Richard G. Sheahan • Marschall S.

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. EF <30%: - ,
(overdrive pacing)
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Symptomatic 1. Holter
Structurally normal LV: :
Dofetilide 2. >95/min, - ,
Amiodarone 3.
Sotalol
Propafenone
Flecainide
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Dofetilide
Amiodarone

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Failed or poorly tolerated antiarrhythmics: ablation with pulmonary vein isolation

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DC: direct current ( ), EF: ejection fraction ( ), INR: International Normalized Ratio (
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Confirm diagnosis: ECG

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Anticoagulation: assess risk factors

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Assessment of comorbidities
1.1. Coronary
/ : disease/angina: rate
artery
2.2. Congestive heart failure

: , Rate and exacerbations I

Hypertension: -with LV hypertrophy, consider adding ARB and avoiding Class I agents
Tacy-brady
EF >40%: syndrome: ,
EF⬎40%:
EF <30%: consider dual chamber pacemaker with atrial- fibrillation
, suppression software that decreases atrial fibrillation burden
EF⬍30%: consider implantable cardioverter defibrillator that combines atrial over drive pacing and atrial defibrillation
Renal function: review
: renally excreted rhythm and rate control medications

Quality of life assessment:

review limitations on physical activity since onset of atrial fibri
llation

,
Asymptomatic without limitations on physical activity:
<24-48 :
1. Holter monitor
1. Holter
to exclude persistently elevated heart rates during persistent atrial
IV
>48 : fibrillation
2. Any average hourly rate ⬎95 beats/min., rate control ␤-blockers, calcium channel
>95/min,
IV ,
, - blockers ,
IV INR: 2 - 3 3-4 3. Consider antiarrhythmic agents for patients with CHF

DC
Synchronized Biphasic DC Cardioversion
May need ibutilide to facilitate cardioversion

, ⱖ2
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Structurally abnormal LV with ⱖ2 episodes: :
ⱖ2
Dofetilide Dofetilide
Amiodarone Amiodarone
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Flecainide

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Failed or poorly tolerated antiarrythmics: ablation with pulmonary vein isolation

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274 IV 

37-4 .
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Confirm diagnosis: ECG

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, LV hypertrophy,
, LA dimensions
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1. / :
2.

: , Rate and exacerbations I

Hypertension: with
- LV hypertrophy, consider adding ARB and avoiding Class I agents
Tacy-brady
EF >40%: syndrome ,
EF 40%: consider single chamber pace maker with rate regulation suppression software that decreases rapid ventricular
responses
EF <30%: EF 30%: consider implantable cardioverter- defibrillator
Renal function: review
: renally excreted rhythm and rate control medications

:
Quality of life assessment: review limitations on physical activity since onset of atrial fibrillation

Rate control
Holter
Directed by Holter monitor to exclude persistently elevated heart rates during persistent atrial fibrillation
Any average hourly ⬎95 beats/min., rate>95/min,
control ␤-blockers, calcium channel
- blockers ,
Digoxin as a second agent or for inactive patients

Holter:
Annual echocardiography and Holter monitor: to avoid tachycardia-induced cardiomyopathy

Rapid ventricular response despite maximally tolerated rate control agents

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 37  275

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AF,

The high incidence of atrial thrombi in AF

patients with increased risk for peripheral
embolization warrants consideration of
anticoagulation unless contraindicated , ,

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276 IV 

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, Losartan
Intervention for End Point Reduction in Hypertension
. ,
(LIFE) Valsartan Antihypertensive Long-term Use
,
Evaluation (VALUE),
, QOL,
280 IV 

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).
LIFE Developed in collaboration with the European Heart Rhythm Associa-
VALUE. , tion and the Heart Rhythm Society. Europace 8(9):651-745, 2006.
This paper is a collaborative effort from the ACC, AHA, and ESC to
,
update 2001 guidelines for the diagnosis and management of AF.
.
,
,
.
. - 1. Hsu LF, Jais P, Sanders P, et al: Catheter ablation for atrial
, fibrillation in congestive heart failure. N Engl J Med 351(23):
2373-2383, 2004.
, This study was designed to evaluate whether catheter ablation for
atrial fibrillation with restoration of sinus rhythm improves cardiac
, function, symptoms, exercise capacity and quality of life in patients with
. CHF. Restoration and maintenance of sinus rhythm by catheter ablation
, Atrial Fibrillation Clopidogrel without the use of drugs was effective and improved objective findings of
cardiac function.
Trial with Irbesartran for Prevention of Vascular Events 2. Klein AL, Grimm RA, Murray RD, et al: Use of transesophageal
(ACTIVE) echocardiography to guide cardioversion in patients with atrial
fibrillation. N Engl J Med 344(19):1411-1420, 2001.
A study of 1222 patients tested the hypothesis that cardioversion can
. be performed safely after only a short period of anticoagulation in
patients in whom transesophageal echocardiography reveals no left atrial
- ,
thrombus. This study found that transesophageal echocardiography-guided
management of atrial fibrillation is a feasible option when planning
. elective cardioversion for the AF patient.
ximelagatran, 3. Ostermayer SH, Reisman M, Kramer PH, et al: Percutaneous left
, atrial appendage transcatheter occlusion (PLAATO system) to
prevent stroke in high-risk patients with non-rheumatic atrial
. ,
fibrillation: Results from the international multi-center feasibility
trials. J Am Coll Cardiol 46(1):9-14, 2005.
, , This article presents the International Multi-Center Feasibility Trials
, reports on the viability of percutaneous left atrial appendage (LAA)
occlusion using the PLAATO system. This study concluded that closing
the LAA using the PLAATO system is practical, can be performed with
(
acceptable risk, and should be considered an alternative in patients with
AF when long-term anticoagulation treatment is inadvisable.
), 4. Singer DE, Albers GW, Dalen JE, et al: Antithrombotic therapy
in atrial fibrillation: The Seventh ACCP Conference on Anti-
. , thrombotic and Thrombolytic Therapy. Chest 126(3 Suppl):
429S-456S, 2004.
,
In this report of the Seventh ACCP Conference on Antithrombotic
and Thrombolytic Therapy, grade 1 and 2 recommendations are made
for the use of antithrombotic therapy in AF.
. , 5. Wachtell K, Lehto M, Gerdts E, et al: Angiotensin II receptor
blockade reduces new-onset atrial fibrillation and subsequent stroke
compared to atenolol: The Losartan Intervention for End Point
, ,
Reduction in Hypertension (LIFE) study. J Am Coll Cardiol 45(5):
. 712-719, 2005.
The Losartan Intervention for End Point Reduction in Hypertension
, (LIFE) study compared the effects of losartan and atenolol on new-onset
. AF. This study concluded that losartan-based antihypertensive therapy
(as compared with atenolol-based antihypertensive therapy) significantly
,
reduced new-onset AF and associated stroke.
/ 6. Wyse DG, Waldo AL, DiMarco JP, et al: A comparison of rate
, , , , control and rhythm control in patients with atrial fibrillation. N
(CHAD) . Engl J Med 347(23):1825-1833, 2002.
This study compared the two approaches, rate and rhythm control, in
the management of AF. There was no significant difference in survival
, INR 2
between the two therapies. Patients randomized to rate control did have
3, . a lower risk for adverse drug effects.

Fuster V, Ryden LE, Cannom DS, et al: ACC/AHA/ESC 2006 guidelines

for the management of patients with atrial fibrillation: A report of the