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Atrial Fibrillation
17.06.2016
Background
•  It is characterized by an irregular and often rapid heartbeat
• Published guidelines from an American College of Cardiology 
(ACC)/American Heart Association (AHA)/European Society of Cardiology 
(ESC) committee of experts on the treatment of patients with atrial 
fibrillation recommend classification of AF into the following 3 patterns 
:
1. Paroxysmal AF – Episodes of AF that terminate spontaneously within 7 
days (most episodes last less than 24 hours)
2. Persistent AF - Episodes of AF that last more than 7 days and may require 
either pharmacologic or electrical intervention to terminate
3. Permanent AF - AF that has persisted for more than 1 year, either 
because     cardioversion has failed or because cardioversion has not been 
attempted
• This classification schema pertains to cases that are not related to a
reversible cause of AF (eg, thyrotoxicosis, electrolyte abnormalities, acute 
ethanol intoxication).
Pathophysiology
Automatic focus
•The pulmonary veins appear to be the most frequent source of these 
automatic foci, but other foci have been demonstrated in several areas 
throughout the atria. Cardiac muscle in the pulmonary veins appears to 
have active electrical properties that are similar, but not identical, to 
those of atrial myocytes. 
Multiple wavelet
•Fractionation of wave fronts propagating through the atria results in 
self-perpetuating "daughter wavelets."
•Increased atrial mass, shortened atrial refractory period, and delayed 
intra-atrial conduction increase the number of wavelets and promote 
sustained AF
Etiology
Atrial fibrillation (AF) is strongly associated with the following risk factors:
•Hemodynamic stress e.g. mitral/tricuspid valve disease, HTN, intracardiac 
tumors or thrombi.
•Atrial ischemia
•Inflammation – Myocarditis and Pericarditis (idiopathic or associated with 
infections, collagen vascular disease or surgeries)
•Noncardiovascular respiratory causes – PE, pneumonia, lung cancers
•Alcohol and drug use e.g. cocaine, chronic alcohol use
•Endocrine disorders e.g. hyperthyroidism, DM, Pheochromocytoma
•Neurologic disorders e.g. SAH, stroke
•Genetic factors
•Advancing age  - strongly age-dependent, affecting 4% of individuals older 
than 60 years and 8% of persons older than 80 year
History
• Initial evaluation – hemodynamic stability (unstable pts refer to ACLS 
protocols which includes cardioversion)
• While up to 90% of AF episodes may not cause symptoms,  
many 
patients experience a wide variety of symptoms, including 
palpitations, dyspnea, fatigue, dizziness, angina, and
decompensated heart failure.
• Any precipitating factors, hx of heart disease, previous episode and 
how was it terminated, 
Physical Examination
• Heart rate, blood pressure, respiratory rate, and oxygen saturation
are particularly important in evaluating hemodynamic stability and
adequacy of rate control in AF.
• Patients will have an irregularly irregular pulse and will commonly be
tachycardic, with heart rates typically in the 110- to 140-range, but
rarely over 160-170. Patients who are hypothermic or who have
cardiac drug toxicity may present with bradycardic atrial fibrillation.
• The physical examination also provides information on underlying
causes and sequelae of atrial fibrillation.
Diagnosis
• The diagnosis of atrial fibrillation is based on the physical finding of an
irregular heart rhythm and is confirmed with an ECG or rhythm strip.
• It appears on ECG as irregularly irregular narrow complex
tachycardia
• Discrete P waves are absent, replaced by irregular, chaotic F waves,
in the setting of irregular QRS complexes
• The ventricular rate is usually between 80 and 180 bpm.
• It is important to pay attention to the electrocardiographic signs of
associated cardiac diseases, such as left ventricular hypertrophy and
preexcitation.
Investigations – Other..
• Include CBC count (anemia, infection), electrolytes, BUN/ creatinine,
cardiac enzymes, thyroid function tests
• ECHO - valvular heart disease, left and right atrial size, left ventricular
(LV) size and function, left ventricular hypertrophy (LVH), and
pericardial disease.
• CT angiography if PE is suspected
• CXR in cases suspected of CHF or Pneumonia
Treatment & Management
• The cornerstones of atrial fibrillation management are rate control and
anticoagulationand rhythm control for those symptomatically limited by
AF.
• One of the major management decisions in AF is determining the risk of
stroke and appropriate anticoagulation regimen for low-, intermediate-,
and high-risk patients. For each anticoagulant, the benefit in terms of
stroke reduction must be weighed against the risk of serious bleeding.
