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ESC CONGRESS 2016

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the most widely used agents, although in patients with
HF with reduced EF, ß-blockers do not have the same
prognostic benefit in patients with AF in sinus rhythm
[Kotecha D et al. Lancet. 2014]. While digoxin does not
impact mortality in HF patients, it can be a useful agent
for long-term heart rate control.
Although atrioventricular node ablation is an important consideration for patients with ongoing and intolerable symptoms, the requirement for pacemaker
implantation means that many patients may instead be
considered for advanced rhythm control with catheter
ablation, surgical ablation, or hybrid approaches.
The recommendations for rate control therapy are
shown in Table 5.
APPROACH TO ANTIARRHYTHMIC DRUGS AND
CATHETER ABLATION FOR RHYTHM CONTROL

Gerhard Hindricks, MD, University of Leipzig, Leipzig,
Germany, pointed out that according to the ESC AF
guidelines, symptom improvement is the main goal of
rhythm control therapy in patients with AF. In patients
on rhythm control therapy, management of cardiovascular risk factors and avoidance of AF triggers should be
pursued to facilitate maintenance of sinus rhythm.
Rhythm control therapy should be selected after careful evaluation and targeted to improve symptoms of
AF. For patients with recent onset AF who are hemodynamically unstable, the need for electrical cardioversion
is urgent and should be instituted promptly. In stable
patients, the choice between electrical cardioversion
and pharmacologic cardioversion depends primarily on

IN REVIEW

FOCUS ON ARRHYTHMIAS

availability and patient/physician choice. Intravenous
amiodarone can be used in patients with HF or ischemic
heart disease. Oral flecainide and propafenone are effective for cardioversion but they cannot be used in patients
with structural heart disease. Intravenous flecainide,
ibutilide, propafenone, and vernakalant are additional
options for patients without structural heart disease.
Vernakalant can also be used in patients with moderate
HF.
Anticoagulation with heparin or a non-VKA oral anticoagulant should be started as soon as possible before every
cardioversion for AF or atrial flutter, whether electrical or
pharmacological. The ESC guidelines recommend anticoagulation for a minimum of 3 weeks before cardioversion
when the duration of AF is > 48 hours or unknown. When
early cardioversion is needed, transesophageal echocardiography is recommended to exclude cardiac thrombus
as an alternative to preprocedural anticoagulation. In
patients with a definite duration of AF < 48 hours, early
cardioversion can be performed without transesophageal
echocardiography. Long-term anticoagulation is necessary for patients with risk factors for stroke, even when
rhythm control is apparently effective.
Long-term therapy to prevent AF recurrence can be
achieved with antiarrhythmic drug (AAD) therapy or catheter or surgical ablation. The ESC recommendations for
long-term rhythm control with AADs are shown in Table 6.
Catheter ablation is more effective than AADs for reducing
recurrent AF but is associated with potential complications,
including periprocedural death (< 0.2%), esophageal injury
(< 0.5%), periprocedural stroke (< 1%), cardiac tamponade

Table 5. Recommendations for Rate Control Therapy
Recommendations

Class

Level

ß-blockers, digoxin, diltiazem, or verapamil are recommended to control heart rate in AF patients with LVEF ≥ 40%.

ß-blockers and/or digoxin are recommended to control heart rate in AF patients with LVEF < 40%.

Combination therapy comprising different rate controlling agents should be considered if a single agent does not
achieve the necessary heart rate target.

IIa

In patients with hemodynamic instability or severely depressed LVEF, amiodarone may be considered for acute control
of heart rate.

IIb

III
(harm)

A resting heart rate of < 110 bpm (lenient rate control) should be considered as the initial heart rate target for rate
control therapy.

IIa

Rhythm rather than rate control strategies should be considered as the preferred management in pre-excited AF and AF
during pregnancy.

IIa

Atrioventricular node ablation should be considered to control heart rate in patients unresponsive or intolerant to
intensive rate and rhythm control therapy, accepting that these patients will become pacemaker dependent.

IIa

In patients with permanent AF (ie, where no attempt to restore sinus rhythm is planned), antiarrhythmic drugs should not
routinely be used for rate control.

AF, atrial fibrillation; LVEF, left ventricular ejection fraction.
Reprinted from Kirchhof P et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016. doi:10.1093/eurheartj/ehw210. By
permission of Oxford University Press on behalf of the European Society of Cardiology.

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