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Key Clinical Updates in Atrial Fibrillation

For regular, moderate drinkers, total abstinence from alcohol reduces but does not usually eliminate atrial fibrillation recurrences.

Up to two-thirds of patients experiencing acute onset (shorter than 36 hours) of atrial fibrillation will spontaneously revert to sinus rhythm without the need for cardioversion. If atrial fibrillation has been present for more than a week, spontaneous conversion is unlikely and cardioversion may be considered for symptomatic patients.

Patients with atrial fibrillation who had stable coronary disease or who were at least 1 year from most recent coronary stent or coronary bypass surgery appeared to have greater risk than benefit from the combination therapy of rivaroxaban and an antiplatelet agent.

An effective treatment strategy in select patients with symptomatic but rare (a few times a year) episodes of atrial fibrillation is on-demand pharmacologic cardioversion. In patients without coronary or structural heart disease, flecainide (200–300 mg) or propafenone (450–600 mg) in addition to a beta-blocker or nondihydropyridine calcium channel blocker is taken as a single dose at the onset of symptoms.

The primary benefit of catheter ablation in patients with atrial fibrillation is an improvement in quality of life. In the CABANA trial, there was no difference in the primary endpoint of death, disabling stroke, serious bleeding, or cardiac arrest in patients randomized to catheter ablation versus medical therapy as first treatment for symptomatic atrial fibrillation.

ESSENTIALS OF DIAGNOSIS

  • Presents as an irregularly irregular heart rhythm on examination and ECG.

  • Prevention of stroke should be considered in all patients with risk factors for stroke (eg, heart failure, hypertension, age 65 or older, diabetes mellitus, prior history of stroke or TIA, and vascular disease).

  • Heart rate control with beta-blocker or calcium channel blockers generally required. Restoration of sinus rhythm with cardioversion, antiarrhythmic medications, or catheter ablation in symptomatic patients.

GENERAL CONSIDERATIONS

Atrial fibrillation is the most common chronic arrhythmia, with an incidence and prevalence that rise with age, so that it affects approximately 9% of individuals over age 65 years. It occurs in rheumatic and other forms of valvular heart disease, dilated cardiomyopathy, ASD, hypertension, and CHD as well as in patients with no apparent cardiac disease; it may be the initial presenting sign in thyrotoxicosis, and this condition should be excluded with the initial episode. Atrial fibrillation often appears in a paroxysmal fashion before becoming the established rhythm. Pericarditis, chest trauma, thoracic or cardiac surgery, thyroid disorders, obstructive sleep apnea, or pulmonary disease (pneumonia, pulmonary embolism) as well as medications such as theophylline and beta-adrenergic agonists may cause attacks in patients with normal hearts. Acute alcohol excess and alcohol withdrawal (termed holiday heart) may precipitate atrial fibrillation. For regular, moderate drinkers, total abstinence from alcohol reduces but usually does not eliminate atrial fibrillation recurrences.

Atrial fibrillation, particularly when the ventricular rate is uncontrolled, can lead to LV dysfunction, heart failure, or myocardial ischemia (when underlying CAD is present). Perhaps the ...

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