ESC Congress FA eBook 2016 - 18

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Figure 1. Cardiovascular Morbidity and Mortality in the RACE II
Trial

Figure 2. Predictors of Mortality: Patients With AF in the
AFFIRM Trial
Risk ratio

Cumulative Incidence, %

Strict

14.9%
12.9%

Lenient

RR = 1.54 (0.42-0.70; P < .001)

Warfarin

-53%

RR = 0.47 (0.36-0.61; P < .001)

Digoxin

RR = 1.50 (1.18-1.89; P < .001)

AA Drugs
0

No. at Risk
303
Strict
311
Lenient

18
Months

282
298

273
290

262
285

246
255

212
218

131
138

Reprinted from van Gelder IC et al. Lenient versus Strict Rate Control in Patients with Atrial
Fibrillation. N Engl J Med 2010;362:1363-1373. Copyright © 2016 Massachusetts Medical
Society. Reprinted with permission from Massachusetts Medical Society.

Table 1. Rate Control in Specific Patient Groups
Typical Atrial Flutter
* Same recommendations, often more difficult to achieve adequate
rate control
* Ablation is now first choice
AF and Wolff-Parkinson-White Syndrome
* ß-blockers, Ca2+ antagonists, digoxin and adenosine are contraindicated
AF patients treated with Class IC AADs to prevent AF
* Rate control drugs should be used concomitantly to avoid atrial
flutter with rapid conduction to ventricles
Patients with brady-tachy syndrome
* DDD pacing + rate control drugs may help to avoid symptoms
AF in patients with ICD
* Stricter rate control to avoid inappropriate shocks
AF in patients with CRT
* Absolute goal is 100% pacing - strict rate in these patients needed
* AV node ablation often indicated
AAD, antiarrhythmic drug; AF, atrial fibrillation; AV, atrioventricular; CRT, cardiac
resynchronization therapy; DDD, dual chamber dual chamber pacing and sensing; ICD,
implantable cardioverter defibrillator.

How rate control is instituted depends on the symptoms,
activity level, and comorbidities of the individual patient
and the relationship between heart rate and left ventricular function in that patient. Sometimes faster heart rates are
required to maintain exercise or other medical conditions.
Prof Van Gelder suggests before beginning rate control
assess comorbidities and underlying triggers like HF, ischemia, anxiety, etc, and initiate drug treatment. When symptoms persist perform a clinical re-assessment and look for
triggers. Ablation of the AV node with pacemaker insertion should be restricted and performed only if absolutely
necessary [Van Gelder IC et al. Lancet. 2016]. Some patient
populations require a special approach (Table 1).

October 2016

-46%

+ 50%

Sinus rhythm

RR = 1.41 (1.10-1.83; P < .0005)
0

0.5

+ 41%
1

1.5

* Other significant factors in model: age, CAD, CHF, smoking, stroke/TIA, normal LVEF, MR.

AA, antiarhythmic; CAD, coronary artery disease; CHF, congestive heart failure; LVEF, left
ventricular ejection fraction; MR, mitral regurgitation; TIA, transient ischemic attack.
Reprinted from Aliot E, Ruskin JN. Controversies in ablation of atrial fibrillation. Eur Heart J. 2008;
Suppl H: H32-H54. doi:10.1093/eurheartj/sun030. By permission of Oxford University Press
on behalf of the European Society of Cardiology.

AF is associated with increased morbidity and mortality and a decrease in patient quality of life [Dorian P et
al. J Am Coll Cardiol. 2000]. Prof Fauchier suggested that
treatment of AF should first aim to prevent stroke, then
address rate control to stabilize symptoms, and only
then turn to rhythm control. Although restoring sinus
rhythm (SR) improves quality of life [Singh SN et al. J Am
Coll Cardiol. 2006] and improves survival, using antiarrhythmic drugs (AADs) can worsen prognosis (Figure 2)
[Aliot E, Ruskin JN. Eur Heart J. Suppl H 2008].
Considerations for pursuing SR include poorly tolerated
symptoms, the type of AF, the general health of the patient,
and anticoagulation status [Piccini JP, Fauchier L. Lancet.
2016]. In choosing a strategy, relevant factors include the
urgency of achieving SR and the type of cardioversion
(electrical or pharmacologic). First-line, most patients
will receive AADs. The best 2-year results are obtained
with amiodarone [Roy D et al. N Engl J Med. 2000]; however, compared with other AADs amiodarone has a slightly
worse safety and tolerability profile. Catheter ablation (CA)
has been shown to be superior to AADs in preventing AF
recurrence and reducing symptoms [Wilber DJ et al. JAMA.
2010] and is considered a Class IA therapy to improve
symptoms in patients with symptomatic paroxysmal AF
who have symptomatic recurrences of AF when on AADs.
CA has also been shown to be superior to AADs for preventing recurrence of persistent AF [Mont L et al. Eur Heart J.
2014] although the optimal approach is still unclear. It may
also lead to improved outcomes for the increasing number
of patients with co-occurring AF and heart failure (HF).
Additional Reading:
Freedman B, Potpara TS, Lip GY. Stroke prevention in atrial fibrillation. Lancet 2016;388
(10046):806-17. doi: 10.1016/S0140-6736(16)31257-0.
Piccini JP, Fauchier L. Rhythm control in atrial fibrillation. Lancet 2016;388(10046):829-40.
doi: 10.1016/S0140-6736(16)31277-6.
Van Gelder IC, Rienstra M, Crijns HJ, Olshansky B. Rate control in atrial fibrillation. Lancet
2016;88(10046):818-28. doi: 10.1016/S0140-6736(16)31258-2.

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