CLINICAL APPROACH OF ATRIAL FIBRILLATION

RECENT RECOMMENDATIONS OF INTERNATIONAL GUIDELINES 1

Dalmo Antonio Ribeiro Moreira M.D, PhD

Medical Section of Electrophysiology and Cardiac Arrhythmias
Dante Pazzanese Institute of Cardiology
São Paulo, Brazil

Part I

Due to its high prevalence, causes and various forms of clinical manifestation, treatment
of atrial fibrillation nowadays, though still a challenge for cardiologists, is becoming more
rational in recent years, particularly with the discovery of the mechanisms of origin and
maintenance, from experimental studies, and also controlled trials and long-term follow-
up. As the old dilemma, reverse or not, recent clinical studies have shown that the
practice of performing only the control of ventricular rate does not appear to be less than
the approach of reversing atrial fibrillation and maintain normal rhythm with antiarrhythmic
drugs, with respect to mortality and stroke. However, despite these findings, patients in
whom sinus rhythm is maintained, has a better quality of life.

Available publications on different aspects involving atrial fibrillation, often do not allow a
definitive conclusion about how to approach patients, necessitating the development of
guidelines to try to standardize the form of treatment, based on information of currently
available studies . This text will present the most recent recommendations obtained from
the American and European guidelines for the treatment of patients with atrial fibrillation.
One must consider first the type of atrial fibrillation the patient has, since the approach
differs in those with acute, chronic persistent or chronic permanent form.

To Restore or Not the Sinus Rhythm

The treatment of symptomatic atrial fibrillation can vary from patient to patient. The
reversion to sinus rhythm should be practiced, if possible, at least once in patients with
atrial fibrillation detected by the first time. The decision should be based on clinical
criteria. There is no doubt that cardioversion should be performed on an emergency basis
in patients in whom atrial fibrillation is manifested by low cardiac output, worsening heart
failure, or is the cause of angina in coronary patients.

Patients who present with acute atrial fibrillation have a chance of spontaneous reversal
in 85-90% of cases in up to 24 hours. Not infrequently, only the control of ventricular rate
to relieve the symptoms may be sufficient in this population. Antiarrhythmic drug can only
accelerate the process of reversal, because on follow-up the restoration of the normal
rhythm occurs in most cases without any aggressive approach. Studies have shown that
in patients with acute atrial fibrillation, after 24 hours sinus rhythm may be present in a
similar way in those who received antiarrhythmics as well as those who received placebo.
Lower probability of spontaneous reversion occurs in cardiac patients and those with
coronary disease.

Young patients, symptomatic patients who present themselves for the first time with
arrhythmia or atrial fibrillation lasting several weeks should undergo anticoagulation,
receive drugs for the control of heart rate and then perform the reversion to sinus rhythm,
initially with antiarrhythmic drugs or by electrical cardioversion in case of drug failure. The
practice of using antiarrhythmic drugs prior to electrical cardioversion is already well
established, because it can cause the restoration of sinus rhythm in approximately 40-
50% of cases or, increase the chance of maintaining this rhythm after the shock. Although
simple and the fact it can be performed in the ambulatory, the chemical cardioversion is
less effective than the electric form. The success of this approach is greatest when atrial
fibrillation has a maximum duration of 7 days (acute and sub-acute atrial fibrillation). After
this period the electrical and structural changes of the atria reduces the effectiveness of
drugs. Remember the possibility of pro-arrhythmic effects of antiarrhythmic drugs, and
their interaction with anticoagulants, which can be intensified or have mitigated its effects,
hindering the control of anticoagulation prior to cardioversion. There is no study showing
that the risk of thromboembolism is different whether chemical or electrical cardioversion
is performed.

Patients in whom atrial fibrillation is symptomatic and control of heart rate does not relieve
symptoms, should undergo cardioversion. The elderly subjects, when the ventricular rate
is well controlled, may abstain from cardioversion, particularly those with a history of
hypertension and heart disease. In these cases, however, anticoagulation should be
maintained.

In young individuals without heart disease, with recurrent paroxysmal atrial fibrillation,
only the control of ventricular rate may be a reasonable approach, and prevention of
recurrence with antiarrhythmic drugs considered in those with symptoms. In this
population, always consider the option of anticoagulation in individuals at risk for
thromboembolism. Radiofrequency ablation, addressing the pulmonary veins is indicated
in selected cases when antiarrhythmic therapy fails.

