AF requires cardioversion (pharmacologic or electrical) to terminate and the episodes last more

Rhythm vs Rate Control

The initial therapy for AF is often directed toward restoration of SR by means of cardioversion and maintenance of SR by antiarrhythmic drugs. The proposed advantages of the rhythm control strategy are symptomatic improvement, improved exercise tolerance, reduced risk of stroke, and possibly discontinuation of anticoagulation. The alternative approach is simply control of the ventricular rate using AV nodal blocking therapy or rate control. This decision is empiric. The strategy of rhythm

Rate Control Agents

The rate control strategy in AF is fairly straightforward. It constitutes using drugs that slow conduction through the AV node, thus avoiding excessively rapid ventricular rates. A persistently high ventricular rate in AF may not only make the patient more symptomatic, but also can lead to tachycardia-induced cardiomyopathy. Conduction through the AV node is in turn influenced by the presence or absence of intrinsic conduction system disease and sympathetic and parasympathetic tone. The AV node

Rhythm Control

The rhythm control strategy includes restoration of SR and maintenance thereafter. Upwards of 70% patients with new-onset AF of <72 hours convert to SR spontaneously with most spontaneous cardioversion occurring within first 24 hours.43 Electrical remodeling of the atria starts as early as at the onset of AF.44 Therefore, timely restoration of SR should be accomplished using electric or pharmacologic cardioversion in patients who do not cardiovert spontaneously. Management of patients with

Selection of an Antiarrhythmic Drug

Current ACC/AHA/ESC suggestions for selection of appropriate antiarrhythmic drug therapy for maintenance of SR are shown in Fig 1. Because ventricular proarrhythmia is more common in patients with structural heart disease or congestive heart failure, choice of antiarrhythmic drug therapy is based on the presence or absence of structural heart disease or CHF. Class Ic drugs are preferred for patients with structurally normal hearts due to their long-term safety and tolerability profile. Sotalol

Adjuvant Therapy

This section briefly reviews the evidence supporting adjuvant non-antiarrhythmic drugs for the prevention of AF. These drugs work primarily by preventing atrial remodeling, as shown in Fig 2. Adjuvant therapy for AF has been extensively reviewed in the current literature.84

Conclusions

As outlined above, there are multiple treatment options available for management of AF. An ideal approach to AF management should start with prevention of AF in the population at highest risk using adjuvant therapy outlined above. When AF develops, it is reasonable either to pursue the strategy of simple rate control or to cardiovert the patient and maintain SR using antiarrhythmic drugs. The rhythm control strategy is favored in patients with intolerable symptoms and those who are young with

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    Competing Interests. None.

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