• Several risk factor assessment algorithms have been developed to aid the
clinician on decisions on anticoagulation for patients with AF. The
CHADS2 index (Cardiac failure, Diabetes, Stroke [or S2 = transient ischemic
attack]) is the most widely used of these algorithms.The CHADS2 index uses
a point system to determine yearly thromboembolic risk.
CHADS2 Score for Stroke Risk Assessment
in Atrial Fibrillation
Score CHADS2 Risk Criteria
1 point Congestive heart failure
1 point Hypertension
1 point Age >75 years
1 point Diabetes mellitus
2 points Stroke/transient ischemic attack
Table 1. CHADS2
Score: Stroke Risk Assessment in Atrial Fibrillation
Treatment Recommendations Based on
CHADS2
Score
CHADS2Score Risk Recommendation
0 Low Aspirin (81-325 mg) daily
1 Intermediate
Aspirin (81-325 mg) daily or warfarin
(INR 2.0–3.0), based on patient
preference
2 or more
High (CHADS2 revised) or
intermediate (CHADS2 classic)
Warfarin (INR 2.0-3.0), unless there
are reasons to avoid it
()
• The American Heart Association (AHA), American College of Cardiology (ACC), and Heart
Rhythm Society (HRS), in collaboration with the Society of Thoracic Surgery, released
new AF guidelines in 2014, including the recommendation that for estimation of the
stroke risk in patients with nonvalvular AF, the CHADS2 score be replaced with the more
comprehensive CHA2 DS2 -VASc score.
• In this scoring system, 1 point is assigned for each of the following: congestive heart
failure (CHF), hypertension, diabetes, vascular disease (myocardial infarction [MI],
peripheral arterial disease, aortic plaque), age 65-74 years, and female sex. Two points
each are assigned for age 75 years or older and prior stroke/transient ischemic attack
(TIA)/thromboembolism.
The updated guidelines also state the following:
• Evidence indicates that aspirin’s use as a means of lowering stroke risk in patients with
AF should be reduced or eliminated
• In addition to warfarin, 3 new anticoagulants are recommended for patients with
nonvalvular AF who have previously suffered a stroke or TIA or whose CHA 2 DS 2 -VASc
score is 2 or above: dabigatran etexilate, rivaroxaban, and apixaban
• Radiofrequency catheter ablation can be used as initial treatment in recurrent
symptomatic paroxysmal AF
Rate control
• Control of ventricular rate is a critical component of management of new-
onset AF
• Beta-blockers and calcium channel blockers are first-line agents for rate
control in AF. These drugs can be administered either intravenously or
orally. Commonly used are IV metoprolol or diltiazem in AF with RVR.
• Amiodarone can be used as a rate-controlling agent for patients who are
intolerant of or unresponsive to other agents, such as patients with CHF
who may otherwise not tolerate diltiazem or metoprolol.
• In patients with inadequate ventricular rate control despite drug therapy,
atrioventricular (AV) nodal ablation and pacemaker implantation may be
considered
Anticoagulation
• Acute cardioversion for AF carries a risk of thromboembolism unless
anticoagulation therapy is initiated prior to the procedure and
continued post procedure. Risk of thromboembolism is similar in
patients undergoing either pharmacologic or electrical cardioversion.
The risk of thromboembolic events is greatest when AF has been
present for longer than 48 hours.
• Patients with newly diagnosed AF and patients awaiting electrical
cardioversion can be started on intravenous heparin (activated partial
thromboplastin time [aPTT] of 45-60 seconds) or low-molecular-
weight heparin (1 mg/kg bid).
• Patients can be started concomitantly on warfarin in an inpatient
setting while awaiting a therapeutic INR value (2-3).
• New anticoagulants: dabigatran, rivaroxaban, apixaban
Long-Term Management
• Long-term management of atrial fibrillation is focused on reducing the
likelihood of AF recurrence, reducing AF-related symptoms, control of
ventricular rate, and reducing stroke risk.
• Anticoagulation with either aspirin or warfarin should be initiated for all
individuals with AF, except those with contraindications. Selection of the
appropriate antithrombotic regimen for a given patient should be balanced 
between the risk of stroke and the risk of bleeding.