Chemical Cardioversion

The chemical cardioversion of acute atrial fibrillation (lasting less than seven days) may
be performed initially with antiarrhythmic drugs of the IC group represented by flecainide
and propafenone. The pill in the pocket approach utilizes 600 mg orally of propafenone
(for individuals over 70 kg) or 450 mg orally (for those under 70 kg) that restores early
sinus rhythm in up to 94% of cases. This scheme can be employed outside the hospital
only when tested its efficacy and safety in the same patient within the hospital previously.
This drug is contraindicated in patients with ventricular dysfunction, apparent heart failure
and in those with chronic obstructive pulmonary disease, patients with a history of sinus
bradycardia and second degree atrioventricular block, and should not be prescribed to
patients over age 80. During its administration, it is recommended the concomitant use of
beta-blockers or calcium channel antagonist to prevent elevations of ventricular rate if
atrial fibrillation becomes atrial flutter.

Amiodarone is another option for chemical cardioversion of atrial fibrillation. In

hospitalized patients, the recommended oral dose is 1.2 to 1.8 g, divided into smaller
doses until 10 g total, followed by 200-400 mg daily (maintenance). The other scheme is
a single dose of 30 mg / kg. In patients not hospitalized recommended dose is 600-800
mg in divided doses, up to a total of 10 grams, then 200-400 mg (maintenance). Another
option is the intravenous administration at a dose 5-7 mg / kg for 30-60 minutes, then 1.2
to 1.8 grams per day in continuous infusion or in divided doses, up to a total of 10 g then
200-400 mg daily (maintenance dose).
Quinidine should have limited use because of the risk of side effects and pro-arrhythmia
that often render its employment. It has been shown that the risk of death with this agent
is two times higher than those who received placebo. If it is chosen to use is
recommended to admit patients in the hospital for at least three days.

The sotalol is not a good agent for chemical cardioversion of atrial fibrillation due to their
electrophysiological properties. This drug has a reverse-dependent effect, ie, performs
best in slower heart rates, which does not happen in atrial fibrillation because the atrial
rate is extremely fast.

Prevention of Atrial Fibrillation Recurrences

This is perhaps the most important stage of the treatment of patients with atrial fibrillation
after restoration of sinus rhythm. It is crucial that a drug is administered otherwise the
chance of recurrence is very high. Here also highlights the importance of the
administration of antiarrhythmics even prior to cardioversion to prevent immediate
recurrences after the shock. Several factors are related to recurrence: atrial electrical
remodeling and autonomic influences are responsible for early recurrences; histological
remodeling is responsible for late recurrences. Other factors like congestive heart failure
(improper intake of salt and water retention), lack of adjunctive medication (diuretics ,
ACE inhibitors, angiotensina receptor blockers), can also be related to early or late
recurrences of atrial fibrillation after electric cardioversion.

Dependent on the presence or absence of heart disease, hypertension or coronary

disease, one should employ an agent with a profile of greater efficiency, safety and
tolerability. Patients with no heart disease, sotalol or propafenone can be prescribed. In
cases of cardiac disease only amiodarone is indicated. Patients with arterial hypertension
without significant left ventricular hypertrophy, the approach is similar. In those with
severe left ventricular hypertrophy only amiodarone is safe. For those patients with
coronary artery disease the drug of choice is sotalol. In patients with heart failure, only
amiodarone can be prescribed.

In summary, for patients without heart disease, drugs of the IC group and sotalol can be
used safely with low risk of pro-arrhythmia. Furthermore, patients with ventricular
dysfunction, heart failure, heart disease or hypertension with left ventricular hypertrophy,
amiodarone, or alternatively in selected cases, non-pharmacological therapy using
ablation of pulmonary veins with a catheter and radiofrequency might be indicated.

Control of the Ventricular Rate

In patients with permanent atrial fibrillation, when the chemical or electrical cardioversion
is not considered, or in patients who present for the first time in atrial fibrillation (acute or
chronic persistent) and are symptomatic, heart rate control is indicated with drugs that
reduce the driving ability of the atrioventricular node. In this case are considered the
following agents: a) digoxin; b) beta-blockers; c) calcium channel antagonists; d)
associations among these. Digoxin is indicated in patients with little activity and those
with ventricular dysfunction or heart failure, is not a good agent to control heart rate when
the adrenergic state of the patient is high. In such cases it is recommended its
association with beta-blockers or calcium channel antagonists.

Reference

1 - Fuster V, Rydén LE, Cannon DS et al. ACC/AHA/ESC 2006 Guidelines for the
Management of Patients With Atrial Fibrillation. A Report of the 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). J Am Coll Cardiol
2006; 48:e-196.