Management

The management of atrial fibrillation consists of heart rate control, correction of rhythm disturbances, and prevention of thromboembolic complications.  Both rate and rhythm can be effectively corrected with pharmacologic and non-pharmacologic options.  The choice of therapy is patient dependent, and is influenced by the type of atrial fibrillation. 

In the past, most physicians were opting for rhythm over rate control, as they thought that restoring sinus rhythm would improve hemodynamic function, and decrease thromboembolic disease.  However, two recent major clinical trials, the AFFIRM and RACE, comparing both treatment strategies, showed no differences in risk of stroke and mortality.  It is then recommended to start with rate control in most patients, but to adjust the therapy according to patient responsiveness, and difference in clinical scenarios.  Rhythm control was only recommended as the best options in patients with persistent symptoms such as angina, and heart failure with adequate rate control.  Other exception can arise such as in a younger patient in whom cardioversion would be preferred over years of rate control medication, and in an older patient with associated severe heart failure whom cardioversion would increase the cardiac output by up to 25% by restoring the atrial kick. 

Next: Rate Control