• Antiarrhythmic therapy can aid in maintenance of sinus rhythm in certain
patients but requires close monitoring
• As a rule, younger patients with more severe symptoms and fewer
comorbidities tend to derive greater benefit from a long-term focus on
rhythm control. Older patients with structural heart disease (e.g., left
ventricular hypertrophy, prior MI, depressed ejection fraction, atrial dilation)
are less likely to remain in sinus rhythm and are more likely to have serious
side effects from antiarrhythmic drugs, most clinicians focus on long-term
rate control
Anticoagulation
• The goal of long-term anticoagulation in atrial fibrillation is to reduce
the risk of thromboembolism.
• Anticoagulation therapy with warfarin is significantly more effective
than antiplatelet therapy if the INR is adjusted. The INR goal in AF is
usually between 2 and 3.
• The major adverse effect of anticoagulation therapy with warfarin is
bleeding
• Factors that increase the risk of bleeding include: hx of bleeding, age
more than 75 years, liver or renal dse, HTN, DM, anemia, prior stroke,
subtherapeutic INR, genetic predisposition, thrombocytopenia or
aspirin use, malignanacy.
• If risk outweighs benefit then avoid and contraindicated in pregnant
women too.
New anticoagulant regimens
• Compared with warfarin, low-dose new anticoagulant regimens showed
similar overall reductions in stroke or systemic embolic events and a more
favorable bleeding profile, but significantly more ischemic strokes
• Guidelines from the American College of Cardiology Foundation
(ACCF)/American Heart Association (AHA)/Heart Rhythm Society (HRS) on
atrial fibrillation have been updated to include the use of oral direct
thrombin inhibitors (ie, dabigatran)
• The guidelines recommend dabigatran may be used as an alternative to
warfarin for the prevention of stroke and systemic thromboembolism in
patients with paroxysmal-to-permanent atrial fibrillation and risk factors
for stroke or systemic embolization. Patients with atrial fibrillation who are
not candidates include those with prosthetic heart valves or
hemodynamically significant valve disease, severe renal failure (creatinine
clearance ≤15 mL/min), or advanced liver disease.
Rate control
• Strict rate control in patients with stable ventricular function is no longer
recommended.
• AV nodal blocking medications are the cornerstone of rate control in long-
standing AF, oral beta-blockers, nondihydropyridine calcium channel
blockers, and digoxin are effective. Generally, coadministration of beta-
blockers and calcium channel blockers is reserved for patients in whom
adequate rate control cannot be achieved with a single agent.
• Digoxin can be effective in sedentary patients (especially in those with
heart failure) but requires close monitoring of drug levels and renal
function.
• Heart rate control (defined as <80 bpm at rest) may be considered for less
symptomatic patients with AF; a more lenient rate-control strategy (<110
bpm at rest) is reasonable when patients remain asymptomatic and left
ventricular (LV) systolic function is preserved
Rhythm control
• Maintenance of sinus rhythm requires treatment of cardiovascular risk
factors and any underlying disorder (ie, hyperthyroidism) that may have
triggered AF.
• Antiarrhythmic drugs include amiodarone, dofetilide, dronedarone,
flecainide, propafenone, and sotalol; drug selection should be based on
underlying heart disease and comorbidities
• In patients with cardiac disease such as coronary artery disease or systolic
or diastolic heart failure, amiodarone becomes the drug of choice because
of its decreased proarrhythmic effects compared with other
antiarrhythmic drugs.
• Discontinue antiarrhythmic drugs, including dronedarone, when AF
becomes permanent
• Dronedarone is contraindicated for treatment of AF in patients with New
York Heart Association (NYHA) class III and IV HF or patients who have had
an episode of decompensated heart failure in the past 4 weeks
Catheter Ablation
• The goal of catheter ablation and surgical treatment of atrial
fibrillation is to disconnect triggers and/or to modify the substrate
for AF. Mapping and radiofrequency (RF) ablation of AF is one of the
most complex ablation procedures.
• First-line therapy in recurrent symptomatic paroxysmal or persistent
AF
• AF catheter ablation is contraindicated for patients who cannot be
treated with anticoagulant therapy during and after the procedure
and should not be performed with the sole intent of eliminating the
need for anticoagulation.

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Atrial fibrillation

  • 2. Background •  It is characterized by an irregular and often rapid heartbeat • Published guidelines from an American College of Cardiology  (ACC)/American Heart Association (AHA)/European Society of Cardiology  (ESC) committee of experts on the treatment of patients with atrial  fibrillation recommend classification of AF into the following 3 patterns  : 1. Paroxysmal AF – Episodes of AF that terminate spontaneously within 7  days (most episodes last less than 24 hours) 2. Persistent AF - Episodes of AF that last more than 7 days and may require  either pharmacologic or electrical intervention to terminate 3. Permanent AF - AF that has persisted for more than 1 year, either  because     cardioversion has failed or because cardioversion has not been  attempted • This classification schema pertains to cases that are not related to a reversible cause of AF (eg, thyrotoxicosis, electrolyte abnormalities, acute  ethanol intoxication).
