Atrial fibrillation maintenance of rate control and sinus rhythm
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Sinus rhythm  |
Atrial fibrillation  | |
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| ICD-10 | I48 |
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| ICD-9 | 427.31 |
| DiseasesDB | 1065 |
| MedlinePlus | 000184 |
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Atrial Fibrillation Microchapters | |
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Directions to Hospitals Treating Atrial fibrillation maintenance of rate control and sinus rhythm | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.
Overview
Prophylactic antiarrhythmic drug therapy may be required to maintain sinus rhythm, reduce frequency of symptoms, improve hemodynamic function and exercise capacity and prevent tachycardia-induced cardiomyopathy secondary to atrial fibrillation. In patients with heart failure, pharmacological maintenance of sinus rhythm has shown to reduce morbidity.[1][2]
ACCF/AHA 2011 Guidelines of Management of Atrial Fibrillation- Pharmacological Rate Control (DO NOT EDIT) [3]
| Class I |
| "1. Measurement of the heart rate at rest and control of the
rate using pharmacological agents are recommended for patients with persistent or permanent AF.(Level of Evidence: B) " |
| "2. In the absence of pre-excitation, intravenous
administration of a beta blocker, diltiazem, or verapamil is recommended to slow the ventricular response to AF in the acute setting, exercising caution in patients with hypotension or HF. (Level of Evidence: B) " |
| "3. Intravenous administration of digoxin or amiodarone is recommended to control the heart rate in patients with AF and HF who do not have an accessory pathway. (Level of Evidence: B) " |
| "4. In patients who experience symptoms related to AFduring activity, the adequacy of heart rate control shouldbe assessed during exercise, adjusting pharmacologicaltreatment as necessary to keep the rate in the
physiological range (Level of Evidence: C) " |
| "5. Digoxin is effective following oral administration to
control the heart rate at rest in patients with AF and is indicated for patients with HF or LV dysfunction or for sedentary individuals.(Level of Evidence: C) " |
| Class III (Harm) |
| "1. No Benefit.Treatment to achieve strict rate control of heart rate (<80 bpm at rest or <110 bpm during a 6-minute walk) is not beneficial compared to achieving a resting heart rate<110 bpm in patients with persistent AF who have stable ventricular function (LV ejection fraction >0.40) and no or acceptable symptoms related to the arrhythmia, though uncontrolled tachycardia may over time be associated with a reversible decline in ventricular performance (Level of Evidence: B) " |
| "2. Digitalis should not be used as the sole agent to control the rate of ventricular response in patients with paroxysmal AF(Level of Evidence: B) " |
| "3. Catheter ablation of the AV node should not be attempted without a prior trial of medication to control the ventricular rate in patients with AF(Level of Evidence: C) " |
| "4. In patients with decompensated HF and AF, intravenous administration of a nondihydropyridine calcium channel antagonist may exacerbate hemodynamic compromise and is not recommended (Level of Evidence: C) " |
| "5. Intravenous administration of lidocaine, beta blockers, or nondihydropyridine calcium channel antagonists to patients with AF and pre-excitation may accelerate the ventricular response and is not recommended.(Level of Evidence: C) " |
| Class IIa |
| "1. A combination of digoxin and either a beta blocker, diltiazem, or verapamil is reasonable to control the heart rate both at rest and during exercise in patients with AF. (Level of Evidence: B) " |
| "2. It is reasonable to use ablation of the arterioventricular (AV) node or accessory pathway to control heart rate when pharmacological therapy is insufficient or associated with side effects.(Level of Evidence: B) " |
| "3. Intravenous amiodarone can be useful to control the heart rate in patients with AF when other measures are unsuccessful or contraindicated. (Level of Evidence: C) " |
| "4. When electrical cardioversion is not necessary in
patients with AF and an accessory pathway, intravenous procainamide or ibutilide are reasonable alternatives.(Level of Evidence: C) " |
| Class IIb |
| "1. A combination of digoxin and either a beta blocker, diltiazem, or verapamil is reasonable to control the heart rate both at rest and during exercise in patients with AF. (Level of Evidence: B) " |
| "2. It is reasonable to use ablation of the arterioventricular (AV) node or accessory pathway to control heart rate when pharmacological therapy is insufficient or associated with side effects.(Level of Evidence: B) " |
| "3. Intravenous amiodarone can be useful to control the heart rate in patients with AF when other measures are unsuccessful or contraindicated. (Level of Evidence: C) " |
| "4. When electrical cardioversion is not necessary in patients with AF and an accessory pathway, intravenous procainamide or ibutilide are reasonable alternatives.(Level of Evidence: C) " |
ACCF/AHA/HRS 2011 Guidelines- Maintenance of Sinus Rhythm (DO NOT EDIT) [4][3]
| Class I |
| "1. Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended. (Level of Evidence: C) " |
| Class III (Harm) |
| "1.Antiarrhythmic therapy with a particular drug is not recommended for maintenance of sinus rhythm in patients with AF who have well-defined risk factors for proarrhythmia with that agent. (Level of Evidence: A) " |
| "2. Pharmacological therapy is not recommended for maintenance of sinus rhythm in patients with advanced sinus node disease or AV node dysfunction unless they have a functioning electronic cardiac pacemaker. (Level of Evidence: C) " |
| Class IIa |
| "1. Pharmacological therapy can be useful in patients with AF to maintain sinus rhythm and prevent tachycardia-induced cardiomyopathy.(Level of Evidence: C)" |
| "2. Infrequent, well-tolerated recurrence of AF is reasonable as a successful outcome of antiarrhythmic drug therapy.(Level of Evidence: C) " |
| "3. Outpatient initiation of antiarrhythmic drug therapy is reasonable in patients with AF who have no associated heart disease when the agent is well tolerated. (Level of Evidence: C) " |
| "4.Sotalol can be beneficial in outpatients in sinus rhythm with little or no heart disease, prone to paroxysmal AF, if the baseline uncorrected QT interval is less than 460 ms, serum electrolytes are normal, and risk factors associated with class III drug–related pro-arrhythmia are not present. (Level of Evidence: C) " |
| "5.Catheter ablation is a reasonable alternative to pharmacological therapy to prevent recurrent AF in symptomatic patients with little or no LA enlargement. (Level of Evidence: C) " |
Vote on and Suggest Revisions to the Current Guidelines
Guideline Resources
- 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation [3]
- ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter [5]
References
- ↑ Torp-Pedersen C, Møller M, Bloch-Thomsen PE, Køber L, Sandøe E, Egstrup K et al. (1999) Dofetilide in patients with congestive heart failure and left ventricular dysfunction. Danish Investigations of Arrhythmia and Mortality on Dofetilide Study Group. N Engl J Med 341 (12):857-65. DOI:10.1056/NEJM199909163411201 PMID: 10486417
- ↑ Deedwania PC, Singh BN, Ellenbogen K, Fisher S, Fletcher R, Singh SN (1998) Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation: observations from the veterans affairs congestive heart failure survival trial of antiarrhythmic therapy (CHF-STAT). The Department of Veterans Affairs CHF-STAT Investigators. Circulation 98 (23):2574-9. PMID: 9843465
- ↑ 3.0 3.1 3.2 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897
- ↑ 4.0 4.1 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781
- ↑ Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117 (8):1101-20. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199
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