Atrial Fibrillation: Rate/ Rhythm control-Non pharmacological management

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  • These therapeutic goals need to be pursued in parallel, especially upon the initial presentation of newly detected AF.These therapies may already alleviate symptoms, but symptom relief may require additional rhythm control therapy by cardioversion, antiarrhythmic drug therapy, or ablation therapy An irregular rhythm and a rapid ventricular rate in AF can cause symptoms including palpitations, dyspnoea, fatigue, and dizziness.Adequate control of the ventricular rate may reduce symptoms and improve haemodynamics, by allowing enough time for ventricularfilling and prevention of tachycardiomyopathy
  • Requirement of OAC for 45 day, DAPT for 1 yr and life long aspirin in the PROTECT AF trialAdverse events with procedurebased on expert consensus only.
  • Requirement of OAC for 45 day, DAPT for 1 yr and life long aspirin in the PROTECT AF trialAdverse events with procedurebased on expert consensus only.


  • 1. Atrial Fibrillation: Rate/Rhythm Control Non Pharmacological Management Dr Akshay Mehta Dr B Nanavati Hospital Asian Heart Institute
  • 2. Two most important things to know Type of AFSymptoms due to AF
  • 3. First Diagnosed Episode of AFParoxysmal Persistent (> 7 Long standing Permanent(usually days or Persistent (accepted)<= 48 h) requires CV) ( >1 year)
  • 4. EHRA score of AF-related symptomsEHRA class ExplanationEHRA I ‘No symptoms’EHRA II ‘Mild symptoms’; normal daily activity not affectedEHRA III ‘Severe symptoms’; normal daily activity affectedEHRA IV ‘Disabling symptoms’; normal daily activity discontinued
  • 5. Choosing Rate v/s Rhythm ControlTwo types of settingsAcute/UnstableNon acute/Stable
  • 6. Acute/Unstable settingRate Control Rhythm ControlCause: underlying cond severe AF Sx orEx- pneumonia, PE, Thyroid h-dynamic instabNo severe AF Sx orh-dynamic instab pharmac cv electric cvOlder ageLarge LA
  • 7. How RateControl ?
  • 8. Acute/Unstable setting Rhythm control – (Sx or hemody instab) Pharmac cv Electrical cv* <48 hrs *can > 48 hrs* No electrolyte *ischemia imbalance *hypoten* No ECG *HF sign of severe *Preexcited AF with ongoing ishemia instability* Hemodynamic stable + , -
  • 9. ESC 2012
  • 10. Recommendations foranticoagulation pericardioversion
  • 11. ………..recommendations foranticoagulation pericardioversion
  • 12. Non Acute/Stable Setting :Rate Control v/s Rhythm control INCLUDES RATE CONTROL OAC for Both
  • 13. AIMS of management of AF patients:• Prevent complications• Reduce symptoms (palpitations, dyspnoea, fatigue, and dizziness) antithrombotic therapy control of ventricular rate Rx of associated CV disease• ± Additional rhythm control therapy by cardioversion, antiarrhythmic drug therapy, or ablation therapy
  • 14. Randomized trials comparing rate control with rhythm control• Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) : no difference in all cause mortality (primary outcome) or stroke rate• The Rate Control versus Electrical cardioversion for persistent atrial fibrillation (RACE) trial :rate control not inferior to rhythm control for prevention of cardiovascular mortality and morbidity (composite endpoint).• The Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial : in patients with an LVEF ≤35%, no difference in cardiovascular mortality (primary outcome) symptoms of congestive heart failure, or in the secondary outcomes including death from any cause and worsening of heart failure
  • 15. However….• These studies enrolled predominantly older patients (average 70 y)• Most of whom had persistent AF and heart disease,• Follow-up extended over just a few years• Pts were at a stage where difficult to maintain sinus rhythm Hence :• Data don’t necessarily apply in young• Must not lose “window” of opportunity due to electrical and structural remodeling
  • 16. Hence… Rate control may be reasonable initial therapy in older patients with persistent AF with mild symptoms For younger individuals, especially those with paroxysmal lone AF, rhythm control may be a better initial approach.
  • 17. When to do Rate Control ?
  • 18. How to do long-term rate control
  • 19. How MUCH rate control ? < 80, 110 Exercise test if excessive heart rate is anticipated during More strict rate exercise Symptoms control RateControl 24 h ECG for safety No or tolerable Accept lenient symptoms rate control resting<110/mt
  • 20. Rhythm Control Rhythm control therapy is reasonable toameliorate symptoms, in paroxysmal/persistent AF
  • 21. When to do Rhythm Control ?
  • 22. AAD Therapy to maintain sinus rhythm inpatients with recurrent paroxysmal or persistent atrial fibrillation. β-Blockers are recommended for prevention of adrenergic AF-I C & should be considered for rhythm (+ rate) control in a first episode of AF - IIa 2011 Writing Group Members et al. Circulation 2011;123:104-123 Copyright © American Heart Association
  • 23. Antiarrhythmic drugs v/s left atrial ablation for rhythm control in AF ESC 2012
  • 24. Catheter ablation for AF using the CARTO contact mapping system
  • 25. Recommendations for surgical ablation of AF
  • 26. Recommendations for LAAclosure/occlusion/excision - ESC 2012
  • 27. Recommendation for atrioventricular node ablation in AF patientsShould be considered When the rate cannot be controlled with pharmacological agents and when AF cannot be prevented by antiarrhythmic therapy or is associated with intolerable side effects, when direct catheter-based or surgical ablation of AF is not indicated, has failed, or is rejected. IIaShould be considered for patients with permanent AF and an indication for CRT (IIa)Should be considered for CRT nonresponders in whom AF prevents effective biventricular stimulation and amiodarone is ineffective or contraindicated- IIa• In patients with any type of AF and severely depressed LV function biventricular stimulation should be considered after AV node ablation.
  • 28. Summary- management of patients with recurrent paroxysmal AF Recurrent Paroxysmal AF Minimal or no Disabling symptoms symptoms in AF Anticoagulation Anticoagulation and rate control* and rate control as needed as needed No drug for AAD therapy * prevention of AF AF ablation if AAD treatment fails
  • 29. Summary- management of patients with recurrent persistent or permanent AF Recurrent Persistent AF Permanent AF Minimal or no Disabling Anticoagulation and rate symptoms control* as needed symptoms in AF Anticoagulation and Anticoagulation and rate control* as rate control needed AAD drug therapy Electrical cardioversion as needed Continuous anticoagulation as needed and therapy to maintain sinus rhythm * Consider ablation for severely symptomatic recurrent AF after failure of greater than or equal to 1 AAD plus rate control
  • 30. THANK YOU!!!