Tuesday, August 08, 2006

New guidelines on Atrial Fibrillation

For perhaps the first time, the ACC (American College of Cardiology), AHA (American Heart Association), and ESC (European Society of Cardiology), jointly published new guidelines in the Management of Atrial Fibrillation.

In practical terms, the guidelines (appeared in the recent Circulation), followed the previous guidelines (in 2001) of always weighing rate control against rhythm control. Appears that they are both equally efficacious. The role of left atrial ablation as a means of reverting to sinus rhythm, is now acceptable, except that it requires special expertise, something which I hope the local cardiologist takes note. Left atrium ablation is no small task and has a steep learning curve. Also, their longterm results and sequalae, is still in doubt.

The guidelines also state the importance of stroke prevention, with aspirin (those with less then two cardiac risk factors, and normal LA size) or warfarin (in those without contra-indication to anticoagulation).

The approach to acute atrial fibrillation seems a little different from chronic atrial fibrillation. All in all, I take home the message that if you can get the patient to SR, we should starting with medications, like cordarone, or even digoxin. If that fails, class one anti-arrhythmics can be tried, but be aware of their pro-arrhythmic dangers. Left atrial ablation is a good therapy in established centers who do them well. If you are in Malaysia, perhaps it is reasonable to just get your rate well controlled with digoxin and beta-blockers. Of course, the patient will need warfarin for stroke prevention. If the patient is assymptomatic after all this, fine. If the patient is still symptomatic, then sending him to an expert in left atrial ablation is reasonable.


santa007 said...

Nice site u have here. Just to add a bit to your guidelines on AF. I do agree with u that there's not much difference in controlling rate or rhythm in chronic AF, but i think the guidelines did mention that even though if the patients are in sinus, they should be anticoagulated as well as the risk of stroke is higher than normal population.

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