The document discusses rate and rhythm control strategies for atrial fibrillation (AF) management. It recommends that a target heart rate of under 80 beats per minute at rest and under 110 beats per minute is sufficient for rate control of AF. While some antiarrhythmic drugs can help with rate control, amiodarone should generally only be used for rhythm control. Catheter ablation and pacemakers are options for non-pharmacological rate control. The document also discusses catheter ablation as a first-line therapy for AF according to recent clinical trials, and lifestyle modifications that can help reduce AF recurrence after ablation.

1. Prof. SALAH ATTA
Professor of Cardiology,
Assiut University

2. • Better symptom control includes assessment of patient’s symptoms, quality of
life and patient preference then optimization of rate control then consider
rhythm control according to patient characterization….

4. Rate control
Rate control is an integral part of AF management, and is often
sufficient to improve AF-related symptoms.
What is recommended target heart rate???
In the RACE II RCT of permanent AF patients, there was no difference in a composite
of clinical events, functional (NYHA) class, or hospitalizations between the strict arm
[target heart rate <80 beats per minute (bpm) at rest and lenient (heart-rate target <110
bpm) arm , similar to an analysis from the AFFIRM (Atrial Fibrillation Follow-up
Investigation of Rhythm Management) and RACE trials.

5. Pharmacological Rate Control of AF

6. Amiodarone controversial use
for rate control of AF
• Some antiarrhythmic drugs (AADs) also have rate-limiting
properties
(e.g. amiodarone, dronedarone, sotalol) but generally they
should be used only for rhythm control (Amiodarone is
Class IA for rhythm control).
• Amiodarone intravenously in acute situations can be useful as a last resort
when heart rate cannot be controlled with combination therapy in patients
who do not qualify for non-pharmacological rate control.

8. Non Pharmacological Rate Control
• Ablate and Pace:
1- Suboptimal rate control>110
with worsening of symptoms and
QOL despite drug combinations
or intolerance to drugs….
Or
2- In severely symptomatic
patients with permanent AF and
at least one hospitalization for
HF (ablation with CRT may be
preferred. His bundle pacing is a
new promising alternative).
3- A patient with CRT for HFrF
and AF with a rate > 80 to
achieve effective biventricular
capture and synchronization.

9. Rate ± Rhythm Control

10. Rate ± Rhythm Control

12. Choices of Antiarrhythmic drugs For Rhythm Control Strategy

13. Recommendations for long term AADs New
New

14. Risk assessment for recurrence of atrial
fibrillation post catheter ablation.
Recurrence of AF after catheter ablation is driven by the
complex interaction of various factors. These include
increasing AF duration, age, and LA size, and structural
factors such as the abundance of epicardial fat tissue and
the presence of atrial substrate as evident from electrical or
morphological markers.

15. Lifestyle and Risk Factors Management
NEW Change
from IIA
(NEW)
Risk factors for AF contributing to the
development of an
abnormal substrate translating into poorer
outcomes with rhythm control strategies.

16. NEW
Results From CAPTAF Trial

18. New
NEW
MANTRA-PAF, RAAFT2
AF Catheter Ablation as a Frist Line Therapy

19. AF Catheter Ablation as a Frist Line TherapyChange from IIA,
CAMERA MRI
trial. JACC Clin
Electrophysiol
2018;
Changed
Indication
3 RCTs on AF ablation vs AAD in HF:
• AATAC circulation 2016 reduction in all cause mortality and hospitalization
• CASTLE-AF, NEJM 2018 with ablation with improved LVEF
• 1 substudy RCT on AF abl. Vs AAD: Reduction in death, stroke, bleeding, a
CABANA subanalysis, HR 2020 mortality with ablation in HF pats.

22. ICE and
FIRE study

23. Rhythm Control strategies of AF

25. Early Treatment of Atrial Fibrillation for Stroke
Prevention Trial - EAST-AFNET 4
• Results of this trial are different from other similar trials such as
CABANA-AF, AFFIRM, and RACE.
• One difference is the population enrolled – recent onset (within 12
months) in EAST-AFNET 4 vs. more sustained AF in the other trials
and higher risk patients.
• There was also a reasonably high rate of AF ablation (8% at
enrollment, 20% by 5 years) in the current trial. Also a good
percentage of the pts were asymptomatic as symptoms were not
among the inclusion criteria….

27. Thank You