  • 4. Etiology Atrial fibrillation (AF) is strongly associated with the following risk factors: •Hemodynamic stress e.g. mitral/tricuspid valve disease, HTN, intracardiac  tumors or thrombi. •Atrial ischemia •Inflammation – Myocarditis and Pericarditis (idiopathic or associated with  infections, collagen vascular disease or surgeries) •Noncardiovascular respiratory causes – PE, pneumonia, lung cancers •Alcohol and drug use e.g. cocaine, chronic alcohol use •Endocrine disorders e.g. hyperthyroidism, DM, Pheochromocytoma •Neurologic disorders e.g. SAH, stroke •Genetic factors •Advancing age  - strongly age-dependent, affecting 4% of individuals older  than 60 years and 8% of persons older than 80 year
  • 5.
  • 7. Physical Examination • Heart rate, blood pressure, respiratory rate, and oxygen saturation are particularly important in evaluating hemodynamic stability and adequacy of rate control in AF. • Patients will have an irregularly irregular pulse and will commonly be tachycardic, with heart rates typically in the 110- to 140-range, but rarely over 160-170. Patients who are hypothermic or who have cardiac drug toxicity may present with bradycardic atrial fibrillation. • The physical examination also provides information on underlying causes and sequelae of atrial fibrillation.
  • 8. Diagnosis • The diagnosis of atrial fibrillation is based on the physical finding of an irregular heart rhythm and is confirmed with an ECG or rhythm strip. • It appears on ECG as irregularly irregular narrow complex tachycardia • Discrete P waves are absent, replaced by irregular, chaotic F waves, in the setting of irregular QRS complexes • The ventricular rate is usually between 80 and 180 bpm. • It is important to pay attention to the electrocardiographic signs of associated cardiac diseases, such as left ventricular hypertrophy and preexcitation.
  • 9.
  • 10. Investigations – Other.. • Include CBC count (anemia, infection), electrolytes, BUN/ creatinine, cardiac enzymes, thyroid function tests • ECHO - valvular heart disease, left and right atrial size, left ventricular (LV) size and function, left ventricular hypertrophy (LVH), and pericardial disease. • CT angiography if PE is suspected • CXR in cases suspected of CHF or Pneumonia
  • 11. Treatment & Management • The cornerstones of atrial fibrillation management are rate control and anticoagulationand rhythm control for those symptomatically limited by AF. • One of the major management decisions in AF is determining the risk of stroke and appropriate anticoagulation regimen for low-, intermediate-, and high-risk patients. For each anticoagulant, the benefit in terms of stroke reduction must be weighed against the risk of serious bleeding. • Several risk factor assessment algorithms have been developed to aid the clinician on decisions on anticoagulation for patients with AF. The CHADS2 index (Cardiac failure, Diabetes, Stroke [or S2 = transient ischemic attack]) is the most widely used of these algorithms.The CHADS2 index uses a point system to determine yearly thromboembolic risk.
  • 12. CHADS2 Score for Stroke Risk Assessment in Atrial Fibrillation Score CHADS2 Risk Criteria 1 point Congestive heart failure 1 point Hypertension 1 point Age >75 years 1 point Diabetes mellitus 2 points Stroke/transient ischemic attack Table 1. CHADS2 Score: Stroke Risk Assessment in Atrial Fibrillation
  • 13. Treatment Recommendations Based on CHADS2 Score CHADS2Score Risk Recommendation 0 Low Aspirin (81-325 mg) daily 1 Intermediate Aspirin (81-325 mg) daily or warfarin (INR 2.0–3.0), based on patient preference 2 or more High (CHADS2 revised) or intermediate (CHADS2 classic) Warfarin (INR 2.0-3.0), unless there are reasons to avoid it ()
  • 14. • The American Heart Association (AHA), American College of Cardiology (ACC), and Heart Rhythm Society (HRS), in collaboration with the Society of Thoracic Surgery, released new AF guidelines in 2014, including the recommendation that for estimation of the stroke risk in patients with nonvalvular AF, the CHADS2 score be replaced with the more comprehensive CHA2 DS2 -VASc score. • In this scoring system, 1 point is assigned for each of the following: congestive heart failure (CHF), hypertension, diabetes, vascular disease (myocardial infarction [MI], peripheral arterial disease, aortic plaque), age 65-74 years, and female sex. Two points each are assigned for age 75 years or older and prior stroke/transient ischemic attack (TIA)/thromboembolism. The updated guidelines also state the following: • Evidence indicates that aspirin’s use as a means of lowering stroke risk in patients with AF should be reduced or eliminated • In addition to warfarin, 3 new anticoagulants are recommended for patients with nonvalvular AF who have previously suffered a stroke or TIA or whose CHA 2 DS 2 -VASc score is 2 or above: dabigatran etexilate, rivaroxaban, and apixaban • Radiofrequency catheter ablation can be used as initial treatment in recurrent symptomatic paroxysmal AF
  • 15. Rate control • Control of ventricular rate is a critical component of management of new- onset AF • Beta-blockers and calcium channel blockers are first-line agents for rate control in AF. These drugs can be administered either intravenously or orally. Commonly used are IV metoprolol or diltiazem in AF with RVR. • Amiodarone can be used as a rate-controlling agent for patients who are intolerant of or unresponsive to other agents, such as patients with CHF who may otherwise not tolerate diltiazem or metoprolol. • In patients with inadequate ventricular rate control despite drug therapy, atrioventricular (AV) nodal ablation and pacemaker implantation may be considered
  • 16. Anticoagulation • Acute cardioversion for AF carries a risk of thromboembolism unless anticoagulation therapy is initiated prior to the procedure and continued post procedure. Risk of thromboembolism is similar in patients undergoing either pharmacologic or electrical cardioversion. The risk of thromboembolic events is greatest when AF has been present for longer than 48 hours. • Patients with newly diagnosed AF and patients awaiting electrical cardioversion can be started on intravenous heparin (activated partial thromboplastin time [aPTT] of 45-60 seconds) or low-molecular- weight heparin (1 mg/kg bid). • Patients can be started concomitantly on warfarin in an inpatient setting while awaiting a therapeutic INR value (2-3). • New anticoagulants: dabigatran, rivaroxaban, apixaban
  • 17.
  • 18. Long-Term Management • Long-term management of atrial fibrillation is focused on reducing the likelihood of AF recurrence, reducing AF-related symptoms, control of ventricular rate, and reducing stroke risk. • Anticoagulation with either aspirin or warfarin should be initiated for all individuals with AF, except those with contraindications. Selection of the appropriate antithrombotic regimen for a given patient should be balanced  between the risk of stroke and the risk of bleeding. • Antiarrhythmic therapy can aid in maintenance of sinus rhythm in certain patients but requires close monitoring • As a rule, younger patients with more severe symptoms and fewer comorbidities tend to derive greater benefit from a long-term focus on rhythm control. Older patients with structural heart disease (e.g., left ventricular hypertrophy, prior MI, depressed ejection fraction, atrial dilation) are less likely to remain in sinus rhythm and are more likely to have serious side effects from antiarrhythmic drugs, most clinicians focus on long-term rate control
  • 19. Anticoagulation • The goal of long-term anticoagulation in atrial fibrillation is to reduce the risk of thromboembolism. • Anticoagulation therapy with warfarin is significantly more effective than antiplatelet therapy if the INR is adjusted. The INR goal in AF is usually between 2 and 3. • The major adverse effect of anticoagulation therapy with warfarin is bleeding • Factors that increase the risk of bleeding include: hx of bleeding, age more than 75 years, liver or renal dse, HTN, DM, anemia, prior stroke, subtherapeutic INR, genetic predisposition, thrombocytopenia or aspirin use, malignanacy. • If risk outweighs benefit then avoid and contraindicated in pregnant women too.
  • 20. New anticoagulant regimens • Compared with warfarin, low-dose new anticoagulant regimens showed similar overall reductions in stroke or systemic embolic events and a more favorable bleeding profile, but significantly more ischemic strokes • Guidelines from the American College of Cardiology Foundation (ACCF)/American Heart Association (AHA)/Heart Rhythm Society (HRS) on atrial fibrillation have been updated to include the use of oral direct thrombin inhibitors (ie, dabigatran) • The guidelines recommend dabigatran may be used as an alternative to warfarin for the prevention of stroke and systemic thromboembolism in patients with paroxysmal-to-permanent atrial fibrillation and risk factors for stroke or systemic embolization. Patients with atrial fibrillation who are not candidates include those with prosthetic heart valves or hemodynamically significant valve disease, severe renal failure (creatinine clearance ≤15 mL/min), or advanced liver disease.
  • 21. Rate control • Strict rate control in patients with stable ventricular function is no longer recommended. • AV nodal blocking medications are the cornerstone of rate control in long- standing AF, oral beta-blockers, nondihydropyridine calcium channel blockers, and digoxin are effective. Generally, coadministration of beta- blockers and calcium channel blockers is reserved for patients in whom adequate rate control cannot be achieved with a single agent. • Digoxin can be effective in sedentary patients (especially in those with heart failure) but requires close monitoring of drug levels and renal function. • Heart rate control (defined as <80 bpm at rest) may be considered for less symptomatic patients with AF; a more lenient rate-control strategy (<110 bpm at rest) is reasonable when patients remain asymptomatic and left ventricular (LV) systolic function is preserved
  • 22. Rhythm control • Maintenance of sinus rhythm requires treatment of cardiovascular risk factors and any underlying disorder (ie, hyperthyroidism) that may have triggered AF. • Antiarrhythmic drugs include amiodarone, dofetilide, dronedarone, flecainide, propafenone, and sotalol; drug selection should be based on underlying heart disease and comorbidities • In patients with cardiac disease such as coronary artery disease or systolic or diastolic heart failure, amiodarone becomes the drug of choice because of its decreased proarrhythmic effects compared with other antiarrhythmic drugs. • Discontinue antiarrhythmic drugs, including dronedarone, when AF becomes permanent • Dronedarone is contraindicated for treatment of AF in patients with New York Heart Association (NYHA) class III and IV HF or patients who have had an episode of decompensated heart failure in the past 4 weeks
  • 23. Catheter Ablation • The goal of catheter ablation and surgical treatment of atrial fibrillation is to disconnect triggers and/or to modify the substrate for AF. Mapping and radiofrequency (RF) ablation of AF is one of the most complex ablation procedures. • First-line therapy in recurrent symptomatic paroxysmal or persistent AF • AF catheter ablation is contraindicated for patients who cannot be treated with anticoagulant therapy during and after the procedure and should not be performed with the sole intent of eliminating the need for anticoagulation.

Editor's Notes

  1. Paroxysmal AF Atrial fibrillation is considered to be recurrent when a patient has 2 or more episodes. If recurrent AF terminates spontaneously, it is designated as paroxysmal. Some patients with paroxysmal AF, typically younger patients, have been found to have distinct electrically active foci within their pulmonary veins. These patients generally have many atrial premature beats noted on Holter monitoring. Isolation or elimination of these foci can lead to elimination of the trigger for paroxysms of AF. Paroxysmal AF may progress to permanent AF, and aggressive attempts to restore and maintain sinus rhythm may prevent comorbidities associated with AF. Persistent AF If recurrent AF is sustained, it is considered persistent, irrespective of whether the arrhythmia is terminated by either pharmacologic therapy or electrical cardioversion. Persistent AF may be either the first presentation of AF or the result of recurrent episodes of paroxysmal AF. Patients with persistent AF also include those with longstanding AF in whom cardioversion has not been indicated or attempted, often leading to permanent AF. Patients can also have AF as an arrhythmia secondary to cardiac disease that affects the atria (eg, congestive heart failure, hypertensive heart disease, rheumatic heart disease, coronary artery disease). These patients tend to be older, and AF is more likely to be persistent. Persistent AF with an uncontrolled, rapid ventricular heart rate response can cause a dilated cardiomyopathy and can lead to electrical remodeling in the atria (atrial cardiomyopathy). Therapy, such as drugs or atrioventricular nodal ablation and permanent pacemaker implantation, to control the ventricular rate can improve left ventricular function and improve quality-of-life scores. Permanent AF Permanent AF is recognized as the accepted rhythm, and the main treatment goals are rate control and anticoagulation. While it is possible to reverse the progression from paroxysmal to persistent and to permanent, this task can be challenging. Lone atrial fibrillation In addition to the above schema, the term &amp;quot;lone atrial fibrillation&amp;quot; has been used to identify AF in younger patients without structural heart disease, who are at a lower risk for thromboembolism. The definition of lone AF remains controversial, but it generally refers to paroxysmal, persistent, or permanent AF in younger patients (&amp;lt; 60 y) who have normal echocardiographic findings.